Brain death is not the same as coma, because someone in a coma is unconscious but still alive.

Brain death occurs when a critically ill patient dies sometime after being placed on life support. This situation can occur after, for example, a heart attack or stroke. The heart continues to beat while the ventilator delivers oxygen to the lungs (the heart can initiate its own beating without nerve impulses from the brain) but, despite the beating heart and warm skin, the person is dead. Since the brain has stopped working, the person wont breathe if the ventilator is switched off. Signs of brain death Some of the signs of brain death include: y The pupils dont respond to light. y The person shows no reaction to pain. y The eyes dont blink when the eye surface is touched (corneal reflex). y The eyes dont move when the head is moved (oculocephalic reflex). y The eyes dont move when ice water is poured into the ear (oculo-vestibular reflex). y There is no gagging reflex when the back of the throat is touched. y The person doesnt breathe when the ventilator is switched off. y An electroencephalogram test shows no brain activity at all. Brain death is not the same as coma Brain death differs from other states of unconsciousness in important ways. For example, coma is similar to deep sleep, except that no amount of external stimuli can prompt the brain to become awake and alert. However, the person is alive and recovery is possible. Brain death is often confused with a persistent vegetative state, but these conditions are not the same either. A persistent vegetative state means the person has lost higher brain functions, but their undamaged brain stem still allows essential functions like heart rate and respiration to continue. A person in a vegetative state is alive and may recover to some degree, given time. Brain death means the person has died. Anguish for the family Because life support machines maintain the persons breathing and heart rate, they are warm to the touch. This gives the illusion that the person is still alive. Family members may hold a false hope that the person is just comatose and could wake up with time or treatment. It is important for the medical staff members to fully explain that brain death is final, and that the person is dead and has no chance of ever regaining consciousness again. Organ donation is possible In some cases, a person who is brain dead may be a candidate for organ donation. If the person was a registered organ donor, or if their family knew of their wish to be an organ donor, their death is declared but the ventilator is left on. Drugs that help preserve the internal organs are still given. The dead person then undergoes an operation to remove viable organs such as kidneys. After the operation is complete, the ventilator is switched off. Funeral arrangements can then be made by the family. Where to get help y Your doctor y Neurologist y Victorian Organ Donor Service - LifeGift Tel. (03) 9349 2278 y Australians Donate Tel. (08) 8351 5222 Things to remember y Brain death occurs when a critically ill patient dies sometime after being placed on life support. y In some cases, a person who is brain dead may be a candidate for organ donation. y Signs of Impending Death Every Caregiver Should Know y One of caregivers' biggest fears is that the care-receiver will die on their shift. Most people have never watched someone die. y It doesn't always happen the way it is portrayed in the movies. y Every death is unique. How your loved-one enters the dying phase will depend on a lot of variables. Even though there is not a specific sequence of events, there will be noticeable changes to be aware of. y Here are a few: y 1. Increased sleeping usually occurs in the days or hours before death. As death approaches you may not be able to wake the care-receiver from a coma-like state.
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y y

y y

2. The care-receiver gradually stops taking in food or beverage. Do not try to force food or water on your loved one. This could cause them to choke. If they are thirsty but can't swallow you can moisten their lips with ice. 3. The care-receiver's body elimination will usually cease. Urine output will drop as the kidneys shut down. 4. Another sign is the fading strength of the heartbeat. Towards the end you may not be able to feel a pulse in the arms or legs. The pulse may race as the heart tries to overcome the fluid buildup in the lungs. Blood pressure may begin to drop. The care-receiver's extremities may seem cool to the touch. 5. Irregular breathing patterns may be part of the dying process. Dyspnea is labored breathing and short breaths. Apnea is a period of no breathing that lasts for between one and sixty seconds. Cheyne-Stokes breathing is a rhythmic waxing and waning of the breathing which may alternate with period of apnea. In the later stages, the "death rattle" may be heard. This is when mucus in the mouth accumulates in the back of the throat and makes a distinct sound. 6. As the ability to take in oxygen decreases, the care-receiver may seem confused and have decreased alertness. Restlessness may occur, too. The care-receiver may pick at his/her clothing or bed linens. He/she may struggle to get comfortable. 7. Fever is common toward the end, as the body tries to fight off mega-infections. 8. The care-receiver's vision may become dim or blurred. However, hearing seems to be one of the last senses to go. 9. The dying person may shout out a yell at the time of death.This is caused by a physical spasm in the voice box rather than an attempt to communicate. When your loved one has died, there will not be a heartbeat or breathing. The eyelids will be slightly open and his/her eyes will be staring straight ahead. The jaw will relax and fall slightly open. Immediately after death, his/her skin will lose it glow. Watching someone die is an extraordinary and emotionally painful experience. And yet, most people report it is also a profound experience, a miracle.

