Death: Determination, Definition and Brain Death

Importance of Death Determination

• Death extinguishes the civil personality of a natural person
• Upon death, property is transferred to the deceased's heirs
• Death dissolves partnership agreements
• Death terminates agency agreements whether for the principal or the agent
• Death extinguishes criminal liability
• Civil cases not surviving death are dismissed if the defendant dies

Definition of Death

• Death signifies life termination
• Characterized by a complete stop of vital functions without resuscitation possibility
• Represents the irreversible loss of living matter properties
• It is an event occurring at a precise time
• Determining death is clinical in nature, not legal

Brain Death

• Brain death is characterised by deep coma
• Absence of electrical brain activity accompanies brain death
• Vital functions cease entirely without any chance of revival

Characteristics of Irreversible Coma

• According to a 1968 Harvard Report, irreversible coma is defined by specific characteristics
• Unreceptivity and Unresponsitivity: The individual doesn't respond to external stimuli or inner needs
• There are no spontaneous movements or breathing
• Reflexes are absent
• An electro-encephalogram shows a flat, or inactive, tracing
• Repeating these tests at least 24 hours will show there is no change

Philadelphia Protocol

• In 1969, the Ad Hoc Committee of Human Transplantation adopted the Philadelphia Protocol for determining death
• Key criteria include lack of responsiveness to both internal and external environment
• No spontaneous breathing movements for 3 minutes, absent of hypocarbia, and while breathing room air
• No muscular movements are present, accompanied by generalized flaccidity
• There is no postural activity or shivering
• Reflexes and responses are absent
• Arterial pressure fails without any drug support
• Iso-electric electro-encephalogram is recorded spontaneously and during auditory/tactile stimulation
• All criteria must be present for 2 hours minimum and certified by 2 physicians

Kinds of Death

• Somatic death is also known as Clinical death
• Molecular death is also known as Cellular death
• Apparent death is also known as the State of Suspended Animation

Signs of Death - Cessation of Heart Action and Circulation

• Heart action and circulation cease upon death
• Methods to detect cessation use the following techniques
• Examination of the heart
• Palpating the pulse
• Listening for heart sounds in the precordial area using Auscultation
• Using fluoroscopic examination
• Using electrocardiograph

Signs of Death - Examination of Peripheral Circulation

• Various tests can be performed during the examination of the peripheral circulation:
• Magnus test
• Opening of small artery
• Icard's test
• Pressure on the fingernails
• Diaphanous test
• Application of heat on the skin
• Palpation of the radial pulse with fingers
• Dropping of melted wax

Signs of Death - Cessation of Respiration

• Cessation of respiration can be persistent and continuous
• Suspension of respiration can occur without death for the following reasons
• Diving, swimming, etc., for no longer than 2 minutes
• Cheynes-Stokes respiration, where the apneic interval is under 15-20 seconds
• Cases of apparent drowning
• Newly-born infants might not breathe immediately after birth

Internal Hypostasis in Visceral Organs

• Post-mortem lividity causes irregular staining in organs, specifically in dependent parts
• Simple congestion results in uniform staining throughout the body
• Post-mortem lividity presents a dull, lusterless mucus membrane
• Simple congestion does not affect the mucus membrane
• In post-mortem lividity, inflammatory exudates are not seen; areas of redness alternate with pale areas in a hollow viscus
• There are no inflammatory exudates during simple congestion

Post-Mortem Lividity vs. Hemorrhage of Scurvy vs. Phosphorus Poisoning

• Skin lesions appear after death in post-mortem lividity
• Skin lesions are present before death in Hemorrhage of Scurvy and Phosphorus Poisoning
• The history of presence needs to be revealed
• Post-mortem lividity is present in the most dependent body portions
• Hemorrhage of Scurvy and Phosphorus Poisoning may occur all over the skin and organs

