Italian Law 219/2017 on Informed Consent PDF

INFORMED CONSENT – LEGGE 219/2017 It is a communication between the patient and the health care professional (HCP) that results in patient authorization to undergo specific treatment (TX) or diagnostic procedures. All the activity performed on the patient  voluntary acceptance after fully underst...

INFORMED CONSENT – LEGGE 219/2017 It is a communication between the patient and the health care professional (HCP) that results in patient authorization to undergo specific treatment (TX) or diagnostic procedures. All the activity performed on the patient  voluntary acceptance after fully understanding and decision-making capacity without coarctation. ART 32- SELF DETERMINATION OF THE PATIENT LAW 219/2017  NO HEALTH TX CAN BE STARTED OR CONTINUED WITHOUT FREE AND INFORMED CONSENT OF THE PATIENT - ART 1  informed consent - ART 2  rules against TX obstinacy - ART 3  informed consent in minors - ART 4-8  Advanced TX provisions and shared care planning ADULTS > 18 YO Family members also take in part in the relationship only if the patient wants  another family member may be involved but the last decision is of the patient. BEING A FAMILY MEMBER DOES NOT MEAN YOU HAVE POWER ON THE PATIENT. Every patient has the right to know their health condition and to be informed in a complete, up-to-date and comprehensive manner regarding diagnosis, prognosis, TX, risk …. Also must be informed about alternatives and, eventually, consequences of any refusal of diagnostic tests or TX. EVERY PERSON CAPABLE OF ACTING (suitability of the subject to carry out valid legal acts > 18 yo) HAS THE RIGHT TO REFUSE TOTALLY OR PARTIALLY ANY DIAGNOSTIC OR TX. It is impossible to overcome the denial of consent in adults. Artificial nutrition and artificial hydration are also considered health TX because they are administered under doctor's prescription. The doctor must respect the will of the patient when refuses or renounces treatment and, as a result, the doctor is exempt from civil/criminal liability. In emergency or urgent situations  health team must ensure the necessary cure, respecting patient's wishes when his/her conditions and circumstances allow this to be accepted Informed consent may also be provided in the form of videorecording or any advice that helps in communication. ADVANCED DIRECTIVES ON TX (DAT) – ESPRESSIONE CONSAPEVOLE DI UN’ATTIVITA’ FUTURA Every adult capable of understanding and willing, in anticipation of a possible future inability to self- determine, can express wishes regarding TX and diagnostic tests. The DAT may be revoked, modified or renamed in every moment. In case of emergency may be revoked also by videorecording. He can indicate a person (TRUSTEE) who takes his place and represents him in relationship with doctors. Also the trustee must be an adult fully capable of understanding and willing  may be revoked at any time. The patient may also not indicate a trustee at all. The doctor is required to comply with DAT  DAT can be disagreed totally or in part by the trustee if indications appear clearly incongruous or do not correspond to the actual clinical conditions. DAT must be drawn in a public deed or private deed and deposited personally at civil registry officer of municipal residence  it will be inserted in the “BANCA DATI NAZIONALE DELLE DAT” SHARED CARE PLANNING (PCC) Concerning the evolution of the consequences of a chronic and disabling pathology or one characterized by unstoppable evolution with inauspicious prognosis  PCC created between patient and doctor (QUANDO LA PROGNOSI E’ INFAUSTA). It is a verbal form kept in medical recordings. HCP must adhere to PCC. The patient and family members are informed about the evolution of pathology and realistic QoL. Also in this case a trustee may be named. TX plan can be updated as the disease progresses, as the patient requests, and as the doctor suggests. MINORS AND DISABLED Minor and incapacitated patient have the right to the valorization of their own capacity of understanding their decisions. MINORS DISABLED Informed consent is expressed or refused by those The consent is expressed by the person itself. There who have parental responsibility or by the may be a support administrator that helps in the guardian, taking into account the will of the minor. expression of informed consent or refusal. The The purpose is to protect the psychophysical supporter may express consent or refusal alone health and life of the minor with full respect for according to disable patient conditions. his/her dignity In both cases  if the legal representative refuses the purposed TX and the doctor considers them to be appropriate and necessary (without any alternative), the decision is referred to a GUARDIANSHIP JUDGE. In conditions of emergency and urgency, even in the absence of parental consent, the doctor, being in the position of guarantee, performs the TX by adequate documentation in medical records. This is because they have the obligation of action for the management of damage or danger for the patients. PAIN TX, PROHIBITION OF UNREASONABLE OBSTINANCY IN TX, AND DIGNITY IN THE PHINAL PHASE OF LIFE The doctors should alleviate the suffering of the patient he/she must refrain from any unreasonable obstinacy in administering care or misappropriated TX. ART 579 PENAL CODE – KILLING OF THE CONSENT ART 580 PENAL CODE – INSTIGATION OR PERSON ASSISTANCE TO SUICIDE Whoever causes the death of a person, even with Whoever induces others to commit suicide or his/her consent, shall be punished by reinforces this intention of others by facilitating imprisonment of 6-15 yrs. the execution and the suicide takes place, shall be punished by imprisonment of 5-12 yrs. Voluntary homicide is applied if: - < 18 yo - If suicide not takes  1-5 yrs - Insane, mental health deficiency, - If < 14 yo  apply law as homicide drugs/alcohol abuse - Forced by violence 25/09/2019 the Constitutional Court found that art 580 was constitutionally