Advance Directives

What kind of medical care would you want if you were too ill or hurt to express your wishes? Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on. A living will tells how you feel about care intended to sustain life. You can accept or refuse medical care. There are many issues to address, including
y The use of dialysis and breathing machines y If you want to be resuscitated if breathing or heartbeat stops y Tube feeding y Organ or tissue donation

A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions if you are unable to do so. Euthhe termination of a very sick person's life in order to relieve them of their suffering. most cases euthanasia is carried out because the person who dies asks for it, but there are cases called euthanasia where a person can't make such a request. What is Euthanasia? Euthanasia is the termination of a very sick person's life in order to relieve them of their suffering.
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A person who undergoes euthanasia usually has an incurable condition. But there are other instances where some people want their life to be ended. In many cases, it is carried out at the person's request but there are times when they may be too ill and the decision is made by relatives, medics or, in some instances, the courts. The term is derived from the Greek word euthanatos which means easy death. Euthanasia is against the law in the UK where it is illegal to help anyone kill themselves. Voluntary euthanasia or assisted suicide can lead to imprisonment of up to 14 years. The issue has been at the centre of very heated debates for many years and is surrounded by religious, ethical and practical considerations. The ethics of euthanasia Euthanasia raises a number of agonising moral dilemmas:
y y y

is it ever right to end the life of a terminally ill patient who is undergoing severe pain and suffering? under what circumstances can euthanasia be justifiable, if at all? is there a moral difference between killing someone and letting them die? At the heart of these arguments are the different ideas that people have about the meaning and value of human existence. Should human beings have the right to decide on issues of life and death? There are also a number of arguments based on practical issues. Some people think that euthanasia shouldn't be allowed, even if it was morally right, because it could be abused and used as a cover for murder. Killing or letting die Euthanasia can be carried out either by taking actions, including giving a lethal injection, or by not doing what is necessary to keep a person alive (such as failing to keep their feeding tube going). 'Extraordinary' medical care It is not euthanasia if a patient dies as a result of refusing extraordinary or burdensome medical treatment. Euthanasia and pain relief It's not euthanasia to give a drug in order to reduce pain, even though the drug causes the patient to die sooner. This is because the doctor's intention was to relieve the pain, not to kill the patient. This argument is sometimes known as the Doctrine of Double Effect. Mercy killing Very often people call euthanasia 'mercy killing', perhaps thinking of it for someone who is terminally ill and suffering prolonged, unbearable pain. Why people want euthanasia Most people think unbearable pain is the main reason people seek euthanasia, but some surveys in the USA and the Netherlands showed that less than a third of requests for euthanasia were because of severe pain. Terminally ill people can have their quality of life severely damaged by physical conditions such as incontinence, nausea and vomiting, breathlessness, paralysis and difficulty in swallowing.

