Dealing with patient death: Step by step process explained by Dr. Dilip Walke

M3 India Newsdesk Feb 03, 2019

In the Sunday Series today we bring another popular article from our archives where Dr. Dilip Walke,  Past Chairman, Ethics and Medicolegal Committeee FOGSI,discusses the medical procedures involved in certifying and handling a patient's death.



In view of the rising incidents of the intolerant behaviour of patients and their relatives towards healthcare professionals, it has become extremely important that all medical professionals in general and the resident doctors, in particular, understand their statutory and regulatory responsibilities while handling a dead patient.

The basic challenge is that as yet death has not been legally defined in our country. The only legally-worded definition of brain stem death in India is available in Transplantation of Human Organs Act 1994 because the concept of brain stem death is evolving all over the world to facilitate cadaveric organ donation for needy recipients.

Historically, a patient is considered to be dead when there is a complete and irreversible cessation of cardiac and respiratory symptoms.


Duties of a resident doctor facing a dead patient

  • Diagnose death
  • Declare death
  • Fill “Death report” as per prescribed format and send it to appropriate authority
  • Certify cause of death
  • Inform the appropriate authorities because the Maharashtra State Government Act, 1976 (Section 5(2) mentions that death must be informed within 72 hours to the local municipal authorities
  • Handle the mob

Resident doctor may have to handle the patient’s death in casualty, ward, or ICU

During other times, reasons for patients being brought dead to the casualty could be:

  • Death from natural causes/calamities: Earthquakes, floods, cyclones, accidents, animal attacks, war, bomb blasts, terrorist attacks with mass injury, homicides, suicides, or drug abuse
  • Patients under the care of a unit/consultant attached to the hospital: Has/has not attended to the patient within 14 days prior to death
  • Patient was under the care of some other consultant/hospital: Has/has not attended to the patient within 14 days prior to death
  • Patient was under no treatment but died due to old age
  • Patient was under no treatment and died young
  • Female patient brought dead within 7 years of marriage

Ward or ICU patient deaths may belong to the following categories:

  1. Cause of death is known: In such a case, it is easy to give a death certificate. One may ask for medical PM if the cause of death is difficult to infer with the consent of the relatives for clinical purpose.
  2. If death has occurred under suspicious circumstances and cause of death is not known, police should be informed and medico-legal postmortem (ML PM) should be done if police insist.
  3. It has been stressed by several medicolegal experts that in every medicolegal death (e.g. death on table) the treating doctors have to insist on a medicolegal post-mortem.

However, one has to understand:

  1. No law in our country prevents a doctor from giving a DC if he/she knows the cause of death (e.g. if a patient dies due to PPH, the cause of death is a multiorgan failure due to severe hypotension due to atonic PPH)
  2. In suspicious cases (e.g. a table death) the prime duty of the treating doctor is to inform the police
  3. The onus of convincing the relatives for medicolegal PM (if foul play is suspected by the investigating officer) is with the police.
  4. Despite the legal right of the doctors to give DC if the cause of death is known, it is prudent for the treating doctors to encourage and facilitate medicolegal PM especially in table death because the court gives more weightage to the cause of death mentioned by the post-mortem surgeon. This is because in such a court case the treating doctor is likely to be an accused party
  5. If in such a situation the treating doctor opted for giving a DC, he/she has to hand over DC to the police and not the relatives.


 

How should the RMO handle the situation step by step?

  1. First step is to establish death. The following helps to routinely recognise and establish death:
  • No spontaneous movements
  • No respiratory effort for more than a minute
  • No heart sounds or palpable pulses for more than a minute
  • Absence of reflexes e.g., corneal
  • Fixed and dilated pupils
  • No response to painful stimuli
  • Rigor mortis seen 3 hours after death

Approved tests for brain stem deaths (Human Organ Transplant Act) 

  • Pupillary light reflex: Dilated and fixed not reacting to light (cranial nerve II and III; nuclei in midbrain)
  • VOR reflex absent (Vestibulo-ocular Caloric test): Eye movement with 50 ml of cold water in ear for 1 minute is absent (cranial nerve III, VI and VIII; nuclei in midbrain/pons)
  • Occulo-cephalic reflex: Dolls eye movement absent (cranial nerve III, VI and VIII; nuclei in midbrain/pons)
  • Corneal reflex absent (cranial nerve V and VII; nuclei in pons)
  • Pharyngeal gag reflex absent (cranial nerve IX and X; nuclei in medulla)
  • Cough (tracheal reflex) absent (cranial nerve X; nuclei in medulla)
  • Vagal nerve function (atropine challenge negative; cranial nerve X; nuclei in Medulla)
  • Response to painful stimulus in trigeminal nerve distribution (cranial nerve V and VII; nuclei in pons)
  • Apnoea test: Raise pCO2 >50 to 60 mmHg by disconnecting ventilator– no spontaneous respiration
  • Tests for cortical functions: EEG/verbal response/co-ordinated and spontaneous eye movement

Declaration of brain stem death as per THO act

Who should diagnose and declare?

Team of four medical experts including: 

  • Medical Administrator In charge of the hospital
  • Authorised Neurologist/Neuro-Surgeon
  • Medical Officer treating the patient

Amendments in the THO Act (2011) have allowed selection of a surgeon/physician and an anaesthetist/intensivist, in the event of the non-availability of approved neurosurgeon/neurologist.

What would the team confirm?

  • Is the patient deeply comatose due to irreversible brain damage of known aetiology?
  • Is he/she on ventilator despite stopping all neuromuscular blocking agents
  • Are all brain-stem reflexes absent?

All the prescribed tests are required to be repeated, after a minimum interval of 6 hours, “to ensure that there has been no observer error” and to document the persistence of the clinical state.

The following investigations are not legally mandatory but may be done if clinician desires:

  • Cerebral angiography particularly a four-vessel angiogram: A gold standard to demonstrate absent cerebral circulation remains
  • CT angiography
  • CT perfusion and magnetic resonance angiography
  • EEG
  • Please note: It is also affected by hypothermia, drugs and metabolic diseases.
  • Transcranial Doppler
  • Radionuclide imaging techniques like Technetium-99 m scan

  1. Second step is to give 'Death report'
  • After declaration of death to the relatives, a death report is prepared in a format prescribed by various municipal corporations; the format has two components- legal and statistical
  • It is the doctor's duty to fill the death report even if we have decided not to give a DC

  1. Third step is to give DC if we know the cause of death

Doctors can safely give DC in the following situations:

  1. If the cause of death is known and it’s a natural death e.g death following a disease or malfunction of the body: DC can be given by the physician who has attended the patient within 14 days prior to death (no such '14 days' rule/case law exists in India, but it is prudent to follow it as it has become a norm).
  2. In case of unnatural death and in a medicolegal case if the cause of death is known: DC should be handed over to the police along with the dead body for final ‘Panchanama”. The investigating officer may choose to accept the DC and hand over a copy to relatives for final cremation. But, the investigating officers may also be suspicious and may still want a medicolegal post-mortem.
  3. In case death has occurred because of old age the cause is 'senility': If the patient was never attended by the physician in past 14 days the local corporate can certify the death due to senility. Several general practitioners have to succumb to social pressures to give DC in such situations.


In another article in the series Dr. Walke throws light on the prescribed format for Death Certificate, gives pointers while filling a death certificate, guiding relatives and following protocols for unnatural deaths. He also busts some common myths about patient deaths. Stay tuned!

 

This article was originally published on 15.11.18

 

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

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