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1 WHO-FIC Education Committee 5 May 2006 Training Certifiers of cause of death Roberto Becker Training Certifiers of cause of death Roberto Becker.

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Presentation on theme: "1 WHO-FIC Education Committee 5 May 2006 Training Certifiers of cause of death Roberto Becker Training Certifiers of cause of death Roberto Becker."— Presentation transcript:

1 1 WHO-FIC Education Committee 5 May 2006 Training Certifiers of cause of death Roberto Becker Training Certifiers of cause of death Roberto Becker

2 2 PreparationPreparation Workshop format Who extends invitations Time Duration Content / adaptations Local examples Workshop format Who extends invitations Time Duration Content / adaptations Local examples

3 3 ContentContent Uses of mortality data Role of the certifier Work done with the information International form for medical certification How to certify Special issues Examples Standard definitions Exercises Uses of mortality data Role of the certifier Work done with the information International form for medical certification How to certify Special issues Examples Standard definitions Exercises

4 4 The importance of Mortality statistics

5 5 USES OF MORTALITY DATA 1. HEALTH SITUATION ANALYSIS  WHO (SEX, AGE), WHEN, WHERE, WHAT CAUSE(S)  HOW LONG AND HOW THE PEOPLE LIVE  HEALTH (INDIRECT) INDICATORS  CRUDE MORTALITY RATE  LIFE EXPECTANCY / IMPACT OF THE CAUSES  INFANT MORTALITY RATE  MATERNAL MORTALITY RATE/RATIO  YEARS OF POTENTIAL LIFE LOST  SPECIFIC RATES (CAUSE, SEX, AGE)  MORTALITY DATA: MAIN INSTRUMENT TO IDENTIFY:  PUBLIC HEALTH PROBLEMS  GROUPS AT RISK  NEEDS OF MEDICAL AND PUBLIC HEALTH RESEARCH  LEADING CAUSES OF DEATH - PRIORITIES  WHO (SEX, AGE), WHEN, WHERE, WHAT CAUSE(S)  HOW LONG AND HOW THE PEOPLE LIVE  HEALTH (INDIRECT) INDICATORS  CRUDE MORTALITY RATE  LIFE EXPECTANCY / IMPACT OF THE CAUSES  INFANT MORTALITY RATE  MATERNAL MORTALITY RATE/RATIO  YEARS OF POTENTIAL LIFE LOST  SPECIFIC RATES (CAUSE, SEX, AGE)  MORTALITY DATA: MAIN INSTRUMENT TO IDENTIFY:  PUBLIC HEALTH PROBLEMS  GROUPS AT RISK  NEEDS OF MEDICAL AND PUBLIC HEALTH RESEARCH  LEADING CAUSES OF DEATH - PRIORITIES

6 6 USES OF MORTALITY DATA 2. EPIDEMIOLOGICAL SURVEILLANCE  MAIN OR FIRST SOURCE OF DATA FOR SOME DISEASES OR CONDITIONS  HIV/AIDS  YELLOW FEVER  RABIES  ACCIDENTS AND POISONING  VIOLENCE  USE AT LOCAL LEVELS  LIST OF DIAGNOSTIC TERMS (PARALYSIS, IMMUNODEFICIENCY)  INVESTIGATION  CONFIRMATION OR CHANGE: CHECKING WITH STATISTICS  SPECIFIC ACTIONS  GROUPS OF POPULATION  WOMEN (MATERNAL MORTALITY)  CHILDHOOD  ADOLESCENCE  ELDERLY  MAIN OR FIRST SOURCE OF DATA FOR SOME DISEASES OR CONDITIONS  HIV/AIDS  YELLOW FEVER  RABIES  ACCIDENTS AND POISONING  VIOLENCE  USE AT LOCAL LEVELS  LIST OF DIAGNOSTIC TERMS (PARALYSIS, IMMUNODEFICIENCY)  INVESTIGATION  CONFIRMATION OR CHANGE: CHECKING WITH STATISTICS  SPECIFIC ACTIONS  GROUPS OF POPULATION  WOMEN (MATERNAL MORTALITY)  CHILDHOOD  ADOLESCENCE  ELDERLY