Psychological factors that cause people to think of euthanasia include depression, fearing loss of control or dignity, feeling a burden, or dislike of being dependent. What is Our Duty to Persons Who are Terminally Ill? Considering first our duty to persons who are terminally ill, it is of supreme irony that while terminal care has always been a major concern of physicians through the centuries, the explosive triumph of medical knowledge in this generation has served to focus attention in directions that have largely excluded the dying.(1) Such care as is offered means, in the popular mind, a hospice in the form of a gloomy building hidden behind high walls where hushed attendants wait, impotent and silent, until death releases their charges from further pain and suffering. The genius of the contribution of Dr. Cicely Saunders has not been the re-creation of the hospice as a less oppressive place for terminal care. The credit for that lies with the nuns of Ireland under the leadership of Mother Mary Aikenhead.(2) Rather it was to reclaim scientific medicine for the care of man, to show that academic excellence, critical research, and teaching all belong to the care of the whole person in his final days every bit as much as they do in any other phase of the fight against disease.(3) Such has been the magnitude of her contribution that the stage has been reached where care for persons who are terminally ill rests on a solid bedrock of scientific observation, and terminal care is at last resuming its rightful place in mainstream medicine. No longer a field reserved for retired and moribund physicians, it is attracting an ever-increasing flow of young and academically orientated physicians. In meeting the challenge of care for persons who are terminally ill, it must never be said or even thought that nothing more can be done. Cure or no cure, patients are entitled to the assurance that everything possible continues to be done. A patient dying of cancer may present a constellation of symptoms, and the goal must be to gain control of them all so that the patient and his family can employ to the fullest extent whatever time remains. Pain looms large in the thoughts of most people at the very mention of cancer, and looms even larger in the arguments of those who would have others adopt euthanasia. However, at least a third of all patients dying of malignant disease suffer no pain at any time.(4) Even though pain is not the most common symptom, this article will consider pain as an illustrative example of what is possible to offer the terminally ill in lieu of euthanasia, and of how much can be done to make the life that remains worth living. The approach to an incurable patient in pain is no different from the approach to any other person in distress. A physician well trained in this area needs to first take a careful history and to conduct a thorough examination. From the observations of Dr. Saunders,(5) it is clear that pain is more than just a disagreeable physical sensation. "Total pain" is comprised of mental, social, spiritual, and physical pain. Failure to remember this complexity is one of the most common reasons why patients fail to achieve adequate symptomatic relief.(6) Mental Pain Mental pain is prevalent when dying, especially in the minds of those who die young and face the distress of leaving behind small children. This distress expresses itself differently at different times, and although few patients follow the sequence described by Elizabeth Kubler-Ross,(7) the elements of denial, anger, bargaining, depression, and acceptance are commonly encountered. When there is little that can be done about the patient's impending death, just standing by them means more than one realizes. At St. Christopher's Hospice, each patient is assured that they will never be alone, and that promise is honored. Social Pain Social pain may arise as a patient contemplates his family as it will be when he is no longer there. If he has been the provider, has he done enough? Will there be problems in relation to housing? Helping the patient put his affairs in order, encouraging him to make a will, and planning with his family for the future may ease this distress. Where available, social services can be mobilized. Knowing that the team looking after him will remain in contact with his family after he has died may also provide the patient with much needed reassurance. Spiritual Pain

