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Medical certification of death Training for Medical Practitioners.

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Presentation on theme: "Medical certification of death Training for Medical Practitioners."— Presentation transcript:

1 Medical certification of death Training for Medical Practitioners

2 2 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

3 3 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

4 4 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

5 5 Source: StatsSA

6 6 Leading categories of deaths in SA

7 7 Leading causes of death, Stats SA 2008 Cause of deathNumber% of all deaths 1Ill-defined and unknown causes80 51513.6 2Tuberculosis74 86312.6 3Influenza and pneumonia45 6027.7 4Intestinal infectious diseases39 3516.6 5Other external causes of accidental injury33 9835.7 6Other forms of heart disease26 1904.4 7Cerebrovascular disease24 3634.1 8Diabetes mellitus19 5583.3 9HIV15 0972.5 10Certain disorders involving the immune system14 6392.5 HIV accounted for 2.5% of all deaths and ranked 9th

8 8 Current Official Mortality System Doctor Health Facility Headman Medico- legal mortuary Abridged death certificate Burial order Forms to be checked and archived Regional Home Affairs Office Full death certificate National Home Affairs Office (Population Register) Forms transferred Statistics South Africa (data processing e.g. ICD coding; analysis; report writing; and dissemination) Cause of deaths statistics Magistrate via SAPS Inquest Criminal proceedings

9 9 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

10 10 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

11 11 A death certificate

12 12 DHA-1663A Page 1 of 3 A. Particulars of deceased 3. Date of death 8. ID no 10. Date of birth 15. Address 11. Sex 9. Age 2. Identification of deceased

13 13 DHA-1663A Page 1 of 3 18. Education 19. Occupation 21. Smoking history 20. Business / industry

14 14 B: Certificate by attending Medical Practitioner DHA-1663A Page 2 of 3 Certificate by attending medical practitioner NATURAL CAUSES___ “…am not in the position to certify that the deceased died exclusively due to natural causes” ___

15 15 D: Particulars of Informant C: Certificate by Forensic Pathologist DHA-1663A Page 2 of 3 MP number:

16 16 E: Particulars of Funeral undertaker DHA-1663A Page 3 of 3


18 18 Immediate cause Intermediate cause Underlying cause Other contributing conditions Time interval Mark if female Cause-of-death cascade

19 19 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)

20 20 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)

21 21 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 lungs due to Squamous cell carcinoma of the esophagus Example: Septicaemia due to S. Pneumoniae otitis media


23 23 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

24 24 Cause-of-death 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 Perinatal Cause of death (Stillbirth and death within one week of birth)

25 25 Cause-of-death 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 circumstancesOld primigravida Perinatal Cause of death (Stillbirth and death within one week of birth)

26 26 Definitions 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. ClassificationManner of death Unnatural deaths Homicide Suicide Legal intervention and War Accidental Road traffic Medical /surgical Natural disasters Other accidents Undetermined intent Natural deaths Natural diseases Unknown Unknown / Could not be determined

27 27 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

28 28 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

29 29 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

30 30 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

31 31 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

32 32 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!

33 33 Terminology to avoid Abbreviations –DM II –MI –MS –HONK 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. Acceptable abbreviations:  TB, PTB  HIV  AIDS

34 34 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

35 35

36 36 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

37 37 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!

38 38 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

39 39 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.

40 40 Case scenario 1 Pulmonary tuberculosis 1 month Acquired immunodeficiency syndrome Human immunodeficiency virus 9 months > 9 months HIV/AIDS > 9 months

41 41 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.

42 42 Case scenario 2 Acute pancreatitis Chronic pancreatitis (Alcohol abuse) 1 day 2 years (10 yrs)

43 43 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.

44 44 Case scenario 3 Gastroenteritis 3 days

45 45 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.

46 46 Cause of death cascade Pneumonia Fracture of L femur Alleged Accidental fall 2 days 2 weeks Natural vs Unnatural? Osteoporosis 2 weeks

47 47 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.

48 48 Cause of death cascade Bronchopneumonia H influenza Meningitis 4 days 1 day Malnutrition months

49 49 What’s wrong? Pulmonary embolism Chest pain Hyperkalemia Fractured pelvis, motor vehicle accident

50 50 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 A- fib Alcoholism

51 51 What’s wrong? CCF, COPD, HPT, IHD, DMII

52 52 What’s wrong? Natural causes

53 53 What’s wrong? Cardiac failure Renal failure Septicaemia

54 54 What’s wrong? Myocardial infarction Angina Hypertension

55 55 What’s wrong? Myocardial infarction Coronary atherosclerosis Rib fractures, pneumothorax

56 56 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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