7 7 USES OF MORTALITY DATA 3. EVALUATION / INVESTIGATION  QUALITY AND RESULTS OF HEALTH CARE  MATERNAL MORTALITY  CASE FATALITY RATE  SURVIVAL  HEALTH PROGRAMS, SPECIFIC DISEASES / CONDITIONS  VACCINE PREVENTABLE  TUBERCULOSIS  DIABETES  CHOLERA  HYPERTENSION  ISCHEMIC HEART DISEASES  NEOPLASMS  ACCIDENTS AND VIOLENCE  TECHNOLOGY  CASE FATALITY RATE (ACUTE DISEASES)  SURVIVAL (CHRONIC DISEASES)  NEOPLASMS  HIV/AIDS  RISK FACTORS / MULTIPLE CAUSES / LINKED CAUSES  QUALITY AND RESULTS OF HEALTH CARE  MATERNAL MORTALITY  CASE FATALITY RATE  SURVIVAL  HEALTH PROGRAMS, SPECIFIC DISEASES / CONDITIONS  VACCINE PREVENTABLE  TUBERCULOSIS  DIABETES  CHOLERA  HYPERTENSION  ISCHEMIC HEART DISEASES  NEOPLASMS  ACCIDENTS AND VIOLENCE  TECHNOLOGY  CASE FATALITY RATE (ACUTE DISEASES)  SURVIVAL (CHRONIC DISEASES)  NEOPLASMS  HIV/AIDS  RISK FACTORS / MULTIPLE CAUSES / LINKED CAUSES

8 8 Medical Certification of Mortality Legal –To certify the occurrence of a death –To define the nature: natural causes or not –Civil Registration / vital statistics Statistical –Demographic aspects: sex, age, ethnic group, residence, socioeconomic data Epidemiology / public health –Cause(s) –Data for specific groups: infant and maternal deaths 1925 – Health Organization of League of Nations proposed a model for medical certification 1948 – ICD-6: Adopted as international form 1950 – Worldwide use Legal –To certify the occurrence of a death –To define the nature: natural causes or not –Civil Registration / vital statistics Statistical –Demographic aspects: sex, age, ethnic group, residence, socioeconomic data Epidemiology / public health –Cause(s) –Data for specific groups: infant and maternal deaths 1925 – Health Organization of League of Nations proposed a model for medical certification 1948 – ICD-6: Adopted as international form 1950 – Worldwide use

9 9 Work done with the information Selection of underlying cause –Definition of Underlying cause –Coding diagnostic terms –General Principle, Sequences, Rules Validation and consistency –Cause by sex by age –Corrections Processing Analysis Decision making Dissemination Selection of underlying cause –Definition of Underlying cause –Coding diagnostic terms –General Principle, Sequences, Rules Validation and consistency –Cause by sex by age –Corrections Processing Analysis Decision making Dissemination

10 10 INTERNATIONAL FORM OF MEDICAL CERTIFICATE OF CAUSE OF DEATH Cause of death approximate interval I Disease or condition directly (a) leading to death due to (or as a consequence of) Antecedent causes (b) Morbid conditions, if any due to (or as a consequence of) giving rise to the above cause stating the underlying (c) condition last due to (or as a consequence of) (d) II Other significant conditions contributing to the death, but not related to the disease or condition causing it Cause of death approximate interval I Disease or condition directly (a) leading to death due to (or as a consequence of) Antecedent causes (b) Morbid conditions, if any due to (or as a consequence of) giving rise to the above cause stating the underlying (c) condition last due to (or as a consequence of) (d) II Other significant conditions contributing to the death, but not related to the disease or condition causing it

11 11 Medical certification Full information required, not only causes of death Sequence “a” due to “b” due to “c” due to “d” Part I / Part II Diagnoses per line Use of Abbreviations ARI, MI, etc. Handwriting ! Full information required, not only causes of death Sequence “a” due to “b” due to “c” due to “d” Part I / Part II Diagnoses per line Use of Abbreviations ARI, MI, etc. Handwriting !

