“When You Wish Upon a Stat…” Part II: To Err Is not to Error!

The following death certificates (DCs), completed by local physicians, were flagged by the local Vital Statistics and referred to the local Medical Examiner (ME) because they contained a number of errors.

Part I.                               

 

 

 

A.   Cardiopulmonary arrest

 

Approximate interval: Onset to death

 

Sudden

Due to (or as a consequence of):

B.

 

Due to (or as a consequence of):

C.

 

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

 

    COPD, Paraplegia

 

Manner of Death

 

Natural

 

  • Cardiopulmonary arrest: This is a non-specific, terminal, mechanistic event common to all deaths and should not be listed. More importantly, the specific etiology is omitted. Listing  of time-associated terms like seconds, minutes, hours, or days, with our without specific numbers in the time-interval column is permitted not vague terms like “sudden”.
  • COPD: Asthma? Emphysema? Bronchitis? Pneumonconiosis?
  • Paraplegia: If this is a complication of injury and also a contributing factor in the death, the manner of death cannot be natural. Clinicians certify deaths due to natural disease only. Injury-associated deaths must be reported to the ME or Coroner!

 

Part I.

 

 

 

A.   Respiratory failure, paraplegia      

Approximate interval: Onset to death

 

1-3 days

Due to (or as a consequence of):

 

B.    Dementia, neurogenic bladder

 

1-3 wks

Due to (or as a consequence of):

 

C.  Paraplegia, Stage IV sacral ulcer

 

1-4 months

Due to (or as a consequence of):

 

D.  Paraplegia, spinal meningeal tumor

 

1-3 years

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

 

Manner of Death

 

Natural

 

This DC is a laundry list of the patient’s current medical conditions, some unrelated, and is a classic example of what the DC is not intended for.

  • Respiratory failure, paraplegia: A non-specific mechanism is listed with a potentially unrelated, injury-associated condition. Another example of a death that should have been reported.
  • Lines ‘b’ and ‘c’ also list 2 conditions, one of which has competing conditions. Dementia has nothing to do with neurgenic bladder. Only one condition per line should be listed.
  • Paraplegia, spinal meningeal tumor: This suggests perhaps that the spinal meningeal tumor may have had something to do with the paraplegia. But it is not clear. When it is not clear or known whether the paraplegia was caused by injury versus a natural disease condition, the death must be reported to the ME or Coroner. It would be necessary to rule out (or in) accidental, homicidal, or suicidal injury as an underlying cause of the paraplegia or confirm that the spinal tumor was the cause. Moreover, the type (meningioma vs melanoma vs other), stage, and grade of the spinal tumor should be included if known.
  • Paraplegia, spinal meningeal tumor, Stage IV sacral ulcer, dementia, neurogenic bladder: Starting with line ‘a’, the place for the immediate cause of death, which is the last condition prior to death, and as read from top to bottom, there is no logical cause-and-effect relationship between these conditions. Respiratory failure and paraplegia are not caused by (or due to) dementia and neurogenic bladder. While neurogenic bladder may be due to paraplegia, Stage IV sacral ulcer is not. Stage IV (decubital) ulcers are often complications of paraplegia stemming from immobility and can also lead to bone infection (osteomyelitis) which in turn can lead to sepsis, multiorgan failure, and death. Was this part of the patient’s terminal course? The lack of cause-and-effect relationship will cause conflicting or overlapping time intervals to be listed. The time intervals, when read from top to bottom, should progressively increase in time. It is also improper to enter ranges of time as done on this DC. If the time intervals don’t make sense, then there’s a good chance that the corresponding conditions don’t either.

 

Part I.

 

 

 

 

D.     Possible arrhythmia         

 

Approximate interval: Onset to death

 

 

Few hours

Due to (or as a consequence of):

 

B.     Congestive heart failure

 

Due to (or as a consequence of):

C.

 

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

 

         CKD, Uncontrolled DM, Cocaine Abuse

 

Manner of Death

 

Natural

 

  • Possible arrhythmia: It is permissible to indicate uncertainty by use of the words “possible” or “probable” in the setting of absent or incomplete medical information. However, use of mechanistic terminology is unnecessary but if used, should be accompanied by a specific etiology. “Hours” or the specific number of hours (not ‘”few”) should be listed in the time interval column.

Congestive heart failure: Not much more specific that “possible arrhythmia”. What cause it? Natural disease ,intoxicant, or complication an injury? The approximate interval from onset to death is also erroneously omitted.

  • COCAINE Abuse: Stop the presses! Was current use (i.e. a positive urine drug screen) ruled out? With this drug possibly a factor in the death, (since the certifier listed it in Part II) the manner of death could change from natural to accidental, in the setting of recreational use and no evidence of suicidality or criminal poisoning. The death in this case should have been reported to the ME or Coroner. The acute and/or chronic effects of cocaine use would be confirmed based on results of postmortem testing and autopsy findings. With uncontrolled diabetes mellitus a factor (since the certifier listed it Part II), postmortem testing would also identify diabetic ketoacidosis, which by itself is a cause of death.
  • CKD, DM: While common medical abbreviations are recognized by vital statistics professionals and nosologists, overlap exists. Use of abbreviations should be avoided to prevent the need to guess intended meaning on the part of  the certifier.

From the identification of the specific types of drugs driving the current drug death crisis to identifying deaths associated with defective medical devices, to the ranking of the most common causes of death, we stay informed (1, 2, 3 ) .

The more accurate and error-free the “raw materials” provided by certifiers of death, the better informed we are and ultimately the better off we are healthwise (4).

References:

  1. Drug overdose death data. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html .
  2. Food and Drug Administration (FDA) Medical Products Program-MedWatch www.fda.gov/medwatch .
  3. Mortality in the United States, 2016. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/nchs/products/databriefs/db293.htm .
  4. . Armstrong E J. 2017. Death Certificate Errors. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner pp. 146-58.

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