2 Death Transplantation.2013

WHEN
DEATH
OCCURS
Objectives
ORGAN
DEATH TRANSPLANTATION
Main Objective: To Main Objective: To gain
recognize the criteria for knowledge about organ
the pronouncement of and tissue transplantation
death Specific Objective:
Specific Objectives: To enumerate and define
To define death and the the different sources of
different stages of death organ and tissues for
To discuss how death is transplantation
established
BRAIN
HEART
CIRCULATORY SYSTEM
RESPIRATORY SYSTEM
http://www.surrey.ac.uk/SBMS/ACADEMICS_homepage/mcfadden_johnjoe/img/circulatory.jpg
Death
Cessation of life in a previously living
organism
A process; NOT an event
Medical & legal status
Legal Medicine, American College of Legal Medicine, 4th ed., p352
Shepherd R, Simpsons Forensic Medicine, 12th ed., p27
Ascertainment of death is a clinical problem,

not a legal problem
Solis P, Legal Medicine, 1987, p112
Deaths Stages
Clinical (somatic) death
Brain death
Biological death
Cellular death

Clinical (somatic) death
The bodys vital functions (respiration and circulation)
cease
May be restored with resuscitative measures
Spontaneous respiration & cardiac activity
Artificial assistance
The individual will never again communicate or
deliberately interact with the environment
Irreversibly unconscious; unaware of both the world &
his own existence
Irreversible unconsciousness with spontaneous
respiration & heart beat
Cannot be accepted as true death
Shepherd R, Simpsons Forensic Medicine, 12th ed., p27-28

Brain death
Follows clinical (somatic death)
Occurs when the brain is deprived of
oxygen within 3 7 minutes of cessation
of circulation
May be averted when resuscitative
measures are instituted

Brain death
Cerebral cortex
Cerebellum
Lower brain centers
Brainstem

Brain death:
Persistent vegetative state
Permanent loss of consciousness
(+) Cardiorespiratory function, unaided or
with artificial assistance
Assumed functioning brainstem activity

but higher cerebral function cannot be
detected
Require hydration and nutrition only
Deaths Stages
Biological death
Permanent extinction of bodily life
All the components of the brain are dead
Cellular death
Cessation of the normal metabolic activity in
the body tissues & cells
Autolysis and decay indisputable evidence
of true death
Cellular death
Different parts of the body die at different times
and stages: differences in cellular metabolism
Skin & bone remain metabolically active (alive) for many hours
may be cultured
WBC are capable of movement for up to 12 hrs after cardiac
arrest
Cortical neurons die after 3-7 minutes of complete oxygen
deprivation
Heart & kidney can be harvested within 8 hrs of biological
death and transplanted successfully
A body dies cell by cell & the complete process may
take many hours
Death
The transfer from one state of viability to
another may be slow or rapid
Age
Physical, constitutional & environmental
factors
Life-extinguishing cause
The physician pronounces death when a
point of irreversibility has been reached

Pronouncement of Death
Formulation of death consists of

A definition of death
Criteria for determining that death occurred
Specific medical tests to show those criteria
are met

Traditional formulation of death
Irreversible cessation of vital fluid (air & blood)
flow
Corresponding (heart-lung) criteria: cessation of
heart & lung function
Specific medical tests available to the MD
Palpation for a pulse
Auscultation for heart & breath sounds
Use of a mirror held under the nose: condensation
from exhaled breath
Visualization of the optic fundus for vessel pulsation
EEG
No motor response
Absence of brainstem reflexes:

(-) grimace or eye opening
(-) corneal reflex
(-) light reflex
(-) oculovestibular response
(-) cough reflex
Apnea test
http://content.nejm.org/cgi/content/full/344/16/1215/F1
New developments and
advancement in medicine
IMMEDIATE DEATH IS
PREVENTED
Development and improvement of
CPR regimen
Establishments of cardiac units,
stroke units
Development of defibrillators,
ventilators, newer and better drugs
Hemodialysis & peritoneal dialysis
Transplantation