illegal  rule n°242 = there are some exceptions for art 580 (QUESTA REGOLA NON SI PUO’ APPLICARE SE IL PAZIENTE NON E’ CAPACE DI INTENDERE E VOLERE). The rule states that IT IS NOT PUNISHABLE WHO FACILITATES SUICIDE IF THIS INTENTION IS FREELY DETERMINED BY THE PATIENT: - IS KEPT ALIVE BY SUSTAINING TX  crucial for the procedure of assisted suicide (mechanical and non-mechanical procedures) - HAS IRREVERSIBLE PATHOLOGY, SOURCE OF PHYSICAL/PSYCHOLOGICAL SUFFERING PROFESSIONAL SECRECY To start a judgment there must be a complaint (querela) PRIVATE PUBLIC ART 359 ART 358 – person in charge of a public service or Persons performing public necessity are: public official - Private individuals who exercise legal or health professions A public service must be understood as an activity - Private individuals who perform a service regulated as a public function, with the lack of declared to be of public necessity powers typical of the latter ART 622 ART 326 Whoever, being informed because of his office, of a Whoever facilitates in anyway the knowledge of secrete, discloses (divulga) it without good reason or official information is punished with imprisonment uses it for his profit is punished for 6 ms to 3 years QUERELA DELLA PERSONA OFFESA If NEGLIGENT (COLPOSA)  1 yr Complaints concern private more than public If financial gain  2-5 yrs interests Ex-officio judgment  criminal action initiated automatically by authorities regarding the willingness of the victim (public interest because it affect values of society) ART 622 ART 326 TRANSMISSION OF SECRECY Making other persons or entities involved in the same case. Those persons are bound to secrecy because of their profession  aware of the secret. Essential conditions are: - Health/administrative reasons need information transferred  - The knowledge remains confined to health services - Transmission takes place with persons all qualified to know the secret and obliged to keep it ART 200 The following persons may not be required to testify what they have learned by reasons of ministry/office/profession, except in cases where they must report to judicial authority: - Religious confessions - Lwayers and legal agents - HCP NON POSSIAMO ESSERE OBBLIGATI A DEPORRE DAVANTI UN GIUDICE REPORT TO JUDICIAL AUTHORITIES ART 365 FAILURE TO REPORT Anyone who, as HCP, has provided assistance or operates in cases that may present the characteristics of crimes (NON-PENALI) for which proceedings must be taken ex offcio, if fails or delayed reporting  punished with a fine up to 516 euro. Per quanto riguarda la valutazione che il sanitario deve compiere ai fini della qualificazione del reato come procedibile d'ufficio, è richiesta la concreta possibilità, tenuto conto di tutte le modalità e di tutte le circostanze del caso, che il fatto presenti i caratteri di un delitto perseguibile d'ufficio, non richiedendosi un più ristretto giudizio di probabilità. This article is not applied if it would expose the assisted person to CRIMINAL PROCEDURES (PENALE). Se c’è morte  DENUNCI Se assistito è una VITTIMA  Se assistito è VITTIMA ma anche Se assistito è un CRIMINALE  DENUNCIO COINVOLTO  NON DENUNCIO NON POSSO DENUNCIARLO HOW TO REPORT?  must indicate: - Person - Contact details - Place where he is - Circumstances of intervention - Means by which was caused and effects (local objective exam of injuries and VP, prognosis) - If > 1 person, only 1 report is enough Most common offenses: - Homicide or its attempts - Infanticide - Deaths and injuries as consequences of another crime - Assistance or incitement to suicide PERSONAL INJURY (VOLUNTARY) - LIEVISSIME < 20 days prognosis - LIEVI – prognosis between 20-40 days - GRAVI > 40 days of prognosis and/or permanent weakening of a sense or organ - GRAVISSIME o Loss of sense o Loss of limb o Loss of organ o Loss of the ability to procreate o Permanent difficulty in speaking o Deformation of the face Judgment report only if there are aggravating circumstances such as poisoning, gunshots, or explosives. ART 572 – MISTREATMENT OF FAMILY MEMBER OR COHABITANTS Whoever mistreats some of the above  imprisonment 3-7 yrs ART 591 – ABANDONMENT OF MINORS OR INCAPACITATED PERSONS Minor < 14 yo Imprisonment  6 ms to 5 yrs SEXUAL VIOLENCE ART 609 bis Whoever, by violence or threat or through authority abuse, forces someone to perform or undergo sexual act, is punished with imprisonment from 6-12 yrs. The same penalty applies to anyone who: - Abuse conditions of physical and mental inferiority of injured person at the moment of abuse - Substitute to another person (inganno) ART 609 ter The penalty is increased by 1/3 if the acts provided are committed: a. Against whom the guilty party is the ascendant, parent, or guardian b. Use of weapons, alcohol, or drugs c. Person simulates the status of public agent d. On person limited in freedom (LA LIMITAZIONE DI LIBERTA’ E’ REATO) e. If victim < 18 yo f. If in proximity of school g. By spouse, divorced or separated PROCEEDINGS: Punishable upon complaint by injured party  deadline to expose it 12 months Filed complaint = irrevocable COMPLAINT EX OFFICIO: - If minor < 18 yo - If done by ascendant or parent - If by a public official - If the act is connected to another crime that is proceeded ex officio ART 609 QUAR. SEXUAL ACTS WITH MINOR Anyone who engages in sexual acts with a person who, at the time of the fact is: - < 14 yo - < 16 yo when guilty is the ascendant/parent/guardian/educator Imprisonment from 3-6 years. With the exception of the previous cases, whoever engages in sexual acts with a person > 14 yo, old by abusing the trust enjoyed by the minor or by abusing the authority or influence exercised over the minor  prison up to 4 years. The penalty is increased if: a. Minor < 14 yo in exchange for money or benefits b. Several people on the victim c. Someone in criminal association for benefits of his activity d. Harm to minor e. Danger to minor WHEN A MINOR GOES WITH A MINOR A minor, outside the cases in art 