Spiritual pain speaks for itself. Many people do not consider the possibility of life after death until it becomes all too apparent that their immediate future is bound up in it. This is not to say that good terminal care is to be regarded as a vehicle for proselytizing. On the contrary, the attitude has to be one of complete tolerance for religious and non-religious persons alike. Nevertheless, in American society many patients will have roots in either the Jewish or Christian faith, and the caregiver must remain sensitive to those patients who will accept solace from the realm of faith. There must be a readiness to refer the patient to a pastor, priest, or rabbi of the patient's choosing. Physical Pain In the management of physical pain, accurate diagnosis is crucial. It has been observed that one out of five cancer patients have only one identifiable source of pain; four out of five have two or more separate causes of pain; and one in three patients have four or more pain producing processes active at any one time.(8) The need for careful history and examination is clear. There is a need to know, for example: a. Is the pain due to invasion of the soft tissues? b. Is the pain due to nerve compression? c. Is the pain due to distention of the liver by multiple secondaries? d. Is the pain due to involvement of the bones, with an actual or threatened pathological fracture? e. Is the pain due to some nonmalignant complication of the disease, such as abscess formation or some other infection? f. Is the pain due to some complication of therapy, such as: pain in a surgical incision, pain following radiotherapy, or gastric irritation caused by aspirin? Having defined the cause or causes of the patient's pain as accurately as possible, the available therapeutic options need to be considered. All too often physicians fail their patients, either through ignorance of the drugs available, or through neglect of the other forms of treatment available. A wide range of pain relieving drugs is available. It is appropriate to begin with well known mild analgesics such as aspirin or acetaminophen. There is an ever increasing number of other drugs which act in the same way as aspirin. These include indomethacin, ibuprofen, naproxen, and sulindac. They differ in duration of action and side effects, but basically all can provide effective relief of mild-to-moderate pain and are especially effective in providing relief of pain arising from bone and joint. A more potent analgesic is represented by codeine, an opiate derivative. People often unnecessarily fear codeine because of its minimal ability to cause addiction. Its main problem, like all opiates, is that it may cause constipation. Often combined with acetaminophen it is an effective analgesic of moderate strength. If more powerful analgesia is needed, and if it has been determined that the pain is likely to be responsive to opiates, there should be no hesitation in prescribing morphine. For relief of severe pain, morphine remains unexcelled although it is shrouded in myths which the medical profession embraces all too often. For example, "I don't want to start you on morphine now, because if I do, when we really need it, it will have lost its effect;" or "I'm afraid if I start you on morphine I may turn you into a drug addict." The fear of drug addiction in terminally ill patients would be laughable if it had not caused so many patients to endure needless pain. It is well documented that if morphine is taken for the relief of pain, habituation does not occur. Unless the disease advances, dosage requirements usually remain remarkably stable for many months, and if some other pain relieving procedure is initiated, such as a nerve block, morphine can be quite rapidly withdrawn without provoking the type of severe withdrawal seen in a true addict. Where can Pain Management be Provided?
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Separate buildings like St. Christopher's Hospice serve as a monument of protest against the shortcomings of modern high-tech medicine,(12) and have had the effect of making people think that the only way of caring for the terminally ill is in such a building. However this is by no means certain, and Dr. Saunders argues that "[p]atients should end their lives in the place most appropriate to them and their families."(13) There is much to be said for the patient continuing to receive care in the same hospital in which he began. At the very least this avoids the impression that he is being shunted off out of the way, to a place where he can expire quietly. There is also the advantage of the ready availability of diagnostic services such as the bacteriology laboratory, the anesthesiologist and the radiotherapy department, if such should be needed. A consultation team of doctors, nurses, and social workers, who have been specially trained in various aspects of terminal care, interacting with the patient's primary care physicians is an increasingly common way of providing a hospice type of care in the context of a general hospital. Many patients are well enough to spend a considerable period of time at home in familiar surroundings with a degree of privacy which no hospital bed could ever afford. A major thrust in terminal care in some quarters of late has been to develop support from visiting nurses and trained volunteers to such a degree that many patients are enabled to live out their days at home. It is well worth the effort. What is the Consequence if Pain Management is Not Provided? As an illustration of the consequences of failure to provide pain management is the story of Frank, culled from the literature of the Hemlock Society.(14) Rigor mortis Once the heart stops beating, blood collects in the most dependent parts of the body (livor mortis), the body stiffens (rigor mortis), and the body begins to cool (algor mortis).

Ads by Google The blood begins to settle in the parts of the body that are the closest to the ground, usually the buttocks and back when a corpse is supine. The skin, normally pink-colored because of the oxygen-laden blood in the capillaries, becomes pale as the blood drains into the larger veins. Within minutes to hours after death, the skin is discolored by livor mortis, or what embalmers call "postmortem stain," the purple-red discoloration from blood accumulating in the lowermost (dependent) blood vessels. Immediately after death, the blood is "unfixed" and will move to other body parts if the body's position is changed. After a few hours, the pooled blood becomes "fixed" and will not move. Pressing on an area of discoloration can determine this; if it blanches (turns white) easily, then the blood remains unfixed. Livor mortis is usually most pronounced eight to twelve hours after death. The skin, no longer under muscular control, succumbs to gravity, forming new shapes and accentuating prominent bones still further. The body then begins to cool. At the moment of death, the muscles relax completelya condition called "primary flaccidity." The muscles then stiffen, perhaps due to coagulation of muscle proteins or a shift in the muscle's energy containers (ATPADP), into a condition known as rigor mortis. All of the body's muscles are affected. Rigor mortis begins within two to six hours of death, starting with the eyelids, neck, and jaw. This sequence may be due to the difference in lactic acid levels among different muscles, which corresponds to the difference in glycogen levels and to the different types of muscle fibers. Over the next four to six hours, rigor mortis spreads to the other muscles, including those in the internal organs such as the heart. The onset of rigor mortis is more rapid if the