12 12 Special issues Avoided diagnoses Suicide AIDS Tuberculosis Drug/alcohol abuse Manipulation of information (e. g. homicides, dengue) Injuries and poisoning Cardiac arrest  infarction ? Incomplete and imprecise information Information on pregnancy Pneumonia (etiology / hypostatic / terminal) Infarction (acute or old / of the myocardium) Endocarditis (acute or chronic / valve / rheumatic ?) Senility / signs & symptoms ARI Avoided diagnoses Suicide AIDS Tuberculosis Drug/alcohol abuse Manipulation of information (e. g. homicides, dengue) Injuries and poisoning Cardiac arrest  infarction ? Incomplete and imprecise information Information on pregnancy Pneumonia (etiology / hypostatic / terminal) Infarction (acute or old / of the myocardium) Endocarditis (acute or chronic / valve / rheumatic ?) Senility / signs & symptoms ARI

13 13 Medical certification – Example 1 Female, 37 years Admitted to an emergency room with generalized edema, exertional dyspnea and ascites Blood pressure 150 / 100, increased cardiac dullness with 80 beats per minute, Liver 5 fingers below the costal border For a few years was being treated for chronic glomerulonephritis With the treatment her health situation improved a little, with blood pressure oscillating between / After one month her health situation deteriorated, dying in one week with pulmonary acute edema Female, 37 years Admitted to an emergency room with generalized edema, exertional dyspnea and ascites Blood pressure 150 / 100, increased cardiac dullness with 80 beats per minute, Liver 5 fingers below the costal border For a few years was being treated for chronic glomerulonephritis With the treatment her health situation improved a little, with blood pressure oscillating between / After one month her health situation deteriorated, dying in one week with pulmonary acute edema

14 14 Medical certification – Example 1 Medical certification – Example 1 Original certificate I a) Hypertension b) Pulmonary edema c) d) II Old nephritis Correct certificate I a) Acute pulmonary edema terminal b) Hypertensive cardiopathy years c) Chronic glomerulonephritis years d) II Correct certificate I a) Acute pulmonary edema terminal b) Hypertensive cardiopathy years c) Chronic glomerulonephritis years d) II

15 15 Medical certification – Example 2 Deaths due to gastroenteritis, Bahia, Brazil, 1984

16 16 Medical certification – Example 2 Deaths due to/With gastroenteritis, Bahia, Brazil, 1984

17 17 Medical certification – Example 2 Attending physician vs. Coroner Coroner: I a) Bronchopneumonia and gastroenteritis b) Attending physician: I a) Bronchopneumonia b) gastroenteritis Coroner: I a) Bronchopneumonia and gastroenteritis b) Attending physician: I a) Bronchopneumonia b) gastroenteritis

18 18 STANDARDIZATION OF CONCEPTS AND DEFINITIONS  LIVE BIRTHS  FETAL DEATH  ABORTION  STILLBIRTH  PERINATAL PERIOD (28/22 WEEKS - 7 DAYS)  PERINATAL MORTALITY  NEONATAL PERIOD  EARLY  LATE  CONDITIONS ORIGINATING IN THE PERINATAL PERIOD  INFANT MORTALITY  NEONATAL  LATE OR POST NEONATAL  MATERNAL MORTALITY  RATE / RATIO  LATE MATERNAL DEATH  PREGNANCY RELATED DEATH  LIVE BIRTHS  FETAL DEATH  ABORTION  STILLBIRTH  PERINATAL PERIOD (28/22 WEEKS - 7 DAYS)  PERINATAL MORTALITY  NEONATAL PERIOD  EARLY  LATE  CONDITIONS ORIGINATING IN THE PERINATAL PERIOD  INFANT MORTALITY  NEONATAL  LATE OR POST NEONATAL  MATERNAL MORTALITY  RATE / RATIO  LATE MATERNAL DEATH  PREGNANCY RELATED DEATH

