1. Certification of death
Dr Priyal Jain
PG Forensic Medicine

2. Definition
Total stoppage of circulation of the blood &
consequent thereupon cessation of the
animal and vital functions.
 Somatic death : complete loss of sensivity
and the ability to move and there is
complete cessation of the functions of the
heart, the brain and the lungs.
 Molecular death : death of the tissue and
the cells individually.


3. Legal definition
Death. means the permanent
disappearance of all evidence of life at
any time after live-birth has taken
place.
(The Registration of Births and Deaths
Act, 1969 )


4. Legal definition
“Deceased person” means a person in whom
permanent disappearance of all evidence of
life occurs, by reason of brain-stem death or
in a cardio-pulmonary sense, at any time
after live birth has taken place.
 Brain-stem death” means the stage at which
all functions of the brain stem have
permanently and irreversibly ceased.
(the transplantation of human organs act,
1994)


5. Gordon`s classification of deaths
Medico-legal deaths : - the cessation of the
vital functions depends upon tissue anoxia
which is brought about in the following four
different ways
1. Defective oxygenation of the blood in the
lung. (anoxic anoxia)
2. Reduced O2 carrying capacity of blood.
3. Depression of oxidative process in tissue.
4. Inefficient circulation through the tissue.


6. Gordon`s classification of deaths
Post mortem findings should be divided in
two groups
1. The basic pathological change of
circulatory failure.
2. The special pathological changes
depending upon the particular type of
death.


7. Circulation stoppage tests
1.
2.
3.
4.
5.
6.
7.
Magnus test
Diaphanous test
Icard test
Application & withdrawal of pressure
Application of heat
Cutting a small artery
ECG tracing

8. Respiration stoppage test

Mirror in front of open mouth and nostrils.

Feather or cotton fibers in front of open
mouth and nostrils.

9. Death certificate
Part I :- records (a) immediate cause and
(b) the morbid condition, if any, giving rise
to the immediate cause
 Part II :- records any other significant
condition ( if important ) contributing to
death but not related to the immediate
cause of death.


12. Duty of the doctor






Who attended the person in last 7 days.
Fill the prescribe format form 4.
No refusal / no delay.
No fee.
Forward to the registering authority.
Symptomatology or modes of death should
not be recorded as cause of death without
mentioning the underlying pathological
cause.

13. Duty of the doctor

In any of the domiciliary deaths not
attended by a medical person before death,
a statement from the relatives of the
deceased should be obtained in writing to
that effect, clearly mentioning the morbidity
condition with sign and symptoms prevailed
preceding death, with duration of such
illness so that the most possible cause of
death could be entered.

14. When not to issue
The injured is brought dead
2. A crime has already been registering by
the police.
3. The police has already been informed
about the case.
4. The cause of death is unknown.
1.

15. Special circumstances
For organ donation cases.
 For withholding life support in terminally ill
person in ICU settings.


16. Test to certify brain-stem death
1.
2.
3.
4.
5.
6.
Pupillary reflex
Extra-ocular movements
Corneal reflex
Gag reflex
Cough reflex
EEG

17. Who will certify
Board of medical experts consist of four
doctors.
 Examine the person on two occasion.


18. Withholding life support(legality)
1. Does the right to refuse treatment extend to
refusal of life supporting systems?
2. Does it extend to the extent that the individual
can insist on the removal of life supporting
systems?
3. Does the exercise of these rights, at any point
cease to be the exercise to lawful (if not
fundamental) rights and enter the forbidden
zone of suicide?

19. Withholding life support(legality)
4. If an individual, to begin with, has these rights,
then, does he lose them when he becomes
incompetent for decision-making as in a state
of unconsciousness?
5. In cases of unconscious patients or patients
who cannot interact or communicate their
decisions who is entitled to exercise these
rights for and on behalf of these patients?

20. Withholding life support(legality)

Indian Law has no clearly stated position on
any of these issues. The opinion of
professional bodies must therefore precede
the evolution of legal provisions in matters
concerning life-supporting interventions, as
no relevant case laws exist in the country.

21. Supreme court of india

In the casse of L.B.Joshi v/s T.B.Ghodbole
SCI held that “ the law requires the
practitioner must bring to his task a
reasonable degree of skill and knowledge
and he must exercise a reasonable degree
of care, neither the very highest nor the
very low degree of care and his
competence is judged in the light of the
particular circumstances of each case.

22. 
The test of the reasonableness of the
decision of the doctor would essentially
depend upon the norms set out and
announced by the professional bodies.

23. Guidelines for limiting life-prolonging
interventions and providing palliative
care (ISCCM)
1. The physician has a moral obligation to inform the
capable patient/family, with honesty and clarity, the poor
prognostic status of the patient when further aggressive
support appears non-beneficial. The physician is
expected to initiate discussions on the treatment options
available including the option of no specific treatment.
2. When the fully informed capable patient/family desires
to consider comfort care, the physician should explicitly
communicate the available modalities of limiting life
prolonging interventions

24. Guidelines for limiting life-prolonging
interventions and providing palliative
care (ISCCM)
3. The physician must discuss the implications of forgoing
aggressive interventions through formal counseling
sessions with the capable patient/family, and work
towards a shared decision-making process. Thus, he
accepts patient’s autonomy in making an informed
choice of therapy, while he fulfills his obligation of
providing beneficent care.
4. Pending consensus decisions or in the event of conflicts
between the physician’s approach and the family’s
wishes, all existingsupportive interventions should
continue. The physician however, is not morally obliged
to institute new therapies against his better clinical
judgment.

25. Guidelines for limiting life-prolonging
interventions and providing palliative
care (ISCCM)
5. The proceedings of the counseling sessions, the
decision-making process, and the final decision should
be clearly documented in the case records, to ensure
transparency and to avoid future misunderstandings.
6. The overall responsibility for the decision rests with the
attending physician /intensivist of the patient, who must
ensure that all members of the caregiver team including
the medical and nursing staff represent the same
approach to the care of the patient.

26. Guidelines for limiting life-prolonging
interventions and providing palliative
care (ISCCM)
7. If the capable patient/family consistently desires that life
support be withdrawn, in situations in which the
physician considers aggressive treatment nonbeneficial, the treating team is ethically bound to
consider withdrawal within the limits of existing laws.
8. In the event of withdrawal or withholding of support, it is
the physician’s obligation to provide compassionate and
effective palliative care to the patient as well as attend
to the emotional needs of the family.