Spectrum of survival
Recover spontaneous
respiration and
consciousness
Remain unconscious but will
regain the ability to breathe
on their own
Remain unconscious &
unable to breathe on their
own; will need artificial
ventilation to remain alive

Brain death
Modern resuscitation technology
Maintain heart & lung function after all brain function
has ceased
Discontinuation of ventilation support
Homicide?
Maintaining these patients in this hopeless
condition is senseless, impractical, &
economically, emotionally, physically draining
Determination of Death
Uniform Determination of Death Act
Formulated by the National Conference of Commissioners on Uniform
State Laws (1980)
Approved by the American Medical Association (1980) & by the
American Bar Association (1981)
An individual who has sustained either (1) irreversible

cessation of circulatory and respiratory functions, or (2)
irreversible cessation of all functions of the entire brain,
including the brain stem is dead. A determination of
death must be made in accordance with accepted
medical standards.
http://www.medterms.com/script/main/art.asp?articlekey=33438
A Definition of Irreversible
Coma (the Harvard Criteria)
Unreceptivity & unresponsitivity
a total unawareness of externally applied stimuli &
inner need & complete unresponsiveness, despite
application of intensely painful stimuli
No spontaneous movements or breathing

absence of all spontaneous muscular movement or
breathing, as well as absence of response to stimuli
such as pain, touch, sound or light

A Definition of Irreversible
Coma (the Harvard Criteria)
No reflexes
fixed, dilated pupils; lack of eye movement despite
turning the head or ice-water stimulus; lack of response
to noxious stimuli; and generally, lack of elicitable deep
tendon reflexes
In addition: confirm the preceding observations by
2 EEGs, taken at least 24 hrs apart
document absence of cortical electrical activity above
baseline
after exclusion of the presence of conditions that can
contribute to a reversible loss of brain activity or function

Terri Schiavo: severe and irreversible
brain damage
Organ & Tissue
Transplantation
Death
Organ Donation Act of 1991
the irreversible cessation of circulatory

and respiratory functions or the
irreversible cessation of all functions of
the entire brain, including the brain stem.
A person shall be medically and legally
dead if either:
http://www.lawphil.net/statutes/repacts/ra1992/ra_7170_1992.html
Death
(1) In the opinion of the attending physician,

based on the acceptable standards of
medical practice, there is an absence of
natural respiratory and cardiac functions
and, attempts at resuscitation would not be
successful in restoring those functions. In
this case, death shall be deemed to have
occurred at the time these functions ceased;
or
Death
(2) In the opinion of the consulting physician,
concurred in by the attending physician, that on
the basis of acceptable standards of medical
practice, there is an irreversible cessation of all
brain functions; and considering the absence of
such functions, further attempts at resuscitation or
continued supportive maintenance would not be
successful in resorting such natural functions. In
this case, death shall be deemed to have
occurred at the time when these conditions first
appeared.
Legal Problems Pertaining
to Transplantation
Consent or authorization to donate
Determination of death in the case of
procurement from a cadaver
Rationing of organs and medical
resources
Shepherd R, Simpsons Forensic Medicine, 12th ed., Arnold 2003, p29

Consent or Authorization to
Donate (Organ Donation Act, 1991)
Section 3. Person Who May Execute A
Legacy. Any individual, at least
eighteen (18) years of age and of sound
mind, may give by way of legacy, to take
effect after his death, all or part of his
body for any purpose specified in Section
6 hereof.
Consent or Authorization to
Donate (Organ Donation Act, 1991)
Section 4. Person Who May Execute a Donation.
(a) Any of the following, person, in the order of property stated
hereunder, in the absence of actual notice of contrary intentions by the
decedent or actual notice of opposition by a member of the immediate
family of the decedent, may donate all or any part of the decedent's
body for any purpose specified in Section 6 hereof:
(1) Spouse;
(2) Son or daughter of legal age;
(3) Either parent;
(4) Brother or sister of legal age; or
(5) Guardian over the person of the decedent at the
time of his death.
b) The persons authorized by sub-section (a) of this Section may make

the donation after or immediately before death.
Determination of Death:
Cadaver Organs
Kidneys (80%); most livers, except those

from living parental donors; and all hearts
for transplantation are harvested from
patients who have been declared brain
dead and maintained on life support.