environment is cold and if the decedent had performed hard physical work just before death. Its onset also varies with the individual's age, sex, physical condition, and muscular build. After being in this rigid condition for twenty-four to eighty-four hours, the muscles relax and secondary laxity (flaccidity) develops, usually in the same order as it began (see Table 1). The length of time rigor mortis lasts depends on multiple factors, particularly the ambient temperature. The degree of rigor mortis can be determined by checking both the finger joints and the larger joints and ranking their degree of stiffness on a one- to threeor four-point scale. Many infant and child corpses will not exhibit perceptible rigor mortis. This decreased perceptible stiffness may be due to their smaller muscle mass. During this period, the body gradually cools in a process called algor mortis. The best way to accurately assess a corpse's temperature is with a core (tympanic membrane, liver, or rectal) thermometer. Rectal insertion may be difficult and cause postmortem injury. A few adult corpses may not undergo perceptible rigor mortis. Folklore in Britain, the Philippines, and elsewhere ascribed fearsome supernatural powers to these "limber corpses." In the early nineteenth century, the American and British poor often prepared their own dead for burial in a process called "laying-out," "streeking," or rendering the "last offices." Women normally washed the corpse, plugged its orifices, closed its eyes and mouth, straightened its limbs, and dressed or shrouded it. It was ritually important to close the eyes quickly, being that they are the first to rigidify in rigor mortis, and it was thought that a corpse with open eyes posed a threat to its kin. As has long been the case in many cultures, they used coins to keep the corpse's eyes closed. The practice of using coins endures, representing a feeling that money, so important in life, may also be important in death.

Autopsy From Wikipedia, the free encyclopedia "Post-mortem" redirects here. For other uses, see Post-mortem (disambiguation). This article is about the medical procedure. For other uses, see Autopsy (disambiguation). An autopsyalso known as a post-mortem examination, necropsy (particularly as to non-human bodies), autopsia cadaverum, orobductionis a highly specialized surgical procedure that consists of a thorough examination of a corpse to determine the cause and manner of death and to evaluate any disease or injury that may be present. It is usually performed by a specialized medical doctor called apathologist.

