For certification of brain stem death (To be filled by the board of medical experts certifying brain-stem death) [See rules 5(4)(c) and 5(4)(d)]

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 functions of the brain-stem. The tests carried out by us and the findings therein are recorded in the brain-stem death Certificate annexed hereto. Dated........................ Signature................................................ 1. R.M.P.- Incharge of the Hospital 2. R.M.P. nominated from the panel of In which brain-stem death has occurred. Names sent by the hospitals and approved by the Appropriate Authority. 3. Neurologist/Neuro-Surgeon 4. R.M.P. treating the aforesaid deceased person (where Neurologist/Neurosurgeon is not available, any Surgeon or Physician and Anaesthetist or Intensivist, nominated by Medical Administrator Incharge from the panel of names sent by the hospital and approved by the Appropriate Authority shall be included) BRAIN-STEM DEATH CERTIFICATE (A) PATIENT DETAILS.......................... 1. Name of the patient: Mr./Ms................................................................. S.O./D.O./W.O. Mr./Ms................................................................... Sex...............................Age..................................... 2. Home Address: ..................................................................................... 3. Hospital Patient Registration Number (CR No.): 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 donation of organ and/or tissue? ............................................................ 6. Is this a Medico-legal Case? Yes.............................No...................... (B) 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 non-reversible coma................................................................................... 2. Findings of Board of Medical Experts: _____________________________________ First Medical Examination Second Medical Examination (1) The following reversible causes of coma have been excluded: Intoxication (Alcohol) Depressant Drugs Relaxants (Neuromuscular blocking agents) Primary Hypothermia Hypovolaemic shock Metabolic or endocrine disorders Tests for absence of brain-stem functions (2) Coma (3) Cessation of spontaneous breathing (4) Pupillary size (5) Pupillary light reflexes (6) Doll’s head eye movements (7) Corneal reflexes (Both sizes) (8) Motor response in any cranial nerve distribution, any responses to stimulation of face, limb or 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 is 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./Ms............................................................................ is declared brain-stem dead. Date: Signatures of members of Brain Stem Death (BSD) Certifying Board as under: 1. Medical Administrator Incharge of the hospital 2. Authorised specialist. 3. Neurologist/Neuro-Surgeon 4. Medical Officer treating the Patient. Note. I. Where Neurologist/Neurosurgeon is not available, then any Surgeon or Physician and Anaesthetist or Intensivist, nominated by Medical Administrator Incharge of the hospital shall be the member of the board of medical experts for brain-stem death certification. II. The minimum time interval between the first and second testing will be six hours in adults. In case of children 6 to 12 years of age, 1 to 5 years of age and infants, the time interval shall increase depending on the opinion of the above BSD experts. III. No.2 and No.3 will be co-opted by the Administrator Incharge of the hospital from the Panel of experts (Nominated by the hospital and approved by the Appropriate Authority).