609 bis, engages in sexual acts with a minor who has reached 13 years old, shall not be punishable if the age is different between subjects is < 4 yrs (13 anni con 17 anni non è reato a meno che non ci sia violenza) VOLUNTARY INTERRUPTION OF PREGNANCY (IVG) LAW 22/05/1978 N° 194 The state guarantees the right to conscious and responsible procreation and recognizes the social value of motherhood. IVG is not a mean of birth control. Family counseling centers assist pregnant women by: - Inform them about their rights under the legislation - Inform them to ensure compliance with provisions of labor legislation for the protection of pregnancy - Implement social interventions - Help to overcome the causes of IVG The administration upon medical prescription, in “consultori”, or health facilities of means necessary to achieve the freely chosen purpose for responsible procreation is also permitted to minors. VOLUNTARY INTERRUPTION CAN BE MADE: < 90 DAYS >90 DAYS Women with circumstances in which continuation of IVG may be practiced if: pregnancy would pose a serious danger to her a. A serious damage to women’s life physical and mental health or in prediction of b. Pathologic processes are ascertained  anomalies/malformations of child may determine danger to physical and mental health of woman (ascertained by GYNECOLOGIST) If the termination is necessary due to IMMINENT Consuelling Trusted doctor DANGER to woman's life, It may be performed centers performs health without carrying out diagnostic procedures. examine the checks and evaluates mother and the circumstances leading We must consider the actual state of the fetus fetus to help to to IVG remove causes leading to IVG Non Autonomous autonomous life of fetus  NON-URGENT = URGENT = life of fetus  IVG + measures the doctor gives certification and terminate in to safeguard the her the document woman can go to case of: fetus’ life but she must wait centers to perform 7 days until she Malformations IVG (urgency is can go to structure Life danger also when 90 days and terminate are terminating) pregnancy Minister of health can authorize clinic to perform abortions by establishing: - % of abortion that will take place in relation to surgical interventions of previous year - % days of hospitalization permitted for abortion in relation to those of the previous year % no less than 20% MINORS If the woman is < 18 yo to interrupt pregnancy there must be authorization by who exercises authority over the woman. < 90 days  if there is a serious reason for not allow or not advising consultation with who has parental authority over the woman of If they refuse their consent or express different opinions  trusted doctor or HCP should submit a report (with his opinion) to guardianship judge that, in 5 days, after having heard the woman and considering her willing, may authorized IVG (NON E’ SOGGETTA A RECLAMO) If the doctor determines that intervention is urgent due to danger situation for the minor certifies the existence of those conditions to justify abortions and this is done without resorting who exercise parental authority or guardianship judge. CONSCIENTIOUS OBJECTION CO exempts HCP from carrying out procedures and activities specifically and necessarily aimed at IVG  this does not exempt them from assistance before and following the intervention. Authorized hospitals must ensure that procedures are carried out  if you are a CO you must say that at the moment of your admission as HCP in the structure. CO cannot be invoked by HCP if their intervention is crucial to saving life of women. L’ISTITUZIONE NON PUO’ ESSERE OBIETTORE DI COSCIENZA. PHARMACOLOGICAL ABORTION MIFEPRISTONE and PG are drugs of choice. In 2020 it has been approved that: - No hospitalization is needed - Until 49th day  1 600 mg oral dose + PG after 36-48 hrs - 50th- 63rd day  1 oral dose - It is not allowed after the 63rd day CERTIFICATI DI MORTE I tre certificati al momento della morte 1. Certificato di costatazione del decesso  lo può fare qualunque medico (chi è presente al momento dell’exitus eventualmente); ci si avvale della semeiotica clinica (interruzione funzioni vitali); deve contenere generalità del defunto, la data, l’ora e il luogo (Su qualsiasi foglio potenzialmente). Verificare se si tratta di una morte violenta (segni di aggressione al collo, per esempio, oppure alla testa – craniopercussione). Se c’è aggressione bisogna fare segnalazione ad autorità giudiziaria. 2. Certificato necroscopico  deve essere redatto dal medico necroscopo del territorio (MMG potrebbe essere necroscopo). MORTE PER ARRESTO CARDIACO  Visita necroscopica viene eseguita non prima di 15 ore e non oltre 30 ore dal decesso (dall’orario della costatazione) o rilevo continuo di ECG (linea isoelettrica) protratto per non meno di 20 minuti. Per valutare la morte: o Rigidità (algor) o Raffreddamento (rigor) o Ipostasi (livor) MORTE IN SOGGETTI CON LESIONI ENCEFALICHE E SOTTOPOSTI A TRATTAMENTI RIANIMATORI  collegio medico Valutiamo se la persona sia tenuta in vita dalle manovre di support  convoco collegio medico (medico legale + medico di reparto + neurologo): o Inizia un periodo di osservazione di almeno 6 ore o Valuto 4 elementi:  Assenza di vigilanza e coscienza  Assenza dei riflessi del tronco encefalo (fotomotorio, corneale, stimoli dolorifici al tirgemino o facciale, faringeo, carenale, oculo vestibolare  le devi fare tutte!!)  