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THE
TRANSPLANTATION OF HUMAN ORGANS
ACT, 1994
(Central
Act 42 0f 1994) |
FORM - 8
[(See rule 4(3) (a) and (b)]
We the following members of the Board of medical experts after
careful personal examination hereby certify that Shri/Smt/Km.......................................................................aged
about.......................son of/wife of/ daughter
of...........................................................resident
of
...................................................................is
dead on account of permanent and irreversible cessation of all
function of the brain stem. The test carried out by us and the
findings therein are recorded in the brain stem death Certificates
annexed hereto.
Dated....................................
Signature............................................
1. R.M.P Incharge of the Hospital in which brain-stem death has
occurred.
2. R.M.P. nominated from the panel of
names approved by the Appropriate Authority
3. Neurologist / Neuro Surgeon nominated
. from the panel of names approved by
Appropriate Authority.
4. R.M.P. treating the aforesaid deceased person
BRAIN STEM DEATH CERTIFICATE
(A) PATIENT DETAILS :
1. Name of the Patient Mr/Ms. ....................................……..........................
S.O./D.O./W.O. Mr. ........................................
.................... ..........
Sex................................ Age ....................... 2.
Home Address
......................................................................
......................................................................
3. Hospital Number
.....................................................................
. .
....................................................................
4. Name and Address of next of kin or
.....................................................................
person responsible for the patient (if none
.....................................................................
exists,this must be specified)
……………………………………………
....................................................................
....................................................................
5. Has the patient or next of kin agreed
....................................................................
to any transplant ?
.....................................................................
6. In this a police Case ?
Yes.............................No............................
(A) PRE-CONDITIONS:
1. Diagnosis : Did the patient suffer from any illness or accident
that led to irreversible brain damage? Specify details
..............................................................................................
...........................................................................................................................................
Date and time of accident/onset of illness
............................................................................
Date and onset of no-responsible coma …............................................................................
2. Finding of Board of Medical Experts : (i) The following
reversible causes of coma have been excluded:
Intoxication (Alcohol)
Depressant Drugs
Relaxants (Neuromuscular blocking agents)
First Medical Examination Second Medical Examination
1st 2nd 1st
2nd
Primary hypothermia
Hypovolaemic shock
Metabolic or endocrine disorders
Tests for absent of brain stem functions
2) Coma
3) Cessation of spontaneous breathing.
4) Pupillary Size
5) Pupillary light reflexes
6) Dolls head eyes movement
7) Corneal reflexes (Both Sizes)
8) Motor response in any cranial nerve distribution, any responses
to simulation of face limb of trunk
9) Gag reflex,
10) Cough (Tracheal)
11) Eye movements on caloric testing bilaterally
12) Apnoea tests as specified
13) Were any respiratory movements seen?
Date and Time of first testing
........................................................................
Date and Time of second testing
........................................................................
This to certify that the patient has been carefully examined twice
after an interval of about six hours and on the basis of findings
recorded above,
Mr/Mrs.................................................................
is declared brain-stem dead.
1. Medical Administrator Incharge of the hospital 2. Authorised
Specialist
3. Neurologist/ Neuro Surgeon
4.
Medical officer treating patient.
NB. I. The minimum time interval between the first testing and
second testing will be six hours.
II. No.2 and No.3 will bo co-opted by the administrator incharge
of the hospital from the panel of experts approved by the
appropriate authority.
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