Stepwise duties of a doctor facing a dead patient: Dr. Walke

M3 India Newsdesk

Dr. Walke, Past Chairman, Ethics and Medicolegal Committee FOGSI guides the reader in dealing with patient death in a stepwise manner- diagnosis, declaration report, handling the authorities, and handling the mob.

In view of the rising incidents of the intolerant behaviour of patients and their relatives towards healthcare professionals, it has become extremely important that all medical professionals in general and the resident doctors, in particular, understand their statutory and regulatory responsibilities while handling a dead patient.

Duties of a resident doctor facing a dead patient

Diagnose death

Declare death

Fill “Death report” as per prescribed format and send it to appropriate authority

Certify cause of death

Inform the appropriate authorities because the Maharashtra State Government Act, 1976 (Section 5(2) mentions that death must be informed within 72 hours to the local municipal authorities

Handle the mob

Stepwise procedure in handling patient death

I. Step 1- To establish death

The following helps to routinely recognise and establish death:

No spontaneous movements

No respiratory effort for more than a minute

No heart sounds or palpable pulses for more than a minute

Absence of reflexes e.g., corneal

Fixed and dilated pupils

No response to painful stimuli

Rigor mortis seen 3 hours after death

Approved tests for brain stem deaths (Human Organ Transplant Act)

Pupillary light reflex: Dilated and fixed not reacting to light (cranial nerve II and III; nuclei in midbrain)

VOR reflex absent (Vestibulo-ocular Caloric test): Eye movement with 50 ml of cold water in ear for 1 minute is absent (cranial nerve III, VI and VIII; nuclei in midbrain/pons)

Occulo-cephalic reflex: Dolls eye movement absent (cranial nerve III, VI and VIII; nuclei in midbrain/pons)

Corneal reflex absent (cranial nerve V and VII; nuclei in pons)

Pharyngeal gag reflex absent (cranial nerve IX and X; nuclei in medulla)

Cough (tracheal reflex) absent (cranial nerve X; nuclei in medulla)

Vagal nerve function (atropine challenge negative; cranial nerve X; nuclei in Medulla)

Response to painful stimulus in trigeminal nerve distribution (cranial nerve V and VII; nuclei in pons)

Apnoea test: Raise pCO2 >50 to 60 mmHg by disconnecting ventilator– no spontaneous respiration

Tests for cortical functions: EEG/verbal response/co-ordinated and spontaneous eye movement

Declaration of brain stem death as per THO act

Who should diagnose and declare?

Team of four medical experts including: Medical Administrator In charge of the hospital, Authorised Neurologist/Neuro-Surgeon, Medical Officer treating the patient

Amendments in the THO Act (2011) have allowed selection of a surgeon/physician and an anaesthetist/intensivist, in the event of the non-availability of approved neurosurgeon/neurologist.

What would the team confirm?

Is the patient deeply comatose due to irreversible brain damage of known aetiology?

Is he/she on ventilator despite stopping all neuromuscular blocking agents

Are all brain-stem reflexes absent?

All the prescribed tests are required to be repeated, after a minimum interval of 6 hours, “to ensure that there has been no observer error” and to document the persistence of the clinical state.

The following investigations are not legally mandatory but may be done if the clinician desires:

Cerebral angiography particularly a four-vessel angiogram: A gold standard to demonstrate absent cerebral circulation remains

CT angiography

CT perfusion and magnetic resonance angiography

EEG

Please note: It is also affected by hypothermia, drugs and metabolic diseases.

Transcranial Doppler

Radionuclide imaging techniques like Technetium-99 m scan

II. Step 2- Give ‘Death report’

After declaration of death to the relatives, a death report is prepared in a format prescribed by various municipal corporations; the format has two components- legal and statistical

It is the doctor’s duty to fill the death report even if we have decided not to give a DC

III. step 3 Give DC if we know the cause of death

Doctors can safely give DC in the following situations:

1 If the cause of death is known and it’s a natural death e.g death following a disease or malfunction of the body: DC can be given by the physician who has attended the patient within 14 days prior to death (no such ’14 days’ rule/case law exists in India, but it is prudent to follow it as it has become a norm).

2 In case of unnatural death and in a medicolegal case if the cause of death is known: DC should be handed over to the police along with the dead body for final ‘Panchanama”. The investigating officer may choose to accept the DC and hand over a copy to relatives for final cremation. But, the investigating officers may also be suspicious and may still want a medicolegal post-mortem.

3 In case death has occurred because of old age the cause is ‘senility’: If the patient was never attended by the physician in past 14 days the local corporate can certify the death due to senility. Several general practitioners have to succumb to social pressures to give DC in such situations.

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