Assenza di respiro spontaneo (EGA: CO2 < 60 mmHg e pH > 7.40 se non c’è respirazione artificiale  ACIDOSI)  Assenza di attività elettrica cerebrale con EEG per almeno 30 minuti o Ripeti questi elementi almeno 2 volte (inizio e fine periodo) o Il momento morte  all’inizio del periodo di osservazione o Casi particolari  angioTC per valutare assenza di flusso ematico a livello encefalico o Attività di origine spinale non conta 3. Scheda ISTAT  denuncia delle cause di morte  lo può compilare medico curante, medico necroscopo o medico legale a. MORTE CON ASSISTENZA MEDICA conoscenza da parte del MMG o specialista del decorso della malattia e il giudizio sulle cause di morte viene formulato dal medico curante b. MORTE SENZA ASSISTENZA MEDICA  si esegue riscontro diagnostico per accertare concatenazione di eventi che portano alla morte; in caso di morte violenta (anche solo sospetto) bisogna fare referto o rapporto ad autorità giudiziaria AUTOPSIA GIUDIZIARE  c’è ipotesi di reato RISCONTRO DIAGNOSTICO (si chiede all’ASL)  ipotesi di reato non c’è (lo può chiedere medico necroscopo, MMG, i familiari del deceduto) MEDICAL LIABILITY CRIMINAL LIABILITY – CRIMINAL CODE CIVIL LIABILITY – MONETARY COMPENSATION CRIME MONETARY COMPENSATION Cannot ask for more than triple of gross salary earned by the doctor in the air of the “crime” PERSONAL AN NOT TRANSFERRABLE TRANSFERRABLE TO AN INSURANCE However, there can be payback from insurance or hospital in cases of DOLO  attività COLPA GRAVE  contro la volontà grave dal punto di del paziente vista della diligenza (opero gamba sbagliata) CERTAIN CAUSALITY DOUBTFUL CAUSALITY You must be sure  il nesso di causa deve essere You don’t have to be sure 100%  there must be the certo link ma it is a probabilistic relationship (nesso probabilitisco) NEGLIGENT CONDUCT – RAPPORTO NON-COMPLIANT CONDUCT – RAPPORTO EXTRACONTRATTUALE CONTRATTUALE – art 1218 (rapporto tra paziente e ospedale) A debtor who does not render the proper performance shall be liable for damages unless he proves that non-performance or delay was caused by the impossibility of performance resulting from a cause beyond his control. ONERE DELLA PROVA SPETTA ALLA STRUTTURA (dimostra che medico ha fatto quello che doveva)  ci può essere rivalsa su medico THE PRESCRIPTION IS 10 YEARS The admission of the patient to the hospital  PROFESSIONAL CONTRACT between the patient and the hospital If the doctor works privately  contractual liability RAPPORTO EXTRACONTRATTUALE – art 2043 (tra paziente e dottore “privato”) Any willful or culpable act which causes unjust damage to someone else obliges the person who has committed the act to compensate for the damage. ONERE DELLA PROVA SPETTA AL PAZIENTE  THE PRESCRIPTION IS 5 YEARS (time you have for the request) IT IS AUTHORITY THAT MUST PROVE IT IS THE “VICTIM” THAT MUST PROVE VS THE DOCTOR AND AGAINST THE HOSPITAL You must demonstrate the causal link between contact and the event ART 40  no one may be punished for an act provided by the law as an offence if it is not a consequence of his action (NON IMPEDIRE UN EVENTO CHE SI HA L’OBBLIGO GIURIDICO DI IMPEDIRE  E’ COME CAUSARLO) ART 41  the concurrence of pre-existing/concurrent causes, even If independent from act/omission  not exclude causal relationship between action and event LAW GELLI-BIANCO (24/2017) Provisions on the safety of care and of the assisted person, and on the professional liability of of HCP ( è una riforma normativa che disciplina la responsabilità sanitaria in Italia; si occupa inoltre di sicurezza delle cure e gestione del rischio clinico). ART1 – SAFETY OF HEALTH - In the interest of individual and community - Risk prevention activities by all HCP - Prevention and managing risk associated with provisions by HCP - Right to safe care - Risk management activities ART 3 HCP facilities shall make available data on all compensation paid in the last 5 years as part of health risk monitoring. ART 37 – MORTUARY POLICE REGULATIONS Relatives or entitled person of deceased may agree with medical director on the carrying out of diagnostic test. ROLE OF GUIDELINES ART 5 Practitioners of HC professions, in the performance of HC service with preventive, diagnostic, TX, palliative, rehabilitation, and forensic purposes, shall comply with recommendations provided by the guidelines  NATIONAL SYSTEM FOR GUIDELINE (SNLG) In the absence of guidelines  HCP shall comply with good clinical and HC practice International GLs are not assimilated to GLs published on SNLG for Gelli-bianco law  they may not be compatible with Italian legal provisions According to the document of united sections: - Ground for exclusion of punishability cannot be invoked in certain culpable hypotheses characterised by negligence (NON-FARE) or imprudence (NON-SAPER FARE MA FARE LO STESSO). - HP will be liable for grave and minor inexperience when GLs or good practice are either missing or wrongly chosen - HP liable for grave inexperience IMPERIZIA  condizione in cui si sa fare una cosa ma si sbaglia a farla IMPRUDENZA  condizione in cui non si sa fare una cosa ma si fa lo stesso NEGLIGENZA  condizione in cui ci si astiene dal far una cosa che avrebbe potuto o dovuto fare ART 13 LEGGE GELLI BIANCO HC facilities shall notify HCP about institutional proceedings against him/her by certified mail. Facilities must be claimed for compensation, not HCP  HCP may be asked to payback only for DOLO or COLPA GRAVE (ART 9 GELLI BIANCO) If the facility does not notify the HCP  cannot ask for payback ASPHYXIA It is absent of pulsation Physiologically  respiration brings oxyegn to tissues There are some conditions  defects in respiratory chain: - Absence of O2 tension in the external atmosphere - Obstruction of ext resp orifices - Block of internal resp moves of thorax - Disease of lungs reducing gas interchange - Decrease in function - Less ability of blood to transport 02 - inability of peripheral cells to utilize O2 delivered MECHANICAL ASPHYXIA Respiratory insufficiency due to external that obstruct air penetration. It occurs with considerable energy and in a short time. Asphyxia death is NERVOUS DEATH because there is cessation of respiratory and cardiac functions become IRREVERSIBLE when the centers regulating respiratory, cardiac and FC are irreversibly compromised (ANOXIC MECHANISM). Especially when it occurs at the level of the neck: 1. jugular veins are occluded  venous stasis  loss of consciousness (2 kg of F Is enough to occlude EJV; 5 kg to occlude IJV) 2. compression or stretching of a reflex area of the carotid sinus and vagus