The End Is Near! But That’s Just the Beginning: A view under the Retrospectroscope.

If hindsight were 20/20, there would be no need for Practice Pearls in 2020.

The Practice Pearls lessons of 2019 put clinician educators in the spotlight. They have the important responsibility of molding future physicians, especially those destined to practice in one of the Primary Care specialties, into not only diagnosticians and caregivers, but also stewards of public health in helping us live longer, smarter and healthier lives. 2019 saw another blow to the already floundering hospital autopsy rate with the handing down of a so-called burden reduction rule put forth by the Centers for Medicare and Medicaid Services (CMS) which in part called for the removal of the requirement for a hospital’s medical staff to attempt to secure autopsies in all cases of unusual deaths and of medical-legal and education interest (1). Not exactly a good thing for clinical resident education. Clinical educators must prepare these doctors-in-training to educate families about the benefits of the autopsy, to take advantage of the expertise of the pathologist in understanding disease processes, to know when and how to report a death to the Medical Examiner or Coroner, and to know how to properly complete a death certificate and why it makes a difference (2,3,4,5). Earlier exposure of these topics to medical students would further bolster the efforts of clinical educators.

Mortality trends in the United States have identified cardiovascular disease, accidental drug overdoses, suicidal injury in adolescents, fall-related injury in the elderly, birth defects, and pregnancy complications as top common causes of death based on cause-specific information listed by the Certifiers of death in the cause-of-death section of the death certificate (6). There is much room for improvement of mortality trends.

The following death certificate was not originally certified by the local Medical Examiner but by a clinician, not so auld lang syne, but in the not- so-distant past of the latter half of 2019:

There’s still work to be done….
Out with the old and in with more, so desperately needed, new pearls of clinical practice wisdom!

References:
1. Omnibus Burden Reduction (Conditions of Participation) Final Rule CMS-3346-F. Available at: https://www.cms.gov/newsroom/fact-sheets/omnibus-burden-reduction-conditions-participation-final-rule-cms-3346-f.
2. “How Trained is the Trainer-Comprehensive Medical Education: The Keystone of Modern Medicine”. Practice Pearls In Death Reporting and Death Certification, March 2019.
3. “Throwing mud at the wall: Sometimes it just doesn’t stick!”. Practice Pearls in Death Reporting and Death Certification, April 2019.
4. “Sch-o-o-o-ol’s-Out-For-the Summer!(But not if you’re a PGY-1 doc.)”. Practice Pearls in Death Reporting and Death Certification, July 2019.
5. “What Say You? Say It Isn’t So! Practice Pearls in Death Reporting and Death Certification”. October2019.
6. “Oh Say I-C-D!”. Practice Pearls in Death Reporting and Death Certification, May 2019.

 

Clinicians, kick off your New Year’s resolution to stay out of the crosshairs of the Funeral Director and Vital Statistics with a NEW AND IMPROVED copy of:

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Oh Say I-C-D !

As certifiers and reviewers of death certificates, we pledge allegiance to the mortality stats. The International Classification of Disease, currently in its 11th revision, is the foundation upon which health, disease, and injury trends derived from statistical data can be compared locally, nationally, and internationally (1,2).

Some mortality trends in the U.S.:
• Cardiovascular disease, still the #1 cause of death (3)
• As a result of drug overdoses, unintentional (accidental) deaths now occupy the 3rd leading cause of death bumping chronic respiratory deaths to the 4th spot (3)
• Suicides are now the #2 cause of death, ages 10-19 years (4)
• Out of all injury-associated deaths, those resulting from accidental falls account for the majority of deaths affecting our elders (5)
• The uptrend of women dying during or shortly after pregnancy continues(6)
• Birth defects, still the leading cause of infant deaths (7)
• Fueled by the opioid crisis, the drug overdose death rates continue to soar (8, 9)

How do we come to know of these trends?

The following is from a real death certificate in which a terminal mechanism, common to many types of deaths, was listed as the cause of death:

 

 

Just so happens that there’s a code for that, but which one of the ICD codes below apply?
MC82 Cardiac arrest

MC82.0 Ventricular tachycardia and fibrillation cardiac arrest

MC82.1 Bradycardic cardiac arrest

MC82.2 Asystolic cardiac arrest

MC82.3 Cardiac arrest with pulseless electrical activity

MC82.4 Cardiopulmonary arrest

MC82.Z Cardiac arrest, unspecified

 

Maybe the real cause of death is somewhere under one of these categories:
ICD-11 – Mortality and Morbidity Statistics

01 Certain infectious or parasitic diseases

02 Neoplasms

03 Diseases of the blood or blood-forming organs

04 Diseases of the immune system

05 Endocrine, nutritional or metabolic diseases

06 Mental, behavioural or neurodevelopmental disorders

07 Sleep-wake disorders

08 Diseases of the nervous system

09 Diseases of the visual system

10 Diseases of the ear or mastoid process

11 Diseases of the circulatory system

12 Diseases of the respiratory system

13 Diseases of the digestive system

14 Diseases of the skin

15 Diseases of the musculoskeletal system or connective tissue

16 Diseases of the genitourinary system

17 Conditions related to sexual health

18 Pregnancy, childbirth or the puerperium

19 Certain conditions originating in the perinatal period

20 Developmental anomalies

21 Symptoms, signs or clinical findings, not elsewhere classified

22 Injury, poisoning or certain other consequences of external causes

23 External causes of morbidity or mortality

It’s clear WHO can code it.
The question is how to decode it?
Specificity, the spice of life.

