You Have A Right NOT to Remain Silent!

Honesty is always the best policy- in death certification. This is particularly true as it applies to the certification of therapy-associated and peri-procedural deaths. While it may be tempting to mute or conceal the true cause of death out of concern for upsetting the family or of future litigation, it is better (and more defensible) to be objective and forthright.

Case Scenario 1:

A 45 year-old man with a history of schizophrenia stabilized on clozapine presents to the emergency department with a 2-day history of painful abdominal distention and absence of bowel movements. While awaiting diagnostic testing, he goes into cardiopulmonary arrest and dies despite resuscitative efforts. The death is reported to the local Medical Examiner who declines jurisdiction. A hospital autopsy is performed. Gross and microscopic examinations are diagnostic for toxic megacolon with perforation and acute peritonitis.

The cause of death is listed as “Cardiopulmonary arrest due to toxic megacolon”. (*Error alert!)

Case Scenario 2:

A 55 year-old man with a history of hypertension and atherosclerotic cardiovascular disease exsanguinates and arrests intra-operatively despite an emergent attempt to access and repair a spontaneously ruptured abdominal aortic aneurysm. Resuscitative efforts are unsuccessful. The death is reported to the local Medical Examiner who declines jurisdiction.  A hospital autopsy is performed.  The finding of massive hemoperitoneum and the rupture site of a 10.0 cm infra-renal aortic aneurysm confirms the source of the exsanguination, accompanied by severe complicated atherosclerosis seen grossly and microscopically.

The cause of death is listed as “Exsanguination”. (*Error alert!)

The monitoring of peri-procedural and therapy-associated deaths is an important facet in the maintenance of public health.  This includes the tracking of morbidity and mortality associated with medications, surgical procedures, and medical devices. MEDWATCH (www.fda.gov/medwatch) is “reporting central” for adverse events and deaths resulting from medical devices and medication errors in the United States. Therapy-associated and peri-procedural deaths are reportable and often accepted and certified by the Medical Examiner or Coroner particularly those that occur unexpectedly during or following diagnostic procedures or administration of medication, for the purposes of ruling out an alternate cause and manner of death. The manner-of-death classification for these deaths will be natural, therapeutic complication (a variant of natural), or accident. Homicide manner of death may be used in rare cases of deliberate administration (or withholding) of a medication. Rarely, the manner of death undetermined will be applied in inconclusive cases.

Deaths occurring in patients with extensive natural disease despite therapeutic interventions are certifiable by clinicians. Application of the “but for” rule is helpful in these instances: that but for the therapeutic/surgical intervention, the patient would have died from disease “X”. This rule is particularly applicable to emergent procedures performed for catastrophic natural disease such as in Scenario 2. Inclusion of the medication or procedure in the cause-of-death statement is necessary for ICD coding purposes, a tracking modality.

Case Scenario 1 may be certified as:

Part I.

 

 

A.  Acute peritonitis

 

Approximate interval: Onset to death

Hours

Due to (or as a consequence of):

B.  Spontaneous acute colonic perforation

 

Hours

 

Due to (or as a consequence of):

C. Toxic megacolon

 

2 days

 

Due to (or as a consequence of):

D. Complications of clozapine medication therapy for schizophrenia

 

Years

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I
 

Hypertensive cardiovascular disease

Manner of Death

Therapeutic Complication

(Natural)

 

 

 

 

And for Case Scenario 2:

Part I.

 

 

A. Exsanguination during emergency laparotomy

 

Approximate interval: Onset to death

 

Minutes

Due to (or as a consequence of):

B. Abdominal aortic aneurysm with spontaneous acute rupture

 

Hours

Due to (or as a consequence of):

C. Severe, complicated aortic atherosclerosis

 

Years

Due to (or as a consequence of):

D.

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I
Manner of Death

Natural

 

 

*Note the use of etiologic specific terminology and the avoidance of unnecessary, non-specific terms. Everyone eventually dies from cardiac and/or cardiopulmonary arrest. Exsanguination can be caused by diseases or trauma. Note also the inclusion of the word “spontaneous”, which distinguishes from a traumatic cause.

 

For more information on peri-procedural death certification and its relevance to public health surveillance, consult Chapters 2 and 8 in Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner.

Stay tuned for your next booster shot of Practice Pearls!

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