Certification of death

Death and Thanatology

  • The study of death and dying is called Thanatology.

  • Encompasses various aspects: medical, physical, psychological, spiritual, and ethical.

Legal Definitions

  • According to the Penal Code of Sri Lanka:

    • "Death denotes death of a human being unless contrary appears from the context."

  • Taphonomy: The study of post-mortem changes.

  • General understanding of death: An irreversible cessation of function of the body.

Types of Death

Somatic Death / Clinical Death

  • Complete and irreversible stoppage of three vital functions:

    • Heart: Circulation

    • Lungs: Respiration

    • Brain: Function.

  • Cells may continue to survive for a time after somatic death.

Cellular Death / Molecular Death

  • Refers to the death of individual tissues and cells.

    • Timing of cellular death can vary; different cells may die at different times post-somatic death.

Brain Death

  • Defined as irreversible cessation of cerebral function, often while heart and lungs may be functioning due to artificial means.

Types of Brain Death

  • Cortical Death: Loss of cortical brain function while the heart and lungs continue to function normally.

  • Brain Stem Death: Function of the brain stem is compromised; respiration and heartbeat cannot operate independently.

    • Called physiological decapitation in legal terms.

  • Combined Brain Death (Whole Brain Death): All brain parts are non-functional; heart and respiration maintained artificially.

Criteria for Certifying Brain Death

  • Patient must be in a deep coma not caused by sedative drugs, metabolic or endocrine diseases.

  • Must not be in hypothermia.

  • Connected to artificial means (mechanical ventilator or heart-lung machine).

Diagnostic Tests for Brain Death

  • Absence of Corneal Reflex.

  • Dilated and Fixed Pupils: Not reacting to light.

  • Absence of Vestibular-Cochlear Reflex.

  • Absence of Cranial Nerve Reflexes to painful stimuli.

  • Absence of Cough Reflex.

Process of Medical Certification of Death

Legal Responsibilities in Sri Lanka

  • Medical practitioners must certify death legally.

  • Necessary procedures include:

    • Confirmation of death

    • Issuing a death certificate

    • Conducting inquests and autopsies

    • Handling deceased organ donor transplantation issues

    • Resolving property transactions and reporting missing persons.

Medico-Legal Aspects of Death

Concepts Related to Death

  • Mechanism of Death

  • Mode of Death

  • Cause of Death

  • Manner of Death

Mechanisms of Death

  • Cardiac Arrest: Stopping of heart function.

  • Respiratory Arrest: Cessation of breathing.

  • Cardio-Respiratory Arrest: Combination of both.

Modes of Death

  • Refers to systemic or organ failure initiating death, which may include:

    • Sepsis

    • Hepato-Renal Failure

    • Asphyxia

    • Shock: Circulatory failure

    • Coma: Nervous system failure.

Manner of Death

  • Classification includes both legal definitions and medical assessments:

    • Natural: Resulting from natural diseases

    • Homicide: An individual killed by another

    • Murder: Intentional killing

    • Culpable Homicide: No intention to kill (similar to second-degree murder in other jurisdictions)

    • Accidental: Unintentional death

    • Suicidal: Self-inflicted death

    • Unascertained: Cause or manner of death remains unknown.

Writing the Cause of Death (COD)

WHO Recommended Format for COD (B33 Form)

  • Ia: Immediate Cause

  • Ib: Underlying Cause for Immediate Cause

  • Ic: Antecedent Cause

  • II: Contributing Diseases

  • Should not include modes of death alone (e.g., cardiac arrest, respiratory failure).

Examples of COD

  1. Example 1:

    • Ia: Myocardial Infarction (Immediate Cause)

    • Ib: Coronary Artery Atherosclerosis (Underlying Cause for Immediate Cause)

    • Ic: Antecedent Cause (not specified)

    • II: Hypertension, Diabetic Mellitus (Contributing Diseases)

  2. Example 2:

    • Ia: Sepsis and Multisystem Failure (Immediate Cause)

    • Ib: Peritonitis (Underlying Cause)

    • Ic: Perforated Appendicitis (Antecedent Cause)

    • II: (Contributing diseases not specified).

Legal Authority in Death Certification

  • Medical doctors have the legal authority for death certification.

  • Must fill out B33 form for hospital deaths if no inquest is indicated, then send to the Registrar General for the issuance of a death certificate.

  • B12 form may be utilized in home deaths if the doctor can confirm the cause of death with no indications of inquest.