nerve  inhibition  syncope  cardiac arrest (5kg to occlude carotid) it is not enough to interrupt cerebral blood flow because there are the vertebral arteries that are protected by the intervertebral course. Weight needed to occlude: - Trachea = 15 kg - Vertebral circulation = 30 kg PATHOPHYSIOLOGY – THE WHOLE PROCESS TAKES 4’-6’ 1. INSPIRATORY PHASE laryngeal closure due to HYPOXEMIA + comoression (JV) and overstimulation of bulbar HYPERCAPNIA and reflex spasm (carotid and centers changes in blood pH vagus nerve) TACHYCARDIA INTENSE DYSPNEA duing HTN inspiration CYANOSIS 2. EXPIRATORY PHASE (CONVULSIVE) progressive hypoxemia and hypercapnia stimulation of nerve loss of consciousness center controlling EXPIRATION HTN BARDYCARDIA MYDRIASIS Symptoms changes SPHINCTER RELAXATION CONVULSIONS 3. APNEIC PHASE BRADYCARDI APNEA Respiratory pause HYPOTN SMALL PULSE MYOSIS 4. TERMINAL PHASE  GASPING (nervous respiratory centers no resumption to impulses to facial are irreversibly respiratory activity muscles simulate impaired breathing) HYPOTN STOP CONTRACTION TACHYCARDIA CLINICAL PRESENTATION OF ASPHYXIA CYANOSIS AND CONGESTION mostly of face and neck and upper third of chest due to reduction in HB in the blood (less venous return) PETECHIAL HEMORRHAGES small pin-point of blood (skin, conjuctiva, pleura (tardien's spots), pericardium). they are < 2 mm ( if more = ecchymoses). form dur to rise in venules P ACUTE PULMONARY EMPHYSEMA due to respiratory efforts leading to rupture of alveolar septa VISCERAL HYPEREMIA blood accumulates in right heart sections so no drainage from VC (congestion, cerebral edema and pulmonary edema) INCREASED BLOOD FLUIDITY (due to CO2 and less fibrinogen DARK BLOOD due to hypoxemia and hypercapnia CLASSIFICATION OF ASPHYXIA OBSTRUCTION/OCCLUSION OF AIRWAYS COMPRESSION OBSTRUCTION OF RESPIRATORY RESPIRATORY ORIFICES AIRWAYS SMOTHERING THROTTLING OR MANUAL CHOCKING (SOFFOCAMENTO) STRANGULATION (STROZZAMENTO) Mechanical occlusion of the mouth Hypoxia due to airway obstruction and nose. between the pharynx and the bifurcation of trachea (congestion, Usually due to  fabric, sheet or May take 15’-20’ cyanosis and petechiae). hand There is compression and reflex Deliberate homicide especially in  spasm due to violent neck children, old and debilitated constriction CAUSES: The prevention of air is also due to: - Foreign body - Dentures and SIGNS/SYMPTOMS - Antero-posteriorization of haemorrhages airways - Acute obstructive - Classic signs of asphyxia - Lateralization of neck lesions (glottis/larynx) - Contusion-type lesions  structures - Food Ecchymoses (teeth, lips, cheeks) and abrasions (also perioral) at respiratory SIGNS/SYMPTOMS orifices and chin region - If by hand  ecchymoses A. EXTERNAL SIGNS have the shape of fingers - Ecchymotic injuries - If soft solid object  no antero-laterally on the skin damage neck (1-2 cm discoid lesions) NO INVOLVEMENT OF NECK - Linear or semi-linear in STRUCTURES. shape abrasions (static For sure there is disproportion of P) strength between the victim and - Abrasion on the neck attacker in the context of homicidal due to assailant or event victim (try to pull away) B. INTERNAL SIGNS - Hemorragic infiltrations in neck muscles - Laryngotracheal cartilagineous injury (squeezed) - Lateral pressure of fingers may displace the horns (if > 30 yo = calcified to fracture)  - Cricoid cartilage breaks (front midline or oblique) GAGGING LIGATURE STRANGULATION DROWING (ANNEGAMENTO) (STRANGOLAMENTO) Mechanical asphyxia is due to entry of liquid in the respiratory tree with Tape placement on the mouth. At the replacement of air content so the beginning the air can pass Constriction of the airways from no normal gas exchange can occur. through the nose but outside due to ligature around the edema/mucous will obstruct the neck. A force acts according to a nose and lead to death. vector that is transverse to the TIMING: major axis of the neck. - 5-6 min in freshwater - 7-8 min in sea water CLASSIFICATION - Typical or complete  SIGNS/SYMPTOMS lesions in every part of A. EXTERNAL SIGNS diameter - Cutis anserina - Atypical or incomplete - Transparent  ligature non conjunctiva completely wrapped - Frothy fluid in air around (from behind) passage (fungo MECHANISMS: schiumoso) = edema fluid from lung - Nervous inhibitory resulting in surfactant mechanism (rapid loss + water of consciousness) B. INTERNAL SIGNS - Asphyxia mechanism - Lungs overdistension SIGNS/SYMPTOMS A. EXTERNAL SIGNS DIAGNOSIS - Ligature mark  excoriated lesion on - Labs tests (electrolyte the skin with evident and fluorine) sulcus (solco duro); it - Diatom (algae found at may also be SOLCO the microscope in the MOLLE if the ligature is lungs, not in soft  encircles the circulation) neck HZ and at lower level involving the entire surface of the neck (continuous); it’s D/D with hanging. It may be single or multiple and keeps the same depth all the way around (D/D with hanging).  - Hemorrhagic vescicles B. INTERNAL SIGNS - Pleural and pericardial petechiae - Neck involvement signs HANGING (IMPICCAMENTO) It is a form of ligature strangulation in which the F is applied to the neck comes from the gravitational drag of the weight of the body or part of it. The lace obstacles air penetration by lifting hyoid bone, epiglottis and the base of tongue  occlude de pharynx. CLASSIFICATION: - Typical  knot on the occipital part - Atypical  knot not on occipital part - Complete whole body suspended - Incomplete  feet or legs or other parts touch the ground as a support SIGNS/SYMPTOMS A. EXTERNAL SIGNS - Hanging mark  oblique from front to back and from bottom to top The mark is:  Discontinuous  Above thyroid  Single  Hemorrhagic  punctuations  Serous/siero- hematic blisters  - Hyposthasis  sock- like in the complete form (LL) or glove-like in incomplete from (UL) - Protrusion of tongue from mouth - Sperm in external urethral meatus B. INTERNAL SIGNS - DOTTO  vagus nerve lesion with hemorrhagic infiltration of neck trunk - AMUSSAT  transversal laceration of carotid intima below bifurcation - MORGAGNI  hemorrhagic infiltration in neck muscle - BOHMER  longitudinal laceration of carotid intima FORENSIC AUTOPSY AND CHANGES AFTER DEATH Earliest forensic dissection  13th century c/o University of BOLOGNA by Bartolomeo da Varignana TYPES OF AUTOPSIES 1. CLINICAL OR ACADEMIC (DIAGNOSTIC)  A medical attendant performs it in order to learn the extent of the disease 2. MEDICO-LEGAL (AUTORITA’ GIUDIZIARIA)  performed on the instruction of legal authority (relatives' permission is not required). The aims are_ a. TIME OF DEATH (EPOCA) b. CAUSE OF DEATH (CAUSE) c. MEANS OF DEATH (MEZZI) The aims of an autopsy are: - Make identification of the body - Determine the cause of death - Determine the mode of dying - Demonstrate any abnormality - Detect injuries - Retain relevant organs - Provide a full written report THANATOLOGY TANATOCHRONOLOGY is the study of the time of death. Cadaveric phenomena (changes in the body in the period after death)  determine the post-mortem interval POSTMORTAL CADAVERIC CHANGES NEGATIVE CADAVERIC PHENOMENA TRANSFORMATIVE PHENOMENA – transformation of the structures of the body (increased degree of destruction) IMMEDIATE ABIOTIC PHENOMENA DISRUPTIVE Loss of consciousness Putrefaction It results from the action of bacteria (endogenous first and then exogenous) involving the entire organism leading to its destruction. It strongly depends on the environment: - Wet or humid  accelerate bacterial proliferation - Cold  decreased bacterial proliferation CASPER’S LAW  Degree of advancement of putrefaction of the body exposed 1 week in the air is equivalent to 2 weeks in water and 8 weeks for the inhumed body (cadevari inumati). There are also endogenous factors: - Obese - General or localized infections at time of death 1  In an average T climate may be expected to begin around 3 days. PHASES OF PUTREFACTION: 1. COLOUR PHASE  (winter takes days; in summer takes hrs) discoloration of the lower abdominal wall (right iliac fossa) due to cecum bacteria; then spreads to tissues (HB into sulfaHB = GREEN)  marbling phenomenon = arborescent red, greenish pattern in the skin visible in LL and sides (usually at 1 week at T 18-20°C) 2. GASEOUS PHASE increased P in the abdomen due to gas formation (eye globes and tongue protrusion). It starts 2-3 weeks and the reddish-green color becomes dark green or black. Internally decomposition goes slower than outside  lining of intestine, adrenal medulla and pancreas autolyse within hrs from death. 3. COLLIQUATIVE PHASE  decrease in the gas amount and breakdown of the thoracic and abdominal wall (liquame cadaverico.  3° mese – 3° anno 4. SKELETALISATION  body reduced to skeleton (tendons tags + skeleton in 12-18 ms and bare bone in 3 yrs) Loss of muscle tone Autolysis  destructive phenomenon due to endogenous cytoplasmatic lytic enzymes (usually together with putrefaction)  seen at a microscope Cessation of cardiac and respiratory functions TRANSFORMATIVE CNS function cessation Mummification Drying of the tissue during liquefactive putrefactions (phase 3). More likely to extend to whole body It occurs in DRY ENVIRONMENT WITH MOVING AIR CURRENT  rapid evaporation from body surface CHARACTERISTICS: - Dry and brittle skin  anatomical prominences - Discoloration  brown skin + white due to mould colonization (also green or black) - Internal organs may be dried or putrified - Mostly in starving indivuals It takes 1-3 years Corification In bodies preserved in metal coffins between the 1st and the 2nd year. There is an initial putrefactive process slowed down by the absence of O2 due to diffusion of metal elements  cessation of putrefaction 2  CHARACTERISTICS: - SHINY YELLOW SKIN - SOFT - ELASTIC CONSECUTIVE PHENOMENA Maceration Occurs in HUMID ENVIRONMENT or in bodies IMMERSED IN WATER (also fetus in the uterus) After hrs, the skin becomes wrinkled (especially in palms and soles) with a swollen appearance until there is the complete lifting of the epidermis of palms and soles (glove-like or sock-like). it usually completes in 1-3 weeks. HYPOSTASIS (LIVOR MORTIS) Adipocere (saponificazione) Accumulation of blood in the lowest areas under Hydrolysis of lipids in the adipose tissue by the influence of gravity and of residual vascular anaerobic bacteria beginning soon after death. function (in early stages) It inhibits putrefaction due to increase acidity of Circulation ceases as arterial propulsion and venous tissues and dehydration caused by consumption return then fail to keep blood moving through the of water in hydrolysis  slowing of the growth of capillary bed + efferent and afferent putrefactive organism Gravity  pulls stagnant blood down to the lowest It occurs in HUMID AND WET ENVIRONMENT WITH accessible areas (bluish-red discoloration) POOR VENTILATION OR IN WATER FOR LONG TIME (also immersed body) Starts as blotchy patches on the upper lateral surfaces of the legs and then coalesces and CHARACTERISTICS: moves down to the lowest areas. PURPLISH RED - White and soapy mass HUE. - Friable or hard Tempi  Si evidenziano nei primi 30’ fino a 2 ore - Oily and viscid to touch dopo la morte, con la massima estensione tra 8-12 - Rancid cheese ore Mostly in: Timing: - Cheeks 1. Total migration  position of body changes - Orbits and they are movable  6-8 hrs - Chest 2. Partial migrability  if the position - Abdominal wall changes, they will be present in both regions - Buttocks  8-12 hrs Timing  3 weeks to 3 months also 12 months is 3. Fixity  they will be fixed and will not still possible redistribute even if body position changes  Relative phase (positive finger P) 12-72 hrs; absolute phase 48-72 hrs) In IMMERSED BODIES  dehydration in more or less (endovascular hemolysis, diffusion of 3 ms (fat released from bites of crustacean) blood pigments into vascular walls and in perivascular tissues) In BURIED BODIES  soil will make body collapsing Pallor of supporting area + local P exclude them