References:
1. World Health Organization: Classifications. Available at: https://www.who.int/classifications/icd/en/
2. World Health Organization: ICD 11 For Morbidty and Mortality Statistics (ICD 11 MMS) 2018 Version. Available at: https://icd.who.int/browse11/l-m/en
3. Centers for Disease Control and Prevention: Leading causes of death. Available at: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
4. National Vital Statistics System Reports: Recent Increases in Injury Mortality Among Children and Adolescents Aged 10–19 Years in the United States: 1999–2016. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_04.pdf
5. Burns E. Deaths from Falls Among Persons Aged ≥65 Years — United States, 2007–2016. Morbidity and Mortality Weekly Report. Available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6718a1.htm
6. Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System: Trends In Pregnancy-Related Deaths. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm
7. National Vital Statistics System Reprts. Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2011–2016. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf
8. Center for Disease Control and Prevention. Infant Mortality. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
9. Centers for Disease Control and Prevention. Drug Overdose Deaths. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html

For more information on how to decode the secret of specificity in death certification, access your declassified copy of:

 

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Throwing mud at the wall: Sometimes it just doesn’t stick!

The following death certificate did not pass the Vital Statistics “sniff test” and was sent to the local Medical Examiner’s office for review and amendment:

By all appearances, the patient had a number of serious health conditions. But which one killed the patient? The heart disease, the diabetes or perhaps the congestive heart failure? Did the spinal abscess causing cord compression and paralysis stem from a remote injury and therefore this really isn’t a natural death as was checked off in the manner-of-death section? How does that cause congestive heart failure? If somehow the paralysis with heart failure are linked and are the main cause of death, why is it listed in Part II instead of Part I?

By simply listing all of the patient’s major medical conditions, the laundry-list, catch-all approach to certifying this death missed the mark of identifying the one disease entity that triggered a series of interrelated complications that over time ultimately led to the death. Which International Classification of Disease (ICD) code applies in this death? More than one is represented. There can only be one.

Buzzwords like paresis and paralysis are red flags for injury as the possible underling cause. Injury and its complications fall under the domain of the Medical Examiner or Coroner (i.e. they are reportable deaths). Following a medicolegal investigation into the death circumstances, deaths resulting from injury will be classified as accident, homicide, or suicide.

An important question regarding the manner in which the spinal abscess with paresis was acquired remains- Gunshot wound to the spine? Intravenous injection of drugs with a dirty needle? Spinal trauma from a fall or a jump? Complication of spinal surgery…for an injury or a birth defect? Complication of natural disease like diabetes? Trends derived from manner of death classification have far-reaching important public health implications (1) .

Reference:
1. National Vital Statistics System-Mortality Data. Available at: https://www.cdc.gov/nchs/nvss/deaths.htm.

More tips on de-mudifying the death certificate can be found in Chapter 8: The Clinician Certifier of Death from 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 .

 

“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.

“When You Wish Upon a Stat…”

these DCs will leave you flat!

The following are cause-of-death statements taken from actual death certificates (DCs) completed by local physicians, flagged by the local Vital Statistics for a number of glaring reasons. Can you identify them?

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

 

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

 

 

Part I.

 

 

 

 

A.  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

 

 

A great amount and variety of statistical information is derived from the classification of different causes of death providing clinical practitioners with foundational information upon which to improve medical diagnosis and optimize patient care. This is facilitated by the classification system known as the International Classification of Disease (ICD) currently in its 11th revision. Clinicians are also (painfully) aware of the related clinical modification coding system ICD-CM which applies codes to medical diagnoses for many purposes including the monitoring of disease rates, medical care review, and basic health statistics. 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 health wise (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.

A Manner of Fact.

How a death happened can be just as important as what caused the death. Yes, manner matters.

Take another look at the cause-of-death statement presented in the last installment of Practice Pearls. It was taken from an actual death certificate:

Part I.

 

 

 

A.                  Pneumonia-Aspiration poss.

 

Approximate interval: Onset to death

 

1 day

Due to (or as a consequence of):

 

B.                  Dysphagia

 

6 months

Due to (or as a consequence of):

 

C.                   Quadriplegia

 

3 years

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
Manner of Death

Natural

 

While aspiration pneumonia could result from dysphagia which in turn could be caused by quadriplegia, the question that should linger in the certifier’s mind is: What is the cause of the quadriplegia? Cervical spinal cord damage by Multiple Sclerosis? Epidural abscess complicating cervical disc surgery? A fall with fracture of the cervical spine and injury to the spinal cord? Or perforating injury to the cervical spinal cord from a remote gunshot wound? The manner of death for each of the four scenarios is very different: Natural vs Therapeutic Complication vs. Accident vs. Homicide. If the death circumstances are or might be accidental, homicidal, therapy-associated 1 or anything not associated with pure natural disease, the death must be reported to the ME/C. If you are a clinician certifier and list ‘quadriplegia’ or other non-specific terms as the underlying cause of death (the lowest line in Part I), expect to be notified by your friendly local Vital Stats professional (or your patient’s funeral home)!