Confirmation of Death

Clinical Indicators

  • Nervous System: No movements, no response to stimuli, absence of reflexes including pupillary reaction to light.

  • EEG Activity: Flat EEG results are significant.

  • Function of Respiration: Requires inspection, palpation, and auscultation for signs of respiration for at least 5 minutes.

  • Circulatory Function:

    • Heart Sounds: No heart sounds should be detected.

    • Pulse and Blood Pressure: Nonexistent.

    • Verification can include an ECG.

Criteria for B12 Form for Community Deaths

  • The doctor must inspect the dead body personally.

  • Confirmation of satisfactory death must occur.

  • Must ascertain the cause of death with no indication for inquest.

  • Should have seen or treated the deceased within the last 14 days.

Sudden Deaths

  • Defined as deaths occurring unexpectedly, when a person was not known to have a severe disease, injury, or poisoning.

  • Death may also occur within 24 hours after onset of symptoms, but not within 24 hours of hospital admission.

Deaths Occurring in Hospital

Procedures for Certifying Death

  • Should be conducted promptly, including filling of the B33 form.

  • The body can only be released to relatives after death certification, provided circumstances are natural with no need for an inquest.

  • If an inquest is required, the police must be informed, and procedures must include reporting to the ISD/JMO.

Reportable Deaths for Police Inquiry

Conditions Requiring Inquest

  • Unknown cause of death (COD).

  • Confirmed COD needing inquest:

    • Homicides

    • Deaths due to violence

    • Suicides, accidents (including RTAs, burns, falls) and all unnatural deaths.

Additional Reportable Situations for Police Query

  • Death in suspicious circumstances or due to negligence, starvation, drug abuse, industrial diseases, and maternal deaths.

Inquest Overview

Definition

  • A judicial inquiry into unnatural deaths, or natural deaths that are unexplained or unexpected.

  • Established under Part VIII of the Code of Criminal Procedure Act No. 15 of 1979.

Inquirer Role

  • Inquirer or Magistrate holds the inquest and is appointed by the Minister (often politically), and they undergo training through the Ministry of Justice.

  • In urban areas, they are referred to as City Coroner.

  • Responsibilities include preparing a report and submitting it to the nearest magistrate.

Public Nature of Inquest

  • An inquest must be held in a publicly accessible place with provisions for public exclusion if needed.

  • It is not a criminal trial but rather a means to determine facts surrounding a death and may provide recommendations for preventing similar incidents.

Duties and Powers of an Inquirer

Responsibilities

  • Investigate suicide cases, animal-related deaths, machinery accidents, sudden unexplained deaths.

  • Ensure immediate action upon receiving death reports.

Powers of Inquirer (ISD)

  • Issuing summons to witnesses and documents.

  • Warrant issuance via police for witnesses failing to attend.

  • Order autopsies through district medical officers.

Steps Following Police Report of Sudden Death

  • Proceed to the location of the body promptly.

  • Record statements from witnesses and relatives.

  • Request JMO for autopsy and submission of relevant reports regarding cause and manner of death.

Specific Inquest Requirements

Authority of Magistrate

  • Magistrates only have the authority for an inquest in cases of:

    • Homicides

    • Deaths in custody or special medical facilities

    • Accidents involving reckless acts.

Autopsy Procedures

Steps to Arrange an Autopsy

  • Proper transportation of bodies to the mortuary.

  • Clinician's representation and duties during autopsy process.

Types of Autopsies

  • Judicial Post Mortem: Conducted by a Judicial Medical Officer with required police presence.

  • Pathological Post Mortem: Conducted under strict protocols and with consent from next of kin.

Compulsory Autopsy Situations

  • Issued by Ministry of Justice:

    • Unknown cause of death

    • Maternal deaths

    • Homicides

    • Deaths from firearm injuries

    • Road traffic deaths.

Conclusion of Inquest

  • The final inquest report establishes the cause and manner of death (natural, accident, suicide, homicide, unascertained).

  • Filings of B18 form by ISD/Magistrate are key for issuing a death certificate through the Registrar General Department.

Procedures When Death Occurs at Home

Confirmation Requirements

  • A doctor must confirm the death and determine the cause using the B12 form or a letter.

  • If a B12 form is issued, the family can directly approach the registrar.

  • For non-coded deaths, an inquest may arise from police notification, where the coroner will specify the apparent cause of death, as autopsies may be needed.

Acknowledgment

  • Thank you for attending to this comprehensive study on death, types of deaths, and death certification processes.