The distribution depends on the body position after death: - Body lying on the back  compression of vascular structures so the skin stays white - Side or face  white areas in the zones of support - Hanging (vertical)  mostly on feet, legs and hands and distal arms 3 Hypostasis are: - Normal  mid axillary line in supine body - Abundant  rise above anterior axillary line - Scarce  posterior axillary line or not cover posterior surface of the back Le regioni epistatiche  bianche (quelle in alto) Le regioni ipostatiche  rosso-violacee (quelle in basso) COLOR OF HYPOSTASIS: - deep purple blue  hypoxia - cherry red  CO poisoning - red brick  cyanide - Aniline (metaHB)  brownish red - Phosphorus  dark brown - Anaerobic septicemia  bronze - Hypothermia  bright pink Hypostasis is found in different organs such as the lungs and myocardium D/D with BRUISING  Incision is performed: if the blood is intravascular is HYPOSTASIS, if it is outside vessels is CONTUSION BODY COOLING (ALGOR MORTIS) The body will cool after death according to Newton’s law of cooling (cooling rate is proportional to difference in T between the body and the surrounding) T is taken at the rectum with mercury thermometer that ranges between 0°-50°C (must be kept in place for several minutes to stabilize)  37°/38° C TIMING OF COOLING: 1. 0-4 hrs  0.5°C/hr (initial plateau phase) 2. 4-15 hrs  1°C/hr (rapid descent phase) 3. 15-24 hrs  0.25-0.75 °C/hr (late plateau phase 4. > 24 hrs  equilibrium with environment T The estimation of time since death must be made by integrating data from an overall assessment of all cadaveric and circumstantial elements. Factors influencing cooling: - Wollen or insulating clothing  clothing accelerate cooling if wet - More or less adipose tissue 4  - Initial T at the time of death (hyperthermia, hypothermia or heat stroke) - Posture  access of air to skin and chance of radiation and convection - Ambient T  in H2O heat loss is more rapid HENSSGE’S MONOGRAM  CALCULATE POST MORTEM INTERVAL considering ambient T, body weight, dry or wet clothes, still or moving air/water BODY STIFFNESS (RIGOR MORTIS) Immediately after death  flaccidity Then  partial or total rigidity (limited period) TIME OF STIFFNESS: - 3-6 hrs  flaccid period  rigor first appears on smaller muscle group (Legge di Nysten  moves craniocaudal) - 6-12 hrs  stiffness in the whole body mass  until autolysis begins - 24-36/48 hrs  maximum intensity of stifness - > 72 hrs  resolution is completed The timing of rigor mortis is influenced by some factors: - T (colder environment = slower the process) - Physical activity shortly before death  rapid if exhausted muscle - Physical constitution (quickly in frail pz) - Age (rapid in children and old age - Nature of death  asphyxia, sepsis This is due to the cessation of metabolic mechanism  ATP is not produced thus there is no energy for contraction and stabilization of actomyosin bridges (retraction of muscle fibers) The muscle fibers stay in contraction until putrefactive phenomena occur (24-36 ore) and the actomyosin bridges are destroyed (not gained again) To test  attempt to flexing or extending the joint and the muscle mass becomes hard and the finger P in quadriceps or pectoralis can be markedly accelerated or retarded It can occur in all muscular tissues: - Skeletal muscles - Iris - Heart  V contract (D/D V hypertrophy) - Erector pili muscles  goose-flesh w/ elevation of cutaneous hairs DEHYDRATION 5 Strongly depends on the environmental conditions in which the body resides. Firstly, it is visible in the most exposed skin and mucous surfaces, eyeballs, and, eventually, where skin lesions are. The related phenomena are: - Decrease endocular tension - Sommer’s scleral spot  blackish colour on the sclera - Corneal opacation (tela di Winslow) - Dehydration of mouth, lips, nose and scrotum mucosae Changes in the weight  15-20 kg/day until putrefactive phenomena 6 BALISTIC INJURIES WEAPONS They can also be distinguished into single-charge weapons (1 bullet at time) multiple-charge weapons (more small projectiles at time)  after 1-2 m they start spread out forming a widening pattern until maximum extension (direct cone)  Types of lesions: o Unique breach with jagged or polycyclic margins o Central breach surrounded by pointed wounds o Multiple small wounds when pellets are totally diverged Ballistics – studies the mechanisms that deal with the flight, behaviour and effects of projectile. INTERNAL BALLISTICS EXTERIORE BALLISTICS TERMINAL BALLISTICS OR WOUND BALLISTICS Processes in a firearm Behaviour of the projectile after Changes caused when a projectile leaving the barrel penetrates the body BALLISTIC injuries are due to KINETIC ENERGY transmitted from bullet to body —> the tissues show different composition thus kinetic energy produces different internal lesions with different features according to the tissue.  The projectile exerts a blunt action by introflettono the skin and dividing it by wedge action + penetration by spinning action of projectile FIREARM WOUNDS - Penetrating – blind bottom wound without exit and perforating - Re-entry – entry, passes through body segment, exits and re-entry - Grazed – strikes the skin at shallow angle leading to elongated area of abrasion without perforation - Tangential – extend through skin exposing subcutaneous tissues  PERMAMENT CAVITY = tissue in line with a trajectory is crushed by excessive pressure built-up directly in front of the tip of moving projectile —> tissue completely disintegrated  TEMPORARY CAVITY = transient displacement or stretching of tissue where the size of cavity is determined by characteristic of tissue and amount of energy realesd.  