Transcript Medical certification of death

Medical certification of death
Training for Medical Practitioners
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 1–3 before the
training
• Complete and submit mock cause of death
certificates for Case scenarios 4–6 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
patient’s 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
Health
Facility
Regional
Home Affairs
Office
Forms to be
checked and
archived
Doctor
Headman
Burial order
National Home
Affairs Office
(Population
Register)
Abridged
death
certificate
Forms
transferred
Full death
certificate
Statistics
South Africa
(data
processing e.g.
ICD coding;
analysis;
report writing;
and
dissemination)
Cause of
deaths
statistics
Medicolegal
mortuary
Magistrate
via
SAPS
Criminal
proceedings
Inquest
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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
10. Date of birth
15. Address
9. Age
11. Sex
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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
Time interval
Immediate cause
Intermediate cause
Intermediate cause
Underlying cause
Other contributing conditions
Mark if female
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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?
Example:
Metastases to lungs
due to
Squamous cell carcinoma of the esophagus
• Infection
– Site
– Organism
• Septicaemia
Example:
Septicaemia
due to
S. Pneumoniae otitis media
– Mechanism!
– NB! Site of origin
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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
Other maternal diseases or conditions
affecting foetus or infant
Other relevant circumstances
Abruptio Placentae
Pre-ecclampsia
Old primigravida
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Definitions
Classification
I
N
T
E
N
T
I
O
N
A
L
• 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.
Manner of death
Unnatural
deaths
U
N
I
N
T
E
N
T
I
O
N
A
L
Homicide
Suicide
Legal intervention and War
Accidental
•
Road traffic
•
Medical /surgical
•
Natural disasters
•
Other accidents
Undetermined intent
Natural
deaths
Unknown
Natural diseases
Unknown / Could not be
determined
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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
Acceptable abbreviations:
 TB, PTB
 HIV
 AIDS
• Stories
– The patient presented three days ago with severe
abdominal pain, but the family says it’s been going on
for a long time. At surgery, extensive peritoneal
sepsis of unknown cause was found.
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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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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
months
AcquiredHIV/AIDS
immunodeficiency syndrome >99months
Human immunodeficiency virus
> 9 months
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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
Acute pancreatitis
Chronic pancreatitis
(Alcohol abuse)
1 day
2 years
(10 yrs)
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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
Gastroenteritis
3 days
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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
Bronchopneumonia
1 day
H influenza Meningitis
4 days
Malnutrition
months
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What’s wrong?
Pulmonary embolism
Chest pain
Hyperkalemia
Fractured pelvis, motor vehicle
accident
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What’s wrong?
Likely cardiac event + PE –
advanced debilitation Severe COPD,
osteoporosis B/L Tib/Fib Frs. Died in
Nursing Home during sleep – H/o Afib Alcoholism
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What’s wrong?
CCF, COPD, HPT, IHD, DMII
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What’s wrong?
Natural causes
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What’s wrong?
Cardiac failure
Renal failure
Septicaemia
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What’s wrong?
Myocardial infarction
Angina
Hypertension
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What’s wrong?
Myocardial infarction
Coronary atherosclerosis
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
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