Medical certification of death Training for Medical Practitioners

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Medical certification of deathTraining for
Medical Practitioners
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CEUs (Ethics) require that you

• Complete and sign attendance register
• HPCSA number
• Contact details (email)
• Complete and submit mock cause of death
  certificate for Case scenarios 13 before the
  training
• Complete and submit mock cause of death
  certificates for Case scenarios 46 immediately
  after the training

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Importance of cause of death statistics

• What you write in the cause of death section of a
  medical certificate of death is as important as
  what you write in a patients medical folder
• It forms part of a permanent legal record
• It produces statistics that are used for public
  health practice
• Indicates the overall health of a community
• Drives health policy decisions
• Determines funding for health interventions
• Health department uses this data to
• Identify needs
• Measure results
• Allocate resources

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Cause of death Death Statistics

• Mortality data are the most accessible and
  frequently used statistics
• It is a powerful source of information because it
  is collected on ALL deaths in SA
• It is derived from the words YOU write in the
  cause of death section of the Notice of
  Death/Stillbirth

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Source StatsSA
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Leading categories of deaths in SA
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Leading causes of death, Stats SA 2008
Cause of death Number of all deaths
1 Ill-defined and unknown causes 80 515 13.6
2 Tuberculosis 74 863 12.6
3 Influenza and pneumonia 45 602 7.7
4 Intestinal infectious diseases 39 351 6.6
5 Other external causes of accidental injury 33 983 5.7
6 Other forms of heart disease 26 190 4.4
7 Cerebrovascular disease 24 363 4.1
8 Diabetes mellitus 19 558 3.3
9 HIV 15 097 2.5
10 Certain disorders involving the immune system 14 639 2.5

• HIV accounted for 2.5 of all deaths and ranked
  9th

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Current Official Mortality System
Current Official Mortality System
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Legislative framework

• Legislative framework provided by the Births and
  Deaths Registration Act, No. 51 of 1992
• Requires that all deaths be registered with the
  Department of Home Affairs and to include a
  medical certification of the cause of death

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The DHA-1663

• The death certificate
• The death notification form / Notice of death
• DHA-1663A with 3 pages (carbon-copied)
  registration of death
• DHA-1663B with 1 page (single page) cause of
  death certification
• Last page (DHA-1663B) SEALED

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A death certificate
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DHA-1663A Page 1 of 3
A. Particulars of deceased
2. Identification of deceased
3. Date of death
8. ID no
9. Age
11. Sex
10. Date of birth
15. Address
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DHA-1663A Page 1 of 3
18. Education
19. Occupation
20. Business / industry
21. Smoking history
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DHA-1663A Page 2 of 3
B Certificate by attending Medical Practitioner
Certificate by attending medical
practitioner NATURAL CAUSES ___ am not in the
position to certify that the deceased died
exclusively due to natural causes ___
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C Certificate by Forensic Pathologist
DHA-1663A Page 2 of 3
MP number
D Particulars of Informant
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DHA-1663A Page 3 of 3
E Particulars of Funeral undertaker
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DHA-1663B Page 1 of 1
G MEDICAL CERTIFICATE OF CAUSE OF DEATH
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Cause-of-death cascade
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Definitions

• Immediate/Terminal cause of death
• A term used to describe the final disease that
  led to the death of the person.
• Underlying cause of death
• The (primary medical) cause of death is the
  initial disease or injury that caused the person
  to die, even if a few days or even months passed
  before the actual demise.
• Mechanism of death
• The physiological disturbance by which a cause
  of death exerts its lethal effect (e.g. cardiac
  arrest, metabolic acidosis)

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Definitions

• Contributing conditions
• Causes which contributed to the death of the
  person, but do not fit into the causal sequence
  reported in Part 1.
• It will always depend on the underlying cause of
  death!
• Example
• Chronic obstructive airways disease
  (Brain tumour)

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Underlying cause of death

• The disease that started the causal sequence
  leading to death e.g. diabetes mellitus,
  ischaemic heart disease, malaria etc.
• Cancer / tumour
• NB! State primary site.
• Benign/malignant?
• Metastases?
• Type of cancer?
• Infection
• Site
• Organism
• Septicaemia
• Mechanism!
• NB! Site of origin

Example Metastases to lungsdue to Squamous
cell carcinoma of the esophagus
Example Septicaemia due to S. Pneumoniae
otitis media
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DHA-1663B Page 1 of 1
G.2 FOR STILLBIRTHS AND DEATHS OCCURING WITHIN
ONE WEEK OF BIRTH
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Stillbirth

