The Patient Died from Complications of Paralysis, Naturally? The perils of forgetting about etiology and why it matters.

The following cause-of-death statement is from an actual death certificate certified the by decedent’s attending physician. It was flagged by the local Vital Statistics agency and sent to the local Medical Examiner’s office for investigation for many glaring reasons, some discussed previously. It is also representative of a reportable death. It will be familiar as it appeared in August 13th’s entry as a PPQ question:

Part I.



A. Hospital-acquired pneumonia

Approximate interval: Onset to death

< 1 week

Due to (or as a consequence of):

B. C-6 quadriplegia


>  1 year

Due to (or as a consequence of):

C. Mucous plugging


>  1 month

Due to (or as a consequence of):

D. Cardiac failure


>  1 month

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



With the advancements in medical care, paralyzed patients are living longer lives but are at risk acquiring a number of disease complications in the interim period that can lead to death. Losing sight of the initial cause of the paralysis will result in a death that does not get reported to the Medical Examiner or Coroner (ME/C). Trauma must be ruled out in patients who die of delayed complications of spinal cord injury with paralysis. If trauma is a known or suspected etiologic factor, then the death is reportable to the ME/C who will investigate the circumstances under which the trauma (injury) was acquired and properly classify the death as accident, suicide, or homicide. Recommendations for the approach to the investigation of these types of deaths are outlined in the 1954 Model Postmortem Examinations Act and have been adopted by most US jurisdictions to varying degrees 1. It is important to also note that the original “trauma” or “injury” may not be physical and thus would include sequela of prolonged cardiopulmonary arrest following a drug or medication overdose or certain types of asphyxia (like chemical/gas or choking). Classification of non-natural manners of death provides valuable information used in fatal injury databases such as the CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS) 2 and in publications by the National Safety Council 3.

There are many chronic medical conditions that represent “red flags” for possible underlying non-natural causes including venous thrombosis, encephalopathy, cerebral infarcts, recurrent infections, and contractures.

So you’ve been wondering what else is wrong with the cause-of-death statement?

  • an overall lack of cause-and-effect relationship between conditions listed in Part I (cardiac failure does not cause mucous plugging and mucous plugging does not cause C-6 quadriplegia)
  • ‘Cardiac failure’ is a non-specific, mechanistic, sometimes terminal process and should never be listed as an underlying cause of death which is what belongs on line ‘D’
  • the manner of death can’t be listed as natural if the quadriplegia was due to a spinal cord injury subsequent to a remote gunshot wound or a mechanical fall regardless that the proximate cause of death was pneumonia



  1. Hanzlick RL. A synoptic review of the 1954 “Model Postmortem Examinations Act”. Acad Forensic Pathol. 2014; 4(14):451-54.
  2. WISQARS. Scientific Data, Statistics, and Surveillance. Available at:
  3. National Safety Council. Injury Facts. The Source for Safety Data. Available at:


You’ll find more on why etiology really does matter in death reporting (and certification) in Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available through this link: .

More pearls for practice are in your future, so stay tuned for the next installation of Practice Pearls!

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