The document summarizes key aspects of death and brain death from a medicolegal perspective. It defines death and outlines the vital systems that cease to function at death. It discusses the presumption of death and survivorship under Indian law. The document then examines the historical definitions of death and milestones in determining brain death. It provides details on the anatomy of the normal brain and causes, mechanisms, and conditions distinct from brain death. The neurological examination for determining brain death and confirmatory testing are described. The key provisions of the Transplantation of Human Organs Act of 1994 and its amendment in 2009 are summarized.

1. Death – medicolegal aspects
Dr Rakhin.K.B

2. Death is a process
rather than an event
Exceptions

3. Def – The cessation of life
3 vital system –
nervous, circulatory, respiratory
Atria mortis – death portal of entry
4 -6 minutes - serious permanent
impairment to brain
6-10 minutes – total loss of function

4. Irreversible damage to brain stem
(somatic death)
Organ transplantation
Loss of spontaneous breathing
ability, cardiac arrest (cellular death
progresses)

5. IEA 108 presumption of survivorship.
Burden of proving that person is alive who
has not been heard of for seven years. -
Provided that when the question is whether a
man is alive or dead, and it is proved that he
has not been heard of for seven years by
those who would naturally have heard of him
if he had been alive, the burden of proving
that he is alive is shifted to the person who
affirms it.

6. IEA 107 presumption of death.
Burden of proving death of person
known to have been alive within thirty
years. - When the question is whether a
man is alive or dead, and it is shown that he
was alive within thirty years, the burden of
proving that he is dead is on the person
who affirms it.

7. Historical Perspective
Prior to the advent of
mechanical respiration, death
was defined as the cessation of
circulation and breathing

8. Historical Perspective
1959 Coma de’passe’ Mollaret and Goulon
1968 Irreversible Coma/Brain Death Harvard
Medical School Ad Hoc Committee
1981 Uniform Determination of Death Act -
President’s Commission for the Study of
Ethical Problems in Medicine (US)
1994 American Academy of Neurology Guidelines
for the determination of Brain Death
1994 Transplantation of Human Organs Act (India)

9. Brain Death Current Consensus
Absent Cerebral Function
Absent Brainstem Function
Apnea

10. Normal Brain Anatomy

11. Normal Brain Anatomy
Cerebral Cortex
Reticular
Activating
Brain Stem System

12. Cerebral Cortex
Cognition
Voluntary Movement
Sensation

13. Brain Stem

14. Brain Stem
Midbrain
Cranial Nerve III
 pupillary function
 eye movement

15. Brain Stem
Pons
Cranial Nerves IV, V, VI
 conjugate eye movement
 corneal reflex

16. Brain Stem
Medulla
Cranial Nerves IX, X
 Pharyngeal (Gag) Reflex
 Tracheal (Cough) Reflex
Respiration

17. Reticular Activating System
Receives multiple
sensory inputs
Mediates wakefulness

18. Causes of Brain Death
Normal Cerebral Anoxia

19. Causes of Brain Death
Normal Cerebral Hemorrhage

20. Causes of Brain Death
Normal Subarachnoid Hemorrhage

21. Causes of Brain Death
Normal Trauma

22. Causes of Brain Death
Normal Meningitis

23. Mechanism of Cerebral Death
Neuronal Injury Neuronal Swelling
ICP>MAP is
incompatible with
life
Decreased Intracranial Increased Intracranial
Blood Flow Pressure

24. Conditions Distinct From Brain Death
Persistent Vegetative State
Locked-in Syndrome
Minimally Responsive State

25. Persistent Vegetative State
Normal Sleep-Wake Cycles
No Response to Environmental Stimuli
Diffuse Brain Injury with Preservation of Brain
Stem Function

26. Locked-in Syndrome
Ventral Pontine Infarct
 Complete Paralysis
 Preserved Consciousness
 Preserved Eye Movement

27. Minimally Responsive State
Static Encephalopathy
Diffuse or Multi-Focal Brain Injury
Preserved Brain Stem Function
Variable Interaction with Environmental Stimuli

28. Brain Death Neurological Examination
Clinical Prerequisites:
 Known Irreversible Cause
 Exclusion of Potentially Reversible Conditions
Drug Intoxication or Poisoning
Electrolyte or Acid-Base Imbalance
Endocrine Disturbances
 Core Body temperature > 32° C
 Team of doctors at least twice, with a reasonable gap of
time in between ( 6 hours or so)