• A child that had at least 26 weeks of
  intra-uterine life (or 28 weeks gestation since
  last menstrual period) but showed no signs of
  life after complete birth
• WHO equates 28 weeks gestation with 1000g

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Cause-of-death
Perinatal Cause of death (Stillbirth and death
within one week of birth)
Main disease or condition in foetus or infant
Other diseases or conditions in foetus or infant
Main maternal disease or condition affecting foetus or infant
Other maternal diseases or conditions affecting foetus or infant
Other relevant circumstances
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Cause-of-death
Perinatal Cause of death (Stillbirth and death
within one week of birth)
Main disease or condition in foetus or infant Hyaline membrane disease
Other diseases or conditions in foetus or infant Down syndrome
Main maternal disease or condition affecting foetus or infant Abruptio Placentae
Other maternal diseases or conditions affecting foetus or infant Pre-ecclampsia
Other relevant circumstances Old primigravida
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Definitions
Classification Manner of death Manner of death
  Unnatural deaths INTENTIONAL Homicide Suicide Legal intervention and War
  Unnatural deaths UNINTENTIONAL Accidental Road traffic Medical /surgical Natural disasters Other accidents
  Unnatural deaths Undetermined intent Undetermined intent
Natural deaths Natural diseases
Unknown Unknown / Could not be determined

• Manner of death
• This gives an indication of the circumstances
  surrounding the death of the person. It can be
  classified as homicide, suicide, accidental,
  natural and (sometimes) undetermined.

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Classification of unnatural deaths

• Physical/chemical influences on the body
• Physical effects gunshot wounds, stab wounds,
  etc.
• Chemical effects poisons, drugs
• Effects of nature on the body lightning, dog
  bite, anaphylaxis due to bee-sting
• Complications of trauma, e.g. bronchopneumonia,
  tetanus, gangrene

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Classification of unnatural deaths

• Physical/chemical influences on the body
• Sudden unexpected deaths
• Previously healthy adults, no obvious cause of
  death
• Cot deaths Sudden infant death syndrome

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Classification of unnatural deaths

• Physical/chemical influences on the body
• Sudden unexpected deaths
• Omission or Co-mission
• Action or neglect by a healthcare practitioner,
  relative or other person may have led to death
• May otherwise seem to be a natural death

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Classification of unnatural deaths

• Physical/chemical influences on the body
• Sudden unexpected deaths
• Omission or Co-mission
• Procedure-related death The Health Professions
  Act, 56 of 1974, Section 48

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Procedure related death

• Any procedure diagnostic, therapeutic or
  palliative
• Death during the procedure
• Death as a result of the procedure
• Where any aspect of the procedure played a
  contributory role in causing death

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Terminology to avoid

• Ill-defined / non-specific conditions
• Old age
• Headache
• Natural causes
• Mechanisms of death
• Heart failure
• Kidney failure
• Dehydration
• Hypoxia
• Sepsis

A mechanism may be written on the very first
line, IF it is followed by a proper disease as
underlying cause of death. But try to avoid it!
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Terminology to avoid

• Abbreviations
• DM II
• MI
• MS
• HONK
• Stories
• The patient presented three days ago with severe
  abdominal pain, but the family says its been
  going on for a long time. At surgery, extensive
  peritoneal sepsis of unknown cause was found.

• Acceptable abbreviations
• TB, PTB
• HIV
• AIDS

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Write legibly for data coders and capturers
Examples of COD from WC local mortality
surveillance

• ADISMAL MESTATIC BREST CANCER
• ATRIAL FIBRILLATION WITH SEPTEMBER
• B CELL LQNIBHEMEM
• BOWL PERFERATION
• DILULOD CARDIOMYOPATH
• HOLOPRONCEPHACY
• LYMPTAMATIE HYPELAETATEMA
• Aala refuflulem AF
• AASCHAENIC HEART DISEASE
• Caramony oiley divan
• Vulval carcinoma to the brain

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(No Transcript)
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Difficult situations HIV

• Drs reluctant to report HIV as a cause of death
• Stigma
• HIV exclusion clauses of insurance policies
• Government directive
• Confidentiality concerns
• As a result mortality data is inaccurate
• Drs report immediate causes of death (TB,
  diarrhoea, pneumonia) or euphemisms for HIV
  (immuno-compromised, retroviral disease) instead
  of HIV
• Facts
• Drs have a legal obligation to provide accurate
  information on cause of death (Births and Deaths
  registration Act, no 51, 1992) provided you
  follow available confidentiality measures (seal
  last page in envelope)
• Insurers have the right to access medical records
  and death certificates but HIV exclusion policies
  were scrapped in 2005 so policies will be paid
  even if death due to HIV there may be a waiting
  period which applies to all natural causes
• If you know or strongly suspect that HIV is a
  cause of death you should state it on the
  DHA-1663

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Difficult situations Dead on Arrival

• Obvious unnatural causes
• refer to Forensic Pathology Service (FPS) in the
  prescribed manner
• Unknown causes
• History from family / ambulance personnel /
  friends
• History from hospital file
• Complete external examination of unclothed body
• Ask senior colleagues
• Make notes
• Forensic Pathology Service
• Your best medical opinion!

