Reporting for Duty Part II: The Buck Stops Here!

It’s worth emphasizing that the major goal of medicolegal death investigation is to ensure that accidental, homicidal and suicidal deaths don’t get missed. In that effort, medical examiners and coroners are the bellwether for public health and safety. As an added benefit, this system of monitoring deaths also serves to document disease outbreaks and the extent and unexpected outcomes of chronic natural disease, especially undiagnosed or misdiagnosed natural disease conditions. Mortality data from death certificates generated by medical examiners’ and coroners’ offices complements that generated by those in clinical practice who certify the deaths of patients with well-documented natural disease conditions. Recognizing the lethal potential of many natural disease conditions, treated or not, will help to dispel the uncertainty many clinicians have when faced with certifying the deaths that result and reduce the knee-jerk tendency to “pass the buck” by reporting the death to the medical examiner/coroner (ME/C).

Time out for the answers to the last PPQ exercise.

Playing the role of the treating clinician of record, consider the following case scenarios and whether or not the circumstances dictate reporting:

  1. Sudden death in the ED in a 23 year-old female presenting with symptoms and signs of hypovolemic shock, electrolyte disturbance, and acute renal failure. Past medical history only of Addison’s disease, non-compliant with her prescribed medication regimen with multiple prior ER visits according to the EMR.

This death needs reporting. True or False?

False. This is an example of sudden death from a natural disease with known lethal potential that would be accelerated by not taking medication as prescribed. “Addisonian crisis with clinicopathologic sequela” is an example of a righteous cause of death that can be listed on the death certificate. Inclusion of terminology such as “non-compliance” is accusatory, unnecessary, and should not be included on a death certificate.

 

  1. Patient pronounced dead after arrival. History of ischemic cardiomyopathy and coronary artery disease with multiple prior admissions for acute exacerbation.

This death needs reporting. True or False?

False. This is an example of natural (chronic) disease with the potential for sudden death. As long as there no history of drug abuse, especially of stimulant types, this death is certifiable by the pronouncing physician or the physician responsible for the patient’s regular care. And yes, one CAN opine what the cause of the death is in this scenario without needing a clinical lab test to tell you so. Cause of death: “Atherosclerotic coronary artery disease with ischemic cardiomyopathy”.

 

  1. Sudden death in an asthmatic presenting in status asthmaticus with a history of cocaine abuse.

This death needs reporting. True or False?

True. There is a history of cocaine abuse. Chronic cocaine abuse by smoking is a recognized cause of the asthma variant of COPD and doing so can trigger an asthma attack at any time. It must be established whether or not cocaine contributed to or directly caused the status asthmaticus through postmortem analysis of blood by the forensic laboratory. If so, then the death is not purely due to natural causes which has implications for manner of death classification (ex. Accident). Clinicians do not certify accidental or other non-natural deaths.

 

  1. Death from bacterial sepsis following spontaneous perforation of ischemic bowel. Remote history of a gunshot wound to the abdomen with visceral injury complicated by bowel adhesions with incarceration requiring multiple abdominal surgeries.

This death needs reporting. True or False?

True. You’ve got gunshot wound in the history mix and the complications could have arisen from it. An automatic ME/C’s case. If you missed that one, shame on you! Unfortunately though, sometimes the little minor detail of the history of a gunshot wound gets lost and left out of the medical records generated over the years of treating the complications of the GSW which in and of themselves can be distinct natural disease entities.

 

  1. Sudden death in a patient visiting from another state, pronounced dead after 36 hours of hospitalization following resuscitative efforts for a respiratory arrest. Accordingly, no electronic medical record exists and the past medical history is otherwise unknown. A prescription for albuterol, metoprolol, atorvastatin, and methadone along with a DAWN kit are found among the patient’s personal effects. The UDS is negative.

This death needs reporting. True or False?

True. Most of the meds are for natural disease problems, like probably asthma, high blood pressure, and high cholesterol. But the methadone and DAWN kit is cause for pause. Maybe methadone was prescribed for chronic pain, but paired with the DAWN kit, more than likely there is a history of opioid abuse. What’s a DAWN kit anyway? Maybe you already know or otherwise for the curious or uninformed, google “DAWN kit”. And another thing, in the context of this scenario, a negative UDS does not mean that drugs were not used prior to death, especially if the hospital’s lab does not test for the many different types of opioids like fentanyl and fentanyl-related substances (aka fentalogues). For more on UDS, see July 30, 2017 installment “UDS-Universal Drug Screen?” at: https://deathreportingandcertification.info/2017/07/30/uds-universal-drug-screen/  

 

 

Like vitamins and minerals…get your copy at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408

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