Reporting Deaths and Post-Mortems

Question 1

What are the Harvard criteria for confirming brain death?

Answer 1

• Unreceptivity and unresponsitivity – the patient shows total unawareness to external stimuli and unresponsiveness to painful stimuli.
• No movements or breathing – all spontaneous muscular movement, spontaneous respiration and response to stimuli are absent.
• No reflexes - fixed, dilated pupils; lack of eye movement or reflex eye movement to ice water placed in the ear; lack of response to stimuli; unelicitable tendon reflexes.

Question 2

What are the functions of the brainstem?

Answer 2

• The provision of supply to the twelve pairs of cranial nerves which mediate smell, sight and eye movement, taste, hearing, facial touch, swallowing, control of heartbeat, breathing and visceral activity.
• The initiation of the act of breathing and hence the flow of oxygen to the brain. Each and every breath has to be triggered by an individual nerve impulse which comes from the brainstem.
• The maintenance of cortical activity in the rest of the brain. This function is the property of the reticular formation, an ill-defined neural network at the top of the brainstem. It generates signals which ‘switch’ the brain into the various levels of consciousness wakefulness, sleep, REM (rapid eye movement) sleep and coma.

Question 3

What are the criteria which have to be filled for diagnosis of brainstem death?

Answer 3

Each patient being considered for a diagnosis of brainstem death has to fulfill various criteria, generally listed as Preconditions, Exclusions and Tests.

Question 4

What are the preconditions a patient must meet for diagnosis of brainstem death?

Answer 4

• The patient must be comatose and incapable of breathing for himself (i.e. the patient is being maintained on a ventilator).
• The cause of the coma must be known beyond doubt.
• There must be irremediable structural brain damage.
• Note that it is not sufficient to propose a possible etiological basis for the diagnosis. The cause of the coma must be known beyond all doubt.

Question 5

What are the exclusions in the diagnosis of brain stem death?

Answer 5

• All patients whose coma is caused by any of the following are automatically excluded:
  
  • Intoxication by drink or drugs – this is particularly relevant in the forensic context.
  • Hypothermia – this can follow immersion in cases of near-drowning.
  • Metabolic or Endocrine Disturbance (e.g. Diabetes and Thyroid malfunction).
• If there is any doubt as to the presence of these conditions, the tests should be postponed. The passage of time will help to resolve the diagnosis in many cases. The patient’s relatives should always be kept informed of any delay, particularly to alleviate their not unreasonable fears that the medical profession is uncertain whether their loved-one is dead or alive. The price of avoiding a catastrophic false diagnosis of death is that occasionally the dead remain “alive” for a short period of time.

Question 6

What are the tests for brainstem death?

Answer 6

• If the patient is having epileptic fits, the brain stem is alive.
• If there is decorticate or decerebrate rigidity, the brainstem is alive.
• If the “Doll’s Head Eye Phenomenon” (oculocephalic reflex) is present, the brain stem is alive.
• If these observations do not indicate that the brainstem is alive, the cranial nerves are tested to elicit brain stem (or “cephalic”) reflexes. If any is positive, brainstem death is excluded.

Question 7

What are the brainstem reflex tests?

Answer 7

• A very bright light is shone into the eyes; the pupils do not react if the patient is dead.
• Firm pressure is applied to the cornea of the eye to elicit blinking; there is no corneal reflex if the patient is dead.
• Ice cold water is passed into the ears to cause reflex eye movement; the vestibule-ocular reflex is absent if the patient is dead.
• If the patient is dead, the cranial nerve motor responses are absent. A pencil shaft is pressed firmly against the fingernail bed (painful stimulus); there is no reflex grimacing.
• A suction catheter passed into the windpipe through the larynx elicits no coughing or gag reflex if the patient is dead.
• These test all the cranial nerves except I, XI and XII.
• The final confirmatory clinical test is the test for apnoea (cessation of breathing). This is established if the patient shows no spontaneous respiratory effort when disconnected from the ventilator.
• A brainstem unresponsive to all these things is dead. We conclude, therefore, that the patient is also dead.

Question 8

What is the commorientes rule?

Answer 8

• Also known as the common calamity.
• This establishes a legal fiction or presumption that in circumstances which render the order of death uncertain, the younger person survived the older one.
• The usual exception to this rule relates to spouses in which the law presumes that each spouse is deemed to have predeceased the other. This prevents the combined estate passing to the relatives of the younger, particularly if there are no children of the marriage.

Question 9

What are the 5 manners of death?

Answer 9

• Natural
• Accident
• Suicide
• Homicide
• Undetermined

Question 10

What are the 3 modes of death?

Answer 10

• The death of the brainstem constitutes death. This occurs as the end point of three fundamental pathways or modes of dying:
  
  • Coma (neurological failure)
  • Syncope (cardiovascular failure)
  • Asphyxia (respiratory failure)
• The mode of dying is not the cause of death.

Question 11

What are the cardiovascular causes of sudden natural death?

Answer 11

• Heart disease
  
  • Coronary artery disease
    
    • Atheroma
    • Ischaemic heart disease - myocardial
    • Infarction
  • Hypertensive heart disease
    
    • Disease of the heart valves - mainly aortic valve disease
    • Cardiomyopathies
    • Myocarditis
    • Infective endocarditis
• Vascular disease
  
  • Ruptured atheromatous aortic aneurysm
  • Dissecting aortic aneurysm
  • Cerebrovascular disease
• Pulomnary embolism

Question 12

What are the CNS causes of sudden natural death?

Answer 12

• Intracranial haemorrhage
• Intracerebral haemorrhage
• Subarachnoid haemorrhage
• Epilepsy
• Infections of the CNS

Question 13

What are the respiratory causes of sudden natural death?

Answer 13

• Pneumonia
• Bronchopneumonia
• Lobar pneumonia
• Viral pneumonia (pneumonitis)
• Asthma
• Bronchitis
• Haemoptysis

Question 14

What are the GI causes of sudden natural death?

Answer 14

• Peritonitis
• Massive haemorrhage

Question 15

What are the genitourinary causes of sudden natural death?

Answer 15

• Ruptured tubal ectopic pregnancy
• Ruptured uterus
• Air embolism
• Amniotic fluid embolism

Question 16

How does sudden natural death result from diabetes mellitus?

Answer 16

• Diabetics may die rapidly from hypoglycemia (low blood glucose), or more slowly from hyperglycemia (too much blood glucose) which is accompanied by severe metabolic disturbance.
• Both conditions are impossible to prove conclusively at autopsy.
• Diabetes also predisposes to the development of atheroma and infections and thus often appears in Part 2 of certified causes of death (contributory causes).

Question 17

What is the aim of carrying out an autopsy?

Answer 17

Whatever the technique, the aim is constant: to provide a comprehensive and thorough examination of all the major organs of the body in order to establish a cause of death and, when appropriate the sequence of events leading to death.

Question 18

What are the samples which can be used for toxicology?

Answer 18

• Vitreous humour
• Urine
• Stomach contents
• Liver
• Hair (for drug analysis)

Question 19

What are the functions of the non-forensic autopsy?

Answer 19

• Confirmation of clinical diagnosis
• Audit of certified cause of death
• Education, training and research
• Collation of accurate statistical information
• Audit and evaluation of hospital procedures