[Refer 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 s / o, w /o, d / o, Shri ... resident of is dead on ac- count 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.
Date . Signature ...
R.M.P., Incharge of the Hospital in which brain-stem death has occurred.
R.M.P., nominated from the panel of names approved by the Appropriate Authority.
Neurologist / Neuro-Surgeon nominated from the panel of names approved by the Appropriate Authority.
R.M.P., treating the aforesaid deceased person.
BRAIN-STEM DEATH CERTIFICATE
(A) Patient Details:
1. Name of the Patient Shri/ Smt ./ Km. ...
S.O. / W.O. / D.O. Shri ..
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. Is this a Police Case? Yes
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-responsible coma ...
2.Findings of Board of Medical Experts:
The following reversible cause of coma have been excluded:-
Relaxants (Neuromuscular blocking agents)
first Medical Examination Second Medical Examination
1st 2nd 1st 2st
Metabolic of endocrine disorders
Test for absence of brain-stem functions
Cessation of spontaneous breathing
Pupillary light reflexes
Dolls head eye movements
Corneal reflexes (Both sizes)
Motor response in any cranial nerve distribution, any responses to stimulation of face, limb or trunk
Eye movements on coloric testing bilaterally
Apnoea tests as specified
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,
Shri / Smt / Km. is declared brain-steam dead.
Medical Administrator Incharge of the hospital.
Neurologist / Neuro-Surgeon.
Medical Officer treating the patient.
I. The Minimum time interval between the first testing and second
Testing will be six hours.
II. No. 2 and No. 3 will be co-opted by the Administrator Incharge of the hospital from the panel of experts approved by the Appropriate Authority.