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


Approximate interval: Onset to death


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



Due to (or as a consequence of):

D. Type 2 Diabetes with renal impairment



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



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: .


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