Medical certification of death

Training 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 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 2008Cause 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 SystemCurrent 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 disseminatio

n)

Cause of deaths

statistics

Magistrate via SAPS

Inquest

Criminal proceeding

s

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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

3. Date of death

8. ID no

10. Date of birth

15. Address

11. Sex

9. Age

2. Identification of deceased

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DHA-1663A

Page 1 of 3

18. Education

19. Occupation

21. Smoking history

20. Business / industry

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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” ___

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D: Particulars of Informant

C: Certificate by Forensic Pathologist DHA-1663A

Page 2 of 3

MP number:

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E: Particulars of Funeral undertaker

DHA-1663A

Page 3 of 3

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G: MEDICAL CERTIFICATE OF CAUSE OF DEATH

DHA-1663B

Page 1 of 1

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Immediate cause

Intermediate cause

Intermediate cause

Underlying cause

Other contributing conditions

Time interval

Mark if female

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

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)

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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 circumstances Old primigravida

Perinatal Cause of death (Stillbirth and death within one week

of birth)

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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.

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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 it’s been going on for a long time. At surgery, extensive peritoneal sepsis of unknown cause was found.

Acceptable abbreviations:TB, PTBHIVAIDS

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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 1A 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

Acquired immunodeficiency syndrome

Human immunodeficiency virus

9 months

> 9 months

HIV/AIDS > 9 months

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Case scenario 2A 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

Fracture of L femur

Alleged Accidental fall

2 days

2 weeks

Natural vs Unnatural?

Osteoporosis

2 weeks

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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

H influenza Meningitis 4 days

1 day

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 A-fib 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