29. Brain Death Neurological Examination
 Coma
 Absent Brain Stem Reflexes
 Apnea

30. Coma
No Response to Noxious Stimuli
Nail Bed Pressure
Sternal Rub
Supra-Orbital Ridge Pressure

31. Absence of Brain Stem Reflexes
 Pupillary Reflex
 Eye Movements
 Facial Sensation and Motor Response
 Pharyngeal (Gag) Reflex
 Tracheal (Cough) Reflex

32. Pupillary Reflex
Pupils dilated with no constriction to bright light

33. Eye Movements
Occulo-Cephalic Response
“Doll’s Eyes Maneuver”

34. Eye Movements
Oculo-Vestibular Response
“Cold Caloric Testing”

35. Facial Sensation and Motor Response
 Corneal Reflex
 Jaw Reflex
 Grimace to Supraorbital or
Temporo-Mandibular Pressure

36. Apnea Testing
Prerequisites
Core Body Temperature > 32° C
Systolic Blood Pressure ≥ 90 mm Hg
Normal Electrolytes
Normal PCO2

37. Apnea Testing
1. Pre-Oxygenation
 100% Oxygen via Tracheal Cannula
 PO2 = 200 mm Hg
2. Monitor PCO2 and PO2 with pulse oximetry
3. Disconnect Ventilator
4. Observe for Respiratory Movement until PCO2 = 60
mm Hg
5. Discontinue Testing if BP < 90, PO2 saturation
decreases, or cardiac dysrhythmia observed

38. Confounding Clinical Conditions
 Facial Trauma
 Pupillary Abnormalities
 CNS Sedatives or Neuromuscular Blockers
 Hepatic Failure
 Pulmonary Disease

39. Observations Compatible with Brain
Death
 Sweating, Blushing
 Deep Tendon Reflexes
 Spontaneous Spinal Reflexes- Triple Flexion
 Babinski Sign

40. Confirmatory Testing
Recommended when the proximate cause of coma is not known or when
confounding clinical conditions limit the clinical examination

41. Confirmatory Testing
EE
G
Normal Electrocerebral Silence

42. Confirmatory Testing
Cerebral Angiography
Normal No Intracranial Flow

43. Confirmatory Testing
Technetium-99 Isotope Brain Scan

44. Confirmatory Testing
MR- Angiography

45. Confirmatory Testing
Transcranial Ultrasonography

46. Confirmatory Testing
Somatosensory Evoked Potentials

47. Transplantation of Human Organs Act
THOA 1994
8 July 1994
7 Chapters, 25 Sections and variable
no. of subsections

48. Transplantation of Human Organs Act
THOA 1994
Some definitions
“Deceased person” – A person in whom permanent
disappearance of all evidence of life occurs, by reason
of brain stem death or in a cardiopulmonary sense, at
any time after live birth has taken place
“Brain stem death” – Stage at which all functions of
the brain stem have permanently and irreversibly
ceased

49. Transplantation of Human Organs Act
THOA 1994
“Donor” – Any person not less than 18 years of
age, who voluntarily authorizes the removal of any
of his human organs for therapeutic purposes under
subsection(1) or (2) of section(3)
“Human Organ” – Any part of a human body
consisting of a structured arrangement of tissues
which if wholly removed, cannot be replicated by
the body.

50. Transplantation of Human Organs Act
THOA 1994
The brain stem death need to be certified by a team of
doctors consisting of the following
1) The RMP in charge of the hospital in which the brain stem death
has occurred.
2) An independent RMP, being a specialist to be nominated by
RMP in clause(1), from the panel of names approved by the
appropriate authority.
3) A neurologist or a neurosurgeon to be nominated by the RMP
specified in clause(1) from the panel of names approved by the
appropriate authority.
4) The RMP treating the person whose brain stem death has
occurred.

51. Transplantation of Human Organs
(Amendment) Act, 2009
 Human organs and tissues
 Expansion of the term “near relative’
 Tissue
 Transplant coordinator
 Technician for enucleation of cornea
 Non availability of neurosurgeon
 Donor/recipient - near relative - foreign national
 Minors
 Swap donations
 Fine/ imprisonment

52. Concern for man and his fate must always form the chief
interest of all technical endeavors. Never forget this in the
midst of your diagrams and equations.
Albert Einstein