The Diagnosis of Death
The duty of a medical doctor is not confined only in the treatment of his patients, but also there are several other duties to be performed. One among them is death diagnosis, and in case of any unnatural death, reporting the same to the concerned authorities. When a person losses consciousness, a doctor should examine the victim to diagnose the condition and to do the needful. If the victim is dead, it is the doctors duty to declare that the person is dead. If a doctor is not available at the site, the situation has to be handled even by a layman. Hence it is very essential to know the basic techniques of first-aid and death diagnosis.
We all know that, death is the termination of the biological functioning of the living organism. It is the ultimate of every living creature on the earth. Once we are born, it is definite that one day our soul will leave the material body for ever. Scientifically, death is due to complete and irreversible cessation of the vital functions of the brain, heart, and lungs.
STAGES OF DEATH
The death occurs in two stages:
1.Somatic, systemic or clinical death
2.Cellular or molecular death
In somatic death, though life ceases in the organism as a whole, it can persist in different body parts, organs, tissues and cells. The body cells can survive for varying periods and can respond to various chemical, thermal and electrical stimuli. The period of survival of cells depends upon the oxygen demand. And when the cells and tissues die, it is considered as molecular death. Normally, molecular death is complete within 3 to 4 hours of somatic death. However, in common parlance, death means somatic death.
WHAT CAUSES DEATH?
Irrespective of the remote causes, a person dies as a result of failure of any one of these organs like brain, heart, lung. This is called the proximate cause of death. The remote causes may be due to injury, infection, blood loss, poisoning, drugs, tumors, malnutrition, dehydration, starvation etc. A sudden death may be due to failure of systems like cardiovascular, respiratory, CNS, abdominal, endocrinal, iatrogenic, special cases in children, malnutrition, disease, accident, injury, predation, suicide, homicide, war, and also due to some indeterminate causes.
SIGNS OF DEATH
The signs of death can be studied under three headings: Immediate signs, early signs and late signs.
Immediate signs: These signs indicate somatic or clinical death.
– Insensibility (Loss of sensation, movements and reflexes)
– Loss of EEG rhythm
– Cessation of circulation indicated by flat ECG and absence of respiration.
But signs like loss of sensation, movements, loss of respiration, absence of pulse and heart sounds etc are also seen in conditions like prolonged fainting attacks, vagal inhibition, epilepsy, narcosis, electrocution. Hence, such signs cant be considered with cent percent surety. They could however be taken as conclusive only when associated with total loss of EEG rhythm for a continuous period of 5 minutes and a flat ECG for 5 minutes.
Early signs: These signs denote molecular or cellular death, which follow about 12 to 24 hours.
– Algor motris: It is the cooling of the body after death.
– Postmortem lividity: It is the discoloration after death. It starts within 1 to 3 hours and gets fixed in 6 to 8 hours.
– Rigor mortis: It is the stiffness of body after death. It starts 2 to 3 hours after death and takes 12 hours to develop, persists for another 12 hours, and takes 12 hours to pass off completely.
Late signs: These signs represent the decomposition or decay of the dead body, or in certain situations, modification of the dead body into adipocere or mummification. Late signs follow after about 24 hours. The putrefaction of the body is indicated by the appearance of greenish discoloration which appears 12 to 24 hours after death. Marbling is the network like markings on the skin, which comes after 12 hours and becomes prominent in 36 to 48 hours after death. Maggots also starts appearing as a result of putrefaction.
It is the irreversible end of all cerebral activity, but brain stem is still working. When the brain death occurs, the victim can be kept alive by maintaining the working of heart and lungs with the help of sophisticated instruments and some drugs. The body can survive by maintaining the supply of the oxygenated blood to the brain stem. When the brain stem also stops working, it is taken as a significant indication of death.
This condition is also called apparent death. Here the vital functions of the body are at such a low pitch that they cant be detected by routine methods of clinical examination. Suspended animation may persist for a few seconds to several minutes. This condition can be noticed in apparently drowned, newborn, after anesthesia, cerebral concession, electrocution, heatstroke, mesmeric trance, overdose of barbiturates, opium, deep shock etc. Suspended animation can be revived by resuscitation techniques.
DIAGNOSIS OF DEATH
Diagnosis of death is not easy when it is performed immediately after death, specially by a inexperienced person. Rarely, some difficulty can be raised due to suspended animation, excessive doses of sedatives and hypnotics, hypothermia, alcohol intoxication etc. When you are asked to do the death diagnosis, the situation should be handled skillfully. The room where the victim is resting should not be overcrowded. Allow only a few people to be present at the site. There should be proper light, air entry and free from noises and other disturbances.
Inspection: The inspection should be finished in a few seconds without wasting much time. Look at the victim from head to foot and look for any body movements of chest, abdomen, wings of nose etc. Then feel the radial pulse. If it is not felt, go for carotid pulse lateral to the thyroid cartilage (never press both carotids at the same time, feel only one side without much pressing). Then take the stethoscope and auscultate the chest for heart sounds and respiratory sounds. If there is sings of cardiorespiratory failure, give mouth to mouth or mouth to nose respiration along with external cardiac massaging to resuscitate the cardio-respiratory function.
If no response even after the cardiac resuscitation, it is the doctors duty to confirm death of the victim. Once again confirm the cessation of respiration by keeping the stethoscope on chest/larynx for 5 minutes and also cessation of cardiac activity by keeping stethoscope on the precordium for 5 minutes. Feather test can be done to see for any current of air through the nose. Open the eyelids and move the head from side to side. If the eyeball is fixed and moves along with the head, it is a sign of death.
Take a clinical torch and check the eye for pupillary constriction when the light enters the eye. When the body dies, the pupil dilates and the cornea looses its glossy appearance. But this may not be clear immediately after death. And in those who are having eye lesions specially the aged with diabetes, the findings may be confusing. When a person dies, the pallor appear in a few minutes. Look for the capillary filling after blanching the victim’s nails. In a dead body, the capillary refilling is not seen.
In case of doubt ECG and EEG monitoring can be done. A flat ECG for 5 minutes is an accepted evidence of death. Absence of EEG waves for five minutes confirms death. However, EEG and ECG are not required to give a death certificate since death diagnosis is possible by clinical examination in majority of cases. However, these tests are having a confirmatory value.
LEGAL ASPECTS OF DEATH
Legal aspects of death varies among different countries. There are difference in opinion on the definition of brain death. However, as per the modern thinking, a person is presumed to be dead if he cant spontaneously pickup and survive when the artificial means are withdrawn. The irreversible brain damage can be confirmed by a flat EEG.
In case of any signs of unnatural death or when the death is unexpected, the cause of death has to be confirmed by a medico-legal autopsy. Unnatural death may be an accident, suicide, homicide, or even may be a natural death but unexpected and taken place under doubtful circumstances. All cases of unnatural death cases should undergo a medico-legal autopsy to identify the exact cause of death, time of death, position of the body at the time of death etc. Hence it is the duty of a medical practitioner to inform the authorities whenever he comes across any unnatural death.