Autopsies are either performed for legal or medical purposes. For example, a forensic autopsy is carried out when the cause of death may be a criminal matter, while a clinical or academic autopsy is performed to find the medical cause of death and is used in cases of unknown or uncertain death, or for research purposes. Autopsies can be further classified into cases where external examination suffices, and those where the body is dissected and internal examination is conducted. Permission from next of kin may be required for internal autopsy in some cases. Once an internal autopsy is complete the body is reconstituted by sewing it back together. [edit]History The term "autopsy" derives from the Ancient Greek autopsia, "to see for oneself", derived from (autos, [1] "oneself") and (opsis, "eye"). Around 3000 BC, the ancient Egyptianswere one of the first civilizations to practice the removal and examination of the internal organs of humans in the religious practice of mummification.[1][2] Autopsies that opened the body to determine the cause of death are attested at least in the early third millennium BC, although they were opposed in many ancient societies where it was believed that the outward disfigurement of dead persons prevented them from entering the afterlife[3] (as with the Egyptians, who removed the organs through tiny slits in the body).[1]Notable Greek autopsists were Erasistratus and Herophilus of Chalcedon, who lived in 3rd century BC Alexandria, but in general, autopsies were rare in ancient Greece.[3] In 44 BC,Julius Caesar was the subject of an official autopsy after his murder by rival senators, and the physician's report noted that the second stab wound Caesar received was the fatal one.[3]By around 150 BC, ancient Roman legal practice had established clear parameters for autopsies.[1] The dissection of human remains for medical reasons continued to be practiced irregularly after the Romans, for instance by the Arab physicians Avenzoar and Ibn al-Nafis, but the modern autopsy process derives from the anatomists of the Renaissance. Giovanni Morgagni (16821771), celebrated as the father of anatomical pathology,[4] wrote the first exhaustive work on pathology, De Sedibus et Causis Morborum per Anatomen Indagatis (The Seats and Causes of Diseases Investigated by Anatomy, 1769).[1] The great nineteenth-century medical researcher Rudolf Virchow, in response to a lack of standardization of autopsy procedures, established and published specific autopsy protocols (one such protocol still bears his name). [edit]Purpose The principal aim of an autopsy is to determine the cause of death, the state of health of the person before he or she died, and whether any medical diagnosis and treatment before death was appropriate. In most Western countries the number of autopsies performed in hospitals has been decreasing every year since 1955. Critics, including pathologist and former JAMA editor George Lundberg, have charged that the reduction in autopsies is negatively affecting the care delivered in hospitals, because when mistakes result in death, they are often not investigated and lessons therefore remain unlearned. When a person has given permission in advance of their death, autopsies may also be carried out for the purposes of teaching or medical research. An autopsy is frequently performed in cases of sudden death, where a doctor is not able to write a death certificate, or when death is believed to result from an unnatural cause. These examinations are performed under a legal authority (Medical Examiner or Coroner or Procurator Fiscal) and do not require the consent of relatives of the deceased. The most extreme example is the examination of murder victims, especially when medical examiners are looking for signs of death or the murder method, such as bullet wounds and exit points, signs ofstrangulation, or traces of poison. Many religions such as Judaism and Islam usually discourage the
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performing of autopsies on their adherents. Organizations such as Zaka in Israel andMisaskim in the USA generally guide families how to ensure that an unnecessary autopsy is not made. [edit]In medicine Autopsies are important in clinical medicine as they can identify medical error and assist continuous improvement. A study that focused on myocardial infarction (heart attack) as a cause of death found significant errors of omission and commission,[5] i.e. a sizable number cases ascribed to myocardial infarctions (MIs) were not MIs and a significant number of non-MIs were actually MIs. A systematic review of studies of the autopsy calculated that in about 25% of autopsies a major diagnostic error will be revealed.[6] However, this rate has decreased over time and the study projects that in a contemporary US institution, 8.4% to 24.4% of autopsies will detect major diagnostic errors. A large meta-analysis suggested that approximately one-third of death certificates are incorrect and that half of the autopsies performed produced findings that were not suspected before the person died.[7] Also, it is thought that over one fifth of unexpected findings can only be diagnosed histologically, i.e. by biopsy or autopsy, and that approximately one quarter of unexpected findings, or 5% of all findings, are major and can similarly only be diagnosed from tissue. One study found that "Autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis, among others".[8] Focusing intubated patients, one study found "abdominal pathologic conditions--abscesses, bowel perforations, or infarction--were as frequent as pulmonary emboli as a cause of class I errors. While patients with abdominal pathologic conditions generally complained of abdominal pain, results of examination of the abdomen were considered unremarkable in most patients, and the symptom was not pursued".[9] [ [edit]Types There are three main types of autopsies:[10]


Medico-Legal Autopsy or Forensic or coroner's autopsies seek to find the cause and manner of death and to identify the decedent.[10] They are generally performed, as prescribed by applicable law, in cases of violent, suspicious or sudden deaths, deaths without medical assistance or during surgical procedures.[10]

Clinical or Pathological autopsies are performed to diagnose a particular disease or for research purposes. They aim to determine, clarify, or confirm medical diagnoses that remained unknown or unclear prior to the patient's death.[10] Anatomical or academic autopsies are performed by students of anatomy for study purpose only.

Forensic autopsy A forensic autopsy is used to determine the cause of death. Forensic science involves the application of the sciences to answer questions of interest to the legal system. In United States law, deaths are placed in one of five manners:
  