19 19 CASE 1 Female, 30 years A month before the admission she had several hematemesis episodes and, since then, deterioration of her general condition, extreme pallor and frequent melena. On the day of the hospitalization (18/11), new hematemesis. At the physical examination: Blood pressure 80/ 60 mm/Hg, pulse 128/ min, good hydration, pale mucous membranes (+++), `spleen at 1 finger, smooth, and hard liver at 1 finger. In view of the fact that the patient came from a schistosomiasis endemic area, the clinical diagnosis was rupture of esophageal varices due to portal hypertension due to liver fibrosis schistosomiasis. This diagnosis was confirmed subsequently by liver biopsy. In addition the species of the helminth was established as "mansoni". The tamponade of the varices was not satisfactory. Operated (19/11): splenectomy and ligature of the cardiotuberositarious veins. The hematemesis persisted and the patient died in irreversible shock on 22/11. Necropsy was not done. Female, 30 years A month before the admission she had several hematemesis episodes and, since then, deterioration of her general condition, extreme pallor and frequent melena. On the day of the hospitalization (18/11), new hematemesis. At the physical examination: Blood pressure 80/ 60 mm/Hg, pulse 128/ min, good hydration, pale mucous membranes (+++), `spleen at 1 finger, smooth, and hard liver at 1 finger. In view of the fact that the patient came from a schistosomiasis endemic area, the clinical diagnosis was rupture of esophageal varices due to portal hypertension due to liver fibrosis schistosomiasis. This diagnosis was confirmed subsequently by liver biopsy. In addition the species of the helminth was established as "mansoni". The tamponade of the varices was not satisfactory. Operated (19/11): splenectomy and ligature of the cardiotuberositarious veins. The hematemesis persisted and the patient died in irreversible shock on 22/11. Necropsy was not done.

20 20 CASE 1 I a) Rupture of esophageal varices 1 month b) Liver fibrosis years c) Schistosomiasis mansoni years d) II CASE 1 I a) Rupture of esophageal varices 1 month b) Liver fibrosis years c) Schistosomiasis mansoni years d) II

21 21 CASE 2 Female, 66 years Has had rheumatic fever for 30 years, with mitral stenosis as a complication. Five years ago began presenting congestive cardiac failure with compensation after treatment. The condition recently worsened, the cardiac failure becoming irreversible and the patient died. Four years ago it was confirmed that she had hypertension, with measurements that ranged between / Female, 66 years Has had rheumatic fever for 30 years, with mitral stenosis as a complication. Five years ago began presenting congestive cardiac failure with compensation after treatment. The condition recently worsened, the cardiac failure becoming irreversible and the patient died. Four years ago it was confirmed that she had hypertension, with measurements that ranged between /

22 22 CASE 2 I a) Congestive cardiac failure 5 years b) Mitral stenosis 30 years c) Rheumatic fever 30 years d) II Hypertension CASE 2 I a) Congestive cardiac failure 5 years b) Mitral stenosis 30 years c) Rheumatic fever 30 years d) II Hypertension

23 23 CASE 3 Male, 72 years Ten months ago the patient was operated on for cancer in the upper part of the stomach (verified histopathologically). He subsequently presented pulmonary metastases and his clinical condition deteriorated progressively. One week before death he presented bronchopneumonia. The patient was hypertensive for many years and 3 months before death had a stroke, remaining hemiplegic. Male, 72 years Ten months ago the patient was operated on for cancer in the upper part of the stomach (verified histopathologically). He subsequently presented pulmonary metastases and his clinical condition deteriorated progressively. One week before death he presented bronchopneumonia. The patient was hypertensive for many years and 3 months before death had a stroke, remaining hemiplegic.

24 24 CASE 3 I a) Bronchopneumonia 7 days b) Pulmonary metastases months c) Stomach cancer, upper part 10 + months d) II Hypertension years Stroke 3 months CASE 3 I a) Bronchopneumonia 7 days b) Pulmonary metastases months c) Stomach cancer, upper part 10 + months d) II Hypertension years Stroke 3 months

25 25 CASE 4 Female, 3 years Girl with Tetralogy of Fallot, doing relatively well, in preparation to being submitted to surgery. One morning she was found dead by her mother. Female, 3 years Girl with Tetralogy of Fallot, doing relatively well, in preparation to being submitted to surgery. One morning she was found dead by her mother.

26 26 CASE 4 I a) Tetralogy of Fallot3 years b) c) d) II

27 27 CASE 5 Male, 42 years The mason was working on a scaffolding, at the twelfth floor when accidentally fell to the ground, dying instantaneously. The Coroner reported multiple injuries (skull, hip and limbs). Male, 42 years The mason was working on a scaffolding, at the twelfth floor when accidentally fell to the ground, dying instantaneously. The Coroner reported multiple injuries (skull, hip and limbs).