Determination of Death:
Cadaver Organs
Section 9. Manner of Executing a Donation
In all donations, the death of a person from whose body
an organ will be removed after his death for the purpose
of transplantation to a living person, shall be diagnosed
separately and certified by two (2) qualified physicians
neither of whom should be:
(a) A member of the team of medical practitioners who will effect the
removal of the organ from the body; nor
(b) The physician attending to the receipt of the organ to be
removed; nor
(c) The head of hospital or the designated officer authorizing the
removal of the organ.
Rationing of Organs and
Medical Resources
Organ shortage
Sources of organs and tissues for
transplantation
Fetuses and anencephalic infants
Living donors
Artificial and animal transplants
Organ & Tissue
Transplantation: Sources
Homologous transplantation
Live donation
Cadaveric donation
Xenografts
Cloning

Homologous
Transplantation
Tissue is moved between sites on the
same body
skin from the thigh grafted onto a burn site
bone chips from the pelvis grafted to a
fragmented fracture site to assist in the
healing
homologous blood transfusion in cases
where there is religious objection to the use
of anonymously donated blood

Live Donation
Tissue is taken from a
living donor whose tissues
have been matched to or
are compatible with those
of the recipient
blood transfusion
bone marrow transfusion
kidneys
part of a singleton organ,
e.g., liver

Anti-Trafficking Persons
Act, 2003
Section 4. Acts of Trafficking in Persons. - It shall be
unlawful for any person, natural or juridical, to commit
any of the following acts:
..
(g) To recruit, hire, adopt, transport or abduct
a person, by means of threat or use of force,
fraud, deceit, violence, coercion, or
intimidation for the purpose of removal or
sale of organs of said person;
Cadaveric Donation
The major source of all

tissues for transplantation.
Organs are obtained while

circulation is present or
immediately after
cessation of the circulation
for the best results.
Xenografts
Grafting of animal tissue into humans

Clinical trails have been performed with
limited success
Difficulty with cross-matching the tissues
Concern about the possibility of transfer of
animal viruses to an immunocompromised
human host

Cloning
Cloning of animals for use as transplant

donors - a potentially cheaper solution

2 Death Transplantation.2013

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WHEN

Ascertainment of death is a clinical problem,

Legal Medicine, American College of Legal Medicine, 4th ed., p352

Shepherd R, Simpsons Forensic Medicine, 12th ed., p27-28

Legal Medicine, American College of Legal Medicine, 4th ed., p352

Legal Medicine, American College of Legal Medicine, 4th ed., p352

Assumed functioning brainstem activity

Legal Medicine, American College of Legal Medicine, 4th ed., p353

Formulation of death consists of

Legal Medicine, American College of Legal Medicine, 4th ed., p353

Absence of brainstem reflexes:

Legal Medicine, American College of Legal Medicine, 4th ed., p353

Shepherd R, Simpsons Forensic Medicine, 12th ed., p28

An individual who has sustained either (1) irreversible

No spontaneous movements or breathing

Legal Medicine, American College of Legal Medicine, 4th ed., p353

Legal Medicine, American College of Legal Medicine, 4th ed., p353

the irreversible cessation of circulatory

(1) In the opinion of the attending physician,

Shepherd R, Simpsons Forensic Medicine, 12th ed., Arnold 2003, p29

b) The persons authorized by sub-section (a) of this Section may make

Kidneys (80%); most livers, except those

Legal Medicine, American College of Legal Medicine, 4th ed., p328

Shepherd R, Simpsons Forensic Medicine, 12th ed., Arnold 2003, p29

Shepherd R, Simpsons Forensic Medicine, 12th ed., Arnold 2003, p29

Shepherd R, Simpsons Forensic Medicine, 12th ed., Arnold 2003, p29

The major source of all

Organs are obtained while

Grafting of animal tissue into humans

Shepherd R, Simpsons Forensic Medicine, 12th ed., Arnold 2003, p29

Cloning of animals for use as transplant

Shepherd R, Simpsons Forensic Medicine, 12th ed., Arnold 2003, p29

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