PULSING CAVITY = alternation of dilating and compression due to shockwaves The tissue act in different ways More elastic fibers tissue (lungs, muscles and bowel) can withstand displacement without significant damage Denser tissues (liver, brain) may be lacerated severely PRIMARY LESIONS They can develop if a bulletin hits and PERFORATE the body: 1. Entrance wound – where bullet enters The characteristics vary depending on distance:   Important distance – also depend on mechanical action exerted on the skin  If direct contact shot there is alteration of the wound morphology due to the gases (due to high pressure that penetrate with bullet and expand in subcutaneous tissues) and the weapon actions (excoriation, bursting larger that the bullet and star shape) – NO SECONDARY EFFECTS OF SHOT. You may see Werkgartner sign (mould due to gun shutter)  Close range (> 10-15 cm and < 40-50 cm) – additional effects are added (SECONDARY EFFECTS OF SHOT) o Due to inorganic components of the shot (deflagrating of firing charge, action of gases, action of flame, direct action) —> their presence makes possible the identification of entrance wound o Among SECONDARY EFFECTS OF SHOT are (may be seen all together only if the distance is 10-15 cm):  Blackening/smudging – carbonaceous deposition on skin, easily wiped off by detersion (deposition of small oils rsidues of launch charge) – grey and bluish (suicidal = soot staining of clothing = close discharge)  Tattooing (alone if distance if >10-15 cm and 40-50 cm) – annular area of abrasion due to forward motion of the bulling intending the skin. They are almost always found and they can be CIRCULAR (if perpendicular) or OVAL (obliquely). It may be blackened due to overlying remnants from bullet when hitting uncovered skin. o Distant range – (>40-50cm) the only marks are those produce by interaction of the bullet and the skin (no secondary effects). The projectile produces circular or oval shanked with introfletter margins (diameter of entrance smaller than projectile).  There may be abrasion collar whose size depends on the extent of cone of depression. o Manifested as circular rings concentric to entrance wound if shot is perpendicular to the skin; oval rings, eccentric to entrance wound more distal to direction of shot 2. Intrasomatic pathway – route inside the body (permanent + temporary cavity)  3. Exit wound – bullet leaves the body It can be oval, circular, star-shaped or small linear slits Dimension varies according to size of entrance hole (larger or smaller if completely exhausted projectile) Absence of other features – NO SECONDARY EFFECTS OF THE SHOT Abrasion collar if the bullet encounters external resistance (skin compressed between the bullet and external R) Typical effect of bunker in the skull is BEVELING — cone shaped deformity due to forward moving force of bullet as passes through the layers of bone. Distinguish between entrance and exit wounds is mandatory — morphology can help pathologist to understand dynamics of event What does a forensic doctor should interest in?  Direction of shots  Describe nature of injuries  Estimation of firing distance  Bullets and weapons used LAW 10/2020: BODY DONATION Possible to donate one’s body or part of it or post-mortem tissues for scientific purposes There are 10 articles in this law ART1 The use of the human body or post-mortem tissues is governed by the principles of solidarity and proportionality and is regulated in such a way as to ensure respect for the human body. In minors the parents or whoever has responsibility express the consent. ART2 The Minister for Health shall promote, with respect for free and conscious choice, information initiatives aimed at disseminating among citizens the knowledge of the provisions of this law using the resources available under current legislation for the implementation of institutional communication projects HOW TO DONATE? ART3 It is disposed by the DAT - public act or private document authenticated by a notary or private document delivered directly by the disposer at the civil status office of the municipality of residence The donor is obliged to designate trustee (adult, fully capable of understanding and willin) whose duty is to communicate the existence of specific consent to the doctor that ascertains the death. The donor may revoke consent at any time in accordance with the manner prescribed in subsection. This must be communicated to health authority to which the patient belongs (transmitted to database). In cases where reasons of emergency and urgency prevent the revocation of the consent already expressed with the modalities provided by the law (public act or private document authenticated by a notary or private document delivered directly by the disposer at the civil status office ofthe municipality of residence) it may be expressed by means of a verbal statement collected orvideo-recorded by a doctor with the assistance of two witnesses ART4 Only such centres, including special list, are authorized to receive donor corpse WHICH BODIES CAN BE DONATED? The body and tissues of subjects whose death has been ascertained. The body excluded are:  Infected: HIV, HBV,HCV, TB, syphilis… Radionuclides recent TX Judicial autopsy Severe mutilation or open wounds of traumatic nature Suicide Who died abroad The Reference Centre (guarantee of identification and traceability of the body) will verify the existence of the deceased's declaration in the National Database and will transmit the request for acquisition of the body both to the Local Health Authority where the death occurred and to the one to which the citizen belongs, if different. The ASL of the place of death, will have to authorise the destination and transmit a copy of the necessary documentation, the ISTAT Form, the certification attesting to the absence of infectious diseases, and possibly the health documentation relating to the last hospitalisation. Transport, in any case, may not take place before the corpse has spent at least 24 hours in the morgue, regardless of whether the tanatogram or encephalic death tests have been performed. The deadline for returning the body to the family is twelve months. If the family does not request its return, burial or cremation is the responsibility of the Reference Centre.