Natural Accident Homicide

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Suicide Undetermined

In some jurisdictions, the Undetermined category may include deaths in absentia, such as deaths at sea and missing persons declared dead in a court of law; in others, such deaths are classified under "Other". But, medical examiners also attempt to determine the time of death, the exact cause of death, and what, if anything, preceded the death, such as a struggle. A forensic autopsy may include obtaining biological specimens from the deceased for toxicological testing, including stomach contents. Toxicology tests may reveal the presence of one or more chemical "poisons" (all chemicals, in sufficient quantities, can be classified as a poison) and, the quantity of those chemicals. Because post-mortem deterioration of the body, together with the gravitational pooling of bodily fluids, will necessarily alter the bodily environment, toxicology tests may overestimate, rather than underestimate, the quantity of the suspected chemical. [11] Most states require the State medical examiner to complete an autopsy report and many mandate that the autopsy be videotaped. Following an in-depth examination of all the evidence, a medical examiner or coroner will assign a manner of death as one of the five listed above, and detail the evidence on the mechanism of the death. Clinical autopsy Clinical autopsies serve two major purposes. They are performed to gain more insight into pathological processes and determine what factors contributed to a patient's death. Autopsies are also performed to ensure the standard of care at hospitals. Autopsies can yield insight into how patient deaths can be prevented in the future. Within the United Kingdom, clinical autopsies can only be carried out with the consent of the family of the deceased person as opposed to a medico-legal autopsy instructed by a Coroner (England & Wales) or Procurator Fiscal (Scotland) to which the family cannot object. Prevalence In 2004 in England and Wales, there were 514,000 deaths of which 225,500 were referred to the coroner. Of those, 115,800 (22.5%) resulted in post-mortem examinations and there were 28,300 inquests, 570 with a jury.[12] In the United States, autopsy rates fell from 17% in 1980[13] to 14% in 1985[13] and 11.5% in 1989,[14] although the figures vary notably from county to county. Process The body is received at a medical examiner's office or hospital in a body bag or evidence sheet. A new body bag is used for each body to ensure that only evidence from that body is contained within the bag. Evidence sheets are an alternate way to transport the body. An evidence sheet is asterile sheet that the body is covered in when it is moved. If it is believed there may be any significant residue on the hands, for instancegunpowder, a separate paper sack is put around each hand and taped shut around the wrist. There are two parts to the physical examination of the body: the external and internal examination. Toxicology, biochemical tests and/or genetic testing often supplement these and frequently assist the pathologist in assigning the cause or causes of death. [edit]External examination At many institutions the person responsible for handling, cleaning, and moving the body is often called a diener, the German word for servant. In the UK this role is performed by an Anatomical Pathology Technologist who
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will also assist the pathologist in eviscerating the deceased and reconstruction after the autopsy. After the body is received, it is first photographed. The examiner then notes the kind of clothes and their position on the body before they are removed. Next, any evidence such as residue, flakes of paint or other material is collected from the external surfaces of the body. Ultraviolet light may also be used to search body surfaces for any evidence not easily visible to the naked eye. Samples of hair, nails and the like are taken, and the body may also be radiographically imaged. Once the external evidence is collected, the body is removed from the bag, undressed, and any wounds present are examined. The body is then cleaned, weighed, and measured in preparation for the internal examination. The scale used to weigh the body is often designed to accommodate the cart that the body is transported on; its weight is then deducted from the total weight shown to give the weight of the body. If not already within an autopsy room, the body is transported to one and placed on a table. A general description of the body as regards ethnicity, sex, age, hair color and length, eye color and other distinguishing features (birthmarks, old scar tissue, moles, etc.) is then made. A handheld voice recorder or a standard examination form is normally used to record this information. In some countries e.g. France, Germany, and Canada, an autopsy may comprise an external examination only. This concept is sometimes termed a "view and grant". The principles behind this being that the medical records, history of the deceased and circumstances of death have all indicated as to the cause and manner of death without the need for an internal examination.[citation
needed]

[edit]Internal examination If not already in place, a plastic or rubber brick called a "body block" is placed under the back of the body, causing the arms and neck to fall backward whilst stretching and pushing thechest upward to make it easier to cut open. This gives the prosector, a pathologist or assistant, maximum exposure to the trunk. After this is done, the internal examination begins. The internal examination consists of inspecting the internal organs of the body for evidence of trauma or other indications of the cause of death. For the internal examination there are a number of different approaches available:


a large and deep Y-shaped incision can be made starting at the top of each shoulder and running down the front of the chest, meeting at the lower point of the sternum. This is the approach most often used. a T-shaped incision made from the tips of both shoulder, in a horizontal line across the region of the collar bones to meet at the sternum (breastbone) in the middle. a single vertical cut is made from the middle of the neck (in the region of the 'adam's apple' on a male body)

