No Rhyme, No Reasoning.

The cause-of-death statement from the last PPQ installment is shown again below. It was reproduced from an actual death certificate flagged by the local vital statistics and sent to the local Medical Examiner for further investigation and revision for a number of reasons.

 

Part I.

 

A. Cardiac arrest resuscitated with mechanical

ventilation

Approximate interval: Onset to death

2/5/2017

Due to (or as a consequence of):

B.  Encephalopathy of toxic and metabolic causes

 

1 mo.

Due to (or as a consequence of):

C.  Coronary artery disease

 

Longstanding

Due to (or as a consequence of):

D. Type 2 Diabetes with renal impairment

 

Longstanding

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

Dementia, hypertension, hypercholesterolemia, malnutrition, osteoarthritis, shotgun wound to back (1985)

Manner of Death

Natural

 

Part I translation: The patient was resuscitated and survived briefly on mechanical ventilation as a result of an altered brain function (encephalopathy) from some type of toxic exposure or metabolic derangement, as a result of coronary artery disease caused by diabetes associated with kidney dysfunction. These series of statements lack a logical cause-and-effect relationship: While cardiac arrest may be caused by encephalopathy of toxic and metabolic causes, encephalopathy of toxic and metabolic causes is not caused by coronary artery disease. Further, coronary artery disease is not a direct result of Type 2 diabetes.

Read in the opposite direction, starting with line ‘d.’, the interpretation is that the diabetes triggered everything above it (the coronary artery, the toxic/metabolic encephalopathy, and the cardiac arrest). This is medically illogical and lacks cause-and-effect relationship,.

Words like “toxic” or “metabolic causes” imply something not entirely natural and are red flags to Vital Statistics professionals. If toxins or metabolic disturbances of unknown etiology are suspected clinically and the patient dies, the death must be reported to the Medical Examiner or Coroner (ME/C) in lieu of signing the death certificate!

The purpose of Part I of the cause-of-death section is to, in as few words as possible, tell a medical story of the patient’s leading medical condition that triggered a sequence of related medical conditions ultimately leading to the patient’s demise. Reading from top to bottom, each line, like the verse of a song, contains a medical condition that was the result of the condition listed above it (except for line ‘a’ of course!), with a corresponding increase in the time interval. Part II lists other pre-existing or co-existing conditions or risk factors not directly connected to the information in Part I. Upon  reading the  information in both Parts I and II, a snapshot of the patient’s overall general health condition should come to light without having first to read the patient’s medical chart.

Part II of the index case above lists other entities that should cause immediate pause. What about that shotgun wound to the back? Was there any sequela that could be linked to the death? What about the malnutrition? Does that have anything to do with the shotgun wound ? Was the malnutrition from the dementia, or caretaker neglect perhaps?  If  questions regarding acute or delayed complications of  injury, poisoning, or neglect can not be answered, then the death must be reported to the ME/C’s Office !

For time intervals, only certain words are permitted and it is unacceptable to enter dates, abbreviate, or use unclear terminology such as “long standing”.

 

For more on how to become a lyrical genius in death certification, refer to Chapter 8 in: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

 

Doctor Mix-A-Lot.

Attention Certifiers of Death!

Can you bust this rhyme?

Part I.

 

A.   Cardiac arrest resuscitated with  mechanical ventilation

Approximate interval: Onset to death

2/5/2017

Due to (or as a consequence of):

B.   Encephalopathy of toxic and metabolic causes

 

1 mo.

Due to (or as a consequence of):

C.    Coronary artery disease

 

Longstanding

Due to (or as a consequence of):

D.    Type 2 Diabetes with renal impairment

 

Longstanding

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

Dementia, hypertension, hypercholesterolemia, malnutrition, osteoarthritis, shotgun wound to back (1985)

Manner of Death

Natural

 

Clinicians treat patients sometimes with a list of medical conditions that may be as long as one’s arm, so to speak. Teasing out the most important one that is relevant to the patient’s terminal course may present a challenge. This challenge often leads to the “laundry list” approach to certification of death. This is not the approach one should adopt as it is not in line with the intended purpose of death certification. Rather, the cause-of-death statement listed on the death certificate (DC) must tell a story of the patient’s most significant medical condition that led to the demise, harmoniously and to-the-point 1 .

 

Reference:

  1. Armstrong E J. 2017. Chapter 8/Section 8.4: The Clinician Certifier of Death/Death Certificate Errors. In: Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

 

 

 

 

 

 

More on why DC free-style will not win you a Grammy from your local Vital Statistics on the next Practice Pearls!