Autolytic/Autodigestive Changes After Death

• Proteolytic, glycolytic, and lipolytic ferments in glandular tissues continue acting after death, causing autodecomposition of organs
• Weak acids and higher temperatures facilitate this process
• Alkaline reactions and low temperatures delay it
• These changes appear early in parenchymatous and glandular tissues

Putrefaction of the Body

• Putrefaction represents the breakdown of complex proteins into simpler components
• It is associated with foul-smelling gas evolution and a color change in the body

Tissue Changes in Putrefaction

• Colour changes in the tissue
• Evolution of gases in the tissue occurs
• Effects of gas pressure involves blood displacement
• Bloating
• Fluid expulsion
• Possible fetal extrusion
• Floating of the body
• Liquefaction of soft tissue

Factors Modifying Putrefaction Rate

• Internal factors that modify the putrefaction rate are:
  • Age
  • Body condition
  • Cause of death
• External factors that modify the putrefaction rate:
  • Free air
  • Earth
  • Water
  • Clothing

Factors Influencing Changes in the Body After Burial

• State of the body before death
• Time between death and burial
• Environment
• Effect of coffin
• Clothing/coverings on the body when buried
• Depth of burial
• Soil type/condition
• Presence of items that hasten decomposition
• Air access post-burial
• Mass grave
• Trauma on the body

Chronological Sequence of Putrefactive Changes in Temperate Regions:

• Greenish discoloration over the iliac fossae occurs between 1-3 days
• Eyeballs become soft and yielding
• Greenish discoloration spreads over the whole abdomen in 3-5 days
• Greenish discoloration spreads over the external genitals and other body parts at this stage
• Frothy blood forms from the mouth and nostrils
• Abdomen distention with gas begins in 8-10 days
• Cornea falls in and becomes concave
• Purplish-red streaks of veins become prominent on the extremities
• Sphincters become relaxed
• Nails remain firm
• Body turns a greenish-brown color after 14-20 days
• Blisters form all over the body
• The skin peels off
• Features become unrecognizable
• Scrotum distends
• Body swells from distention
• Maggots are found on the body
• Nails and hair loosen and easily detach
• Soft parts turn into a thick, semi-fluid black mass after 2-5 months

Chronological Sequence of Putrefactive Changes in Tropical Regions:

• Rigor mortis is present all over after 12 hours
• Hypostasis develops well and is fixed
• Greenish discoloration appears over the casturn
• Rigor mortis is absent all over after 24 hours
• Green discoloration affects the whole abdomen, spreading to the chest
• Abdomen distends with gases
• Ova of flies start to be seen after 48 hours
• Trunk begins bloating
• Face becomes discolored
• Blisters are present at this stage
• Moving maggots are seen
• After 72 hours, the whole body is grossly swollen and disfigured
• Hair and nails are loose
• Tissues are soft and discolored
• Soft viscera putrefy after 1 week
• Only more resistant viscera are distinguishable after 2 weeks
• Soft tissue is largely gone by this time
• The body skeletonizes after 1 month

Chronological Sequence of Putrefactive Changes When a Body is Submerged in Water:

• If the water is cold, there is very little change within 4-5 days
• Rigor mortis may persist during this period
• The skin on the hands and feet becomes sodden and bleached after 5-7 days
• The face appears softened and develops a faded white color
• After 1-2 weeks, the face swells and turns red
• Greenish discoloration appears on the eyelids, lips, neck, and sternum
• The skin of the hands and feet wrinkles
• The upper surface of the brain turns greenish
• Skin wrinkles in the body after 4 weeks
• Scrotum and penis distend with gas
• Nails and hair still intact.
• Lungs become emphysematous and cover the heart
• The abdomen distends after 6-8 weeks
• The skin of the hands and feet comes off with nails like a glove

Factors Influencing the Floating of a Body in Water

• Age
• Sex
• Body conditions
• Season
• Water
• External influence
• Putrefaction Order