28 28 CASE 5 I a) Multiple injury of head, hip, and limbs b) Accidental fall from scaffolding while working c) d) II

29 29 CASE 6 Female, 50 years Two years ago the patient found nodes in the left breast. At the medical examination presented great increase of the breast, retracted nipple, and palpable axillary nodes. She was taken to surgery in the month of April with diagnosis of malignant neoplasm of the breast with nodal metastases, with confirmation by surgery and by biopsy. She stayed well for four months, when her general health condition began to deteriorate, presenting increased volume of a nodular liver, jaundice and ascites. Two days before dying she entered in hepatic coma, well documented clinically and by laboratory. The patient died in December of the same year and an autopsy was not performed. Female, 50 years Two years ago the patient found nodes in the left breast. At the medical examination presented great increase of the breast, retracted nipple, and palpable axillary nodes. She was taken to surgery in the month of April with diagnosis of malignant neoplasm of the breast with nodal metastases, with confirmation by surgery and by biopsy. She stayed well for four months, when her general health condition began to deteriorate, presenting increased volume of a nodular liver, jaundice and ascites. Two days before dying she entered in hepatic coma, well documented clinically and by laboratory. The patient died in December of the same year and an autopsy was not performed.

30 30 CASE 6 I a) Hepatic coma 2 days b) Liver metastases months c) Malignant neoplasm of central part of the breast 2 yrs d) II

31 31 CASE 7 Male, 3 hours Child born of spontaneous delivery in poor condition (Apgar score of 2). The pregnancy was normal up to the eighth month, when the mother started to present vaginal hemorrhage, not seeking assistance during the first 24 hours. She was then taken to the hospital where was she admitted with pre-shock. The diagnosis made was hemorrhagic abruptio placentae. The baby was born cyanotic with signs of anoxia, dying in three hours. Male, 3 hours Child born of spontaneous delivery in poor condition (Apgar score of 2). The pregnancy was normal up to the eighth month, when the mother started to present vaginal hemorrhage, not seeking assistance during the first 24 hours. She was then taken to the hospital where was she admitted with pre-shock. The diagnosis made was hemorrhagic abruptio placentae. The baby was born cyanotic with signs of anoxia, dying in three hours.

32 32 CASE 7 I a) Anoxia 3 hours b) Hemorrhagic abruptio placentae 2 days c) d) II

33 33 CASE 8 Male, 55 years Two years before his death, the patient had an acute myocardial infarction, confirmed by electrocardiogram. From then on he began to present affective type mental disorders, with frequent episodes of depression and weeping. In the morning of the day of the death, at home, he shot himself in the chest with a handgun. Taken to the hospital, he died at two o’clock in the afternoon of the same day. Autopsy: Hemothorax (2 liters) and perforation of the upper lobe of the left lung. Male, 55 years Two years before his death, the patient had an acute myocardial infarction, confirmed by electrocardiogram. From then on he began to present affective type mental disorders, with frequent episodes of depression and weeping. In the morning of the day of the death, at home, he shot himself in the chest with a handgun. Taken to the hospital, he died at two o’clock in the afternoon of the same day. Autopsy: Hemothorax (2 liters) and perforation of the upper lobe of the left lung.

34 34 CASE 8 I a) Hemothorax hours b) Perforation of upper lobe of the left lung hours c) Suicide by handgun shot at home hours d) II Acute myocardial infarction 2 years Recurrent depressive disorders CASE 8 I a) Hemothorax hours b) Perforation of upper lobe of the left lung hours c) Suicide by handgun shot at home hours d) II Acute myocardial infarction 2 years Recurrent depressive disorders