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Difficult situations Diabetes and Cardiovascular
disease

• Controversy about UCOD when comorbid DM and CVD
  Does DM cause heart attacks or strokes?
• For diabetic patients dying from MI, reported
  as having diabetes as UCOD ranged from 44 in
  Taiwan to 3 in France (Lu et al, 2010)
• Certifying doctor has to determine which
  condition played the most important role in
  causing death
• If doctor believes DM caused a cardiovascular
  condition it should be included in the causal
  sequence in Part 1
• If doctor is uncertain that DM was the direct
  cause of the cardiovascular condition, diabetes
  should be listed in Part 2

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Case scenario 1

• A 34-year-old male was admitted with severe
  shortness of breath. He had a 9-month history of
  unintentional weight loss, night sweats and
  diarrhea. HIV tests were positive. A chest X-ray
  showed pulmonary cavitation suggestive of
  tuberculosis. Tuberculosis was confirmed by a
  positive sputum smear. The patient did not
  respond to standard tuberculosis treatment. His
  condition deteriorated rapidly and he died a
  month later.

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Case scenario 1
Pulmonary tuberculosis
1 month
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Case scenario 2

• A 48-year-old male developed cramping epigastric
  pain which radiated to his back shortly after
  dinner on the day prior to admission. This was
  followed by nausea and vomiting. The pain was not
  relieved by positional changes or antacids and 24
  hours after the onset the patient sought medical
  attention. He had a 10-year history of excessive
  alcohol consumption and a 2- year history of
  recurrent episodes of similar epigastric pain.
  The diagnosis on admission was an acute
  exacerbation of chronic pancreatitis. Serum
  amylase was 4,032 units per litre. After
  admission the patient seemed to improve but the
  next evening he became restless, disorientated
  and hypotensive. Despite treatment, he remained
  hypotensive and died. An autopsy revealed many
  areas of fibrosis in the pancreas, with some
  areas showing multiple foci of acute inflammation
  and necrosis.

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Case scenario 2
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Case scenario 3

• A 3-month-old child is brought to the emergency
  room, but is clearly dead on admission. She had
  a history of vomiting and diarrhea for three
  days, and appears severely dehydrated, with a
  sunken fontanel and sunken eyes. The child had
  been looked after by her grandparents, because
  the mother was ill. No signs of any injury were
  found on the body and an unnatural cause of death
  was not suspected.

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Case scenario 3
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Example 1

• Female aged 80 years, stumbled and fell over
  while vacuuming at home and sustained a fracture
  of the neck of the left femur. She had an
  operation for insertion of a pin the following
  day. Two weeks later her condition deteriorated,
  she developed hypostatic pneumonia and died two
  days later.

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Cause of death cascade
Pneumonia
2 days
Fracture of L femur
2 weeks
2 weeks
Alleged Accidental fall
Osteoporosis
Natural vs Unnatural?
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Example 2

• A 10-month-old child is brought in by his mother
  because of a fever, which has been present for
  approximately 3 days. On examination the child
  is found to be malnourished, with a distended
  abdomen and loss of muscle mass, and with neck
  stiffness. A lumbar puncture led to the
  diagnosis of H. Influenza meningitis, and IV
  treatment was started. After one day in hospital,
  the child became tachypnoeic, with bilateral
  crepitations in the lungs. He died a few hours
  later.

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Cause of death cascade
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Whats wrong?
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Whats wrong?
Likely cardiac event PE advanced debilitation
Severe COPD, osteoporosis B/L Tib/Fib Frs. Died
in Nursing Home during sleep H/o A-fib
Alcoholism
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Whats wrong?
CCF, COPD, HPT, IHD, DMII
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Whats wrong?
Natural causes
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Whats wrong?
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Whats wrong?
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Whats wrong?
Rib fractures, pneumothorax
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Acknowledgments

• Department of Health, Department of Home Affairs,
  Medical Research Council

Pam Groenewald, Lené Burger, Anastasia Rossouw,
Beatrice Nojilana, Debbie Bradshaw