Influence of Bacteria in Decomposition

• Decomposition occurs due to bacterial action in body tissues
• Aerobic activities dominate early stages of decomposition
• Anaerobic activities are more prominent later on, producing gases
• Softening of tissues is caused by bacterial action and autolytic ferments

Bacteria - Clostridium Welchii

• Clostridium welchii micro-organisms plays an important role in decomposition
• The micro-organism grows in parenchymatous organs and disintegrates cytoplasm
• The micro-organism is responsible for the destruction of nucli and gas generation
• Decomposition involves other destructive agents like flies
• Maggots, reptiles, rodents, other mammals, fishes
• Crabs and molds

Special Modications of Putrefaction

• Mummification
• Saponification
• Adipocere Formation
• Maceration

Mummification

• Dehydration, or mummification of the whole body
• Mummification results in shivering and preservation of the body
• It commonly occurs in warm environments
• The body fluid’s rates of evaporation is faster
• Mummification can be either natural or artificial:
• Natural mummification happens due to natural forces
• Artificial mummification happens due to accelerated evaporation before decomposition begins

Saponification/Adipocere Formation

• Saponification / Adipocere formation represents a condition where body fatty tissues turn into a soft
• A brownish-white substance known as adipocere
• Factors that influence adipocere formation:
• Health before death
• Time between death and burial
• Effect of the coffin
• Presence of clothing
• Type of soil
• Air access after burial
• If it's a Mass grave

Maceration

• Maceration describes tissue softening
• It occurs in a fluid medium without putrefactive microorganisms
• It is common during fetal death in utero

Duration of Death - Rigor Mortis

• Rigor mortis sets in 2-3 hours after death in warm climates
• It is fully developed 12 hours post mortem
• Rigor mortis lasts 18-36 hours
• Rigor mortis ends when putrefaction begins

Duration of Death - Post-Mortem Lividity

• Post-mortem lividity usually forms 3-6 hours after death
• It appears as small petechial-like red spots
• Later, the petechial-like red spots merge and get bigger around the most dependent body portions

Duration of Death - Decomposition

• Decomposition begins early in tropical areas
• Decomposition occurs on average 24-48 hours post-mortem
• Decomposition is inferred from the degree of decomposition

Duration of Death - Entomology of the Cadaver

• Flies can determine death
• The time of death can be approximated based on presence of flies on a cadaver

Duration of Death - Digestion

• The Stomach needs 3-4 hours normally to evacuate its contents after a meal
• Determining the stomach contents amount helps determine time of death

Duration of Death - Bladder

• The Urine amount helps determine time of death
• The recent time voiding his urine is taken into consideration

Duration of Death - Clothing

• The deceased’s apparel is circumstantial proof of time of death

Duration of Death - Blood

• Blood clots inside blood vessels around 6-8 hours post-mortem

Duration of Death - Tissues

• Soft tissues may disappear 1-2 years post-burial in ordinary circumstances

Duration of Death - Bones

• Degree of bone erosion
• Degree of epiphyseal ends of long bones
• Degree of flat bones pulverization
• Degree of weight diminution, the loss of animal matter, help approximate time of death

Duration of Death - Flies

• Clothes provide indicators for drowning cases
• Fleas can survive 24 hrs submerged in water
• Fleas presence indicate whether the person was drowned

Presumption of Death - Rule 131 Section 5 Rules of Court

• Article 390 Civil Code determines:
• Disputable presumption, of not being heard for 7 years = Dead
• Dead for all purposes, except SUCCESSION
• Absentee shall not be presumed dead to open his succession absent for 10years
• Succession opens after 5 years, for those over 75 years old when disappeared

Presumption of Death - Article 391 Civil Code

• The following are presumed dead for all purposes
• Lost vessel on sea voyage, missing airplane, if not heard of for 4 years since loss
• Armed forces member, Missing for 4 years since war
• Person in danger of death, If their existence is unknown for 4 years

Presumption of Survivorship

• Rule 131 Section 5 (jj) Rules of Court determines presumption of survivorship