35 35 CASE 9 Female, 71 years The patient, with a diagnosis of adenocarcinoma of uterine body (verified by biopsy), had a panhysterectomy, followed by chemotherapy and blood transfusions. The patient had an old hypertension (220/ 140) that was being controlled with hypotensors and hyponatremic diet. One year and a half after the surgery she had symptoms of unconsciousness, with deviation of the mouth toward the left, right hemiplegia with patellar hyperreflexia and Babinski. She was treated as having had a stroke, with partial recovery. On the day of the death, two weeks after the beginning of this last episode, she presented deep coma with total areflexia, dying after a few hours, without recovering. The examination of the cerebral spinal liquid revealed hemorrhage. Female, 71 years The patient, with a diagnosis of adenocarcinoma of uterine body (verified by biopsy), had a panhysterectomy, followed by chemotherapy and blood transfusions. The patient had an old hypertension (220/ 140) that was being controlled with hypotensors and hyponatremic diet. One year and a half after the surgery she had symptoms of unconsciousness, with deviation of the mouth toward the left, right hemiplegia with patellar hyperreflexia and Babinski. She was treated as having had a stroke, with partial recovery. On the day of the death, two weeks after the beginning of this last episode, she presented deep coma with total areflexia, dying after a few hours, without recovering. The examination of the cerebral spinal liquid revealed hemorrhage.

36 36 CASE 9 I a) Coma hours b) Hemiplegia 2 weeks c) Stroke 2 weeks d) Hypertension years II Adenocarcinoma of uterine body 2 years

37 37 CASE 10 Female, 32 years The patient was admitted in shock on the emergency service. She was found at the end of the eighth month of pregnancy and she had had only two prenatal visits (fourth and fifth months). This was the fourth pregnancy and the previous ones were normal, with healthy live births. The blood pressure could not be measured, and the pulse was fine and tachycardic (140 p/min). Intense anemia of mucous membranes. According to family information, she had had genital hemorrhage for more than one week, at the beginning with little intensity, but increasing progressively. For two days she was in the bed and today, upon getting up has fainted. The family then brought her to the emergency room. Diagnoses: Acute anemia from hemorrhage due to placenta previa. Dead fetus. The mother was submitted to a caesarean, the death occurring just after the surgery. Female, 32 years The patient was admitted in shock on the emergency service. She was found at the end of the eighth month of pregnancy and she had had only two prenatal visits (fourth and fifth months). This was the fourth pregnancy and the previous ones were normal, with healthy live births. The blood pressure could not be measured, and the pulse was fine and tachycardic (140 p/min). Intense anemia of mucous membranes. According to family information, she had had genital hemorrhage for more than one week, at the beginning with little intensity, but increasing progressively. For two days she was in the bed and today, upon getting up has fainted. The family then brought her to the emergency room. Diagnoses: Acute anemia from hemorrhage due to placenta previa. Dead fetus. The mother was submitted to a caesarean, the death occurring just after the surgery.

38 38 CASE 10 I a) Acute anemia b) Uterine hemorrhage 1 week c) Placenta previa 1 week d) II Caesarean Section Pregnancy of 8 months

39 39 CASE 11 Male, 26 years Three years ago was diagnosed as carrier of HIV, not having any clinical manifestation until ten months ago, when he began to present fever, intense weight loss and a great deal of cough. The diagnosis of AIDS was made and also of tuberculosis of lung. He evolved very poorly, did not respond to the treatment, developed a bronchopneumonia, dying in four days. Male, 26 years Three years ago was diagnosed as carrier of HIV, not having any clinical manifestation until ten months ago, when he began to present fever, intense weight loss and a great deal of cough. The diagnosis of AIDS was made and also of tuberculosis of lung. He evolved very poorly, did not respond to the treatment, developed a bronchopneumonia, dying in four days.

40 40 CASE 11 I a) Bronchopneumonia 4 days b) Tuberculosis of lung 10 months c) Acquired Immunodeficiency Syndrome 10 months d) II Weight loss

41 41 CASE 12 Female, 64 years The lady was exiting a small minibus, taking advantage of the red traffic light, and was hit by a motorcycle, which passed over her abdomen. She was removed alive to an emergency service. At the physical examination she presented signs of rupture of the spleen. A splenectomy was done. The patient lost 1.9 liters of blood and died before the end of the surgery. Female, 64 years The lady was exiting a small minibus, taking advantage of the red traffic light, and was hit by a motorcycle, which passed over her abdomen. She was removed alive to an emergency service. At the physical examination she presented signs of rupture of the spleen. A splenectomy was done. The patient lost 1.9 liters of blood and died before the end of the surgery.

42 42 CASE 12 I a) Acute hemorrhage b) Rupture of the spleen c) Hit by a motorcycle while exiting a minibus d) II Splenectomy


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