In all of the above cases the cut then extends all the way down to the pubic bone (making a deviation to the left side of the navel). Bleeding from the cuts is minimal, or non-existent, because the pull of gravity is producing the only blood pressure at this point, related directly to the complete lack of cardiac functionality. However, in certain cases there is anecdotal evidence to prove that bleeding can be quite profuse, especially in cases of drowning. At this point, shears are used to open the chest cavity. It is also possible to utilise a simple scalpel blade. The prosector uses the tool to saw through the ribs on the lateral sides of the chest cavity to allow the sternum and attached ribs to be lifted as one chest plate; this is done so that the heart and lungs can be seen in situ and that the heart, in particular thepericardial sac is not damaged or disturbed from opening. A scalpel is used to remove any soft tissue that is still attached to the posterior side of the chest plate. Now the lungs and the heart are exposed. The chest plate is set aside and will be eventually replaced at the end of the autopsy.
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At this stage the organs are exposed. Usually, the organs are removed in a systematic fashion. Making a decision as to what order the organs are to be removed will depend highly on the case in question. Organs can be removed in several ways: The first is the en masse technique of letulle whereby all the organs are removed as one large mass. The second is the en bloc method of Ghon. The most popular in the UK is a modified version of this method which is divided into four groups of organs. Although these are the two predominant evisceration techniques in the UK variations on these are widespread. One method is described here: The pericardial sac is opened to view the heart. Blood for chemical analysis may be removed from the inferior vena cava or the pulmonary veins. Before removing the heart, the pulmonary artery is opened in order to search for a blood clot. The heart can then be removed by cutting the inferior vena cava, the pulmonary veins, the aorta and pulmonary artery, and the superior vena cava. This method leaves the aortic arch intact, which will make things easier for the embalmer. The left lung is then easily accessible and can be removed by cutting the bronchus, artery, and vein at the hilum. The right lung can then be similarly removed. The abdominal organs can be removed one by one after first examining their relationships and vessels. Some pathologists, however, prefer to remove the organs all in one "block". Then a series of cuts, along the vertebral column, are made so that the organs can be detached and pulled out in one piece for further inspection and sampling. During autopsies of infants, this method is used almost all of the time. The various organs are examined, weighed and tissue samples in the form of slices are taken. Even major blood vessels are cut open and inspected at this stage. Next the stomach and intestinal contents are examined and weighed. This could be useful to find the cause and time of death, due to the natural passage of food through the bowel during digestion. The more area empty, the longer the deceased had gone without a meal before death. The body block that was used earlier to elevate the chest cavity is now used to elevate the head. To examine the brain, an incision is made from behind one ear, over the crown of the head, to a point behind the other ear. When the autopsy is completed, the incision can be neatly sewn up and is not noticed when the head is resting on a pillow in an open casket funeral. The scalp is pulled away from the skull in two flaps with the front flap going over the face and the rear flap over the back of the neck. The skull is then cut with what is called a Stryker saw, named for its manufacture, to create a "cap" that can be pulled off, exposing the brain. The brain is then observed in situ. Then the brain's connection to the cranial nerves and spinal cord are severed, and the brain is then lifted out of the skull for further examination. If the brain needs to be preserved before being inspected, it is contained in a large container of formalin (15 percent solution of formaldehyde gas in buffered water) for at least two but preferably four weeks. This not only preserves the brain, but also makes it firmer allowing easier handling without corrupting the tissue. [edit]Reconstitution of the body An important component of the autopsy is the reconstitution of the body such that it can be viewed, if desired, by relatives of the deceased following the procedure. After the examination, the body has an open and empty chest cavity with chest flaps open on both sides, the top of the skull is missing, and the skull flaps are pulled over the face and neck. It is unusual to examine the face, arms, hands or legs internally. In the UK, following theHuman Tissue Act 2004 all organs and tissue must be returned to the body unless permission is given by the family to retain any tissue for further investigation. Normally the internal body cavity is lined with cotton wool or an appropriate material, the organs are then placed into a plastic bag to prevent leakage and returned to the body cavity. The chest flaps are then closed and sewn back together and the skull cap is sewed back in place. Then the body may be wrapped in a shroud and it is common for relatives of the deceased to not be able to tell the procedure has been done when the deceased is viewed in a funeral parlor after embalming.

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