Clinicians certify only natural deaths. Medical Examiners and Coroner (ME/C) physicians certify ALL manners of death.

For clinicians, accurate cause and manner of death determination flows from clinical diagnoses, clinical terminal events, and knowledge of the lethal potential of disease 2. For physician ME/Cs, this flows from comprehensive medicolegal death investigation, from scene to autopsy.

For both clinicians and ME/Cs, cause and manner of death determinations summarized in the cause-of-death section on the death certificate have important wide-ranging public health ramifications including increasing overall awareness of certain death trends with aims at death prevention or reduction in mortality rates 3-10. Examples include:

  • Deaths associated with medical procedures and devices: reports and bulletins compiled from data provided by online reporting
  • Fall injury deaths: identifying medical risk factors and in-home hazards
  • Traffic accident deaths: identifying road hazards, intervention by law enforcement regarding distracted or impaired driving
  • Opioid deaths: identifying sources of clandestinely manufactured fentanyl analogues, prompting changes in clinician prescribing habits and promoting alternate treatments for acute and chronic pain
  • Accidental drowning deaths: promoting and instituting measures regarding pool safety and safe boating
  • Homicide deaths of intimate partners-prevention through education in conflict resolution, offender intervention, improvement of services for domestic violence victims
  • Child homicide deaths: education of physicians, social workers, law enforcement and other mandated reporters in recognition of signs of abuse and the creation of integrated multi-agency standard operating procedures

 

References:

  1. Armstrong E J. Chapter 8 Section 8.5: The Clinician Certifier of Death-Peri-procedural and Therapy-Associated Death Certification. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
  2. Armstrong E J. Chapter 7: The Lethal Potential of Disease. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
  3. MedWatch: The FDA Safety Information and Adverse Event Reporting Program. Available at: https://www.fda.gov/safety/medwatch/ .
  4. Fowler KA, Jack SPD, Lyons BH, et. al. Surveillance for Violent Deaths-National Violent Death Reporting System 18 States, 2014. MMWR Surveill Summ. 2018 ;67(SS-2):1-36. Available at: http://dx.doi.org/10.15585/mmwr.ss6702a1 .
  5. Centers for Disease Control and Prevention. Motor Vehicle Safety: Distracted Driving. Available at: https://www.cdc.gov/motorvehiclesafety/distracted_driving/index.html .
  6. Centers for Disease Control and Prevention. U.S. Drug Overdose Deaths Continue to Rise; Increase Fueled by Synthetic Opioids. Available at: www.cdc.gov.
  7. Centers for Disease Control and Prevention: Unintentional Drowning-Get the Facts. Available at: https://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-factsheet.html .
  8. Centers for Disease Control and Prevention: Child Abuse and Neglect Prevention. Available at: https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html .
  9. National Coalition Against Domestic Violence Fact Sheet. Available at: https://www.speakcdn.com/assets/2497/domestic_violence2.pdf .
  10. Deaths from Falls Among Persons Aged ≥65 Years –United States, 2007-2016. MMWR 2018:67:509-514. Available at: http://dx.doi.org/10.15585/mmwr.mm6718a1 .

 

Mind Your Manners. Avoid A Query.

“…but in this world nothing can be said to be certain, except death and taxes”-Benjamin Franklin, 1789.

It is also pretty certain, that a clinician practicing in a primary care specialty will on more than one occasion during his/her career encounter the death of a patient and be called upon to certify the death. Collectively, clinicians certify the majority (about 80 %) of deaths as compared to those certified by medical examiners and coroners (1,2). Those of you who follow the Practice Pearls site regularly know why getting it right matters and the consequences of getting it wrong.

Consider the cause of death statement below taken from an actual death certificate involving a death that  was certified in lieu of reporting to the local Medical Examiner. It was promptly flagged by an astute Vital Statistics professional. Can you identify the reasons why?

Part I.

 

A.                  Pneumonia-Aspiration poss.

Approximate interval: Onset to death

1 day

Due to (or as a consequence of):

B.                  Dysphagia

 

6 months

Due to (or as a consequence of):

C.                   Quadriplegia

 

3 years

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
Manner of Death

Natural

 

References:

  1. Cambridge B and Cina SJ. The accuracy of death certificate completion in a suburban community. Am J Forensic Med Pathol. 2010;31(3):232-35.

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

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!

Tag, You’re It! The Case of the Phantom Physician.

On a regular basis, medical examiner and coroner officials expend excessive amounts of time searching for someone to certify a hospital death resulting purely from natural chronic disease and that otherwise does not fall under the jurisdiction of the medical examiner or coroner (ME/C). Why? Because the first physician contacted refuses to sign the death certificate or, amazingly, not one physician is available to perform this important end-of-life patient care duty often for a patient with not only multiple diagnostic workups for previous clinical encounters (documented in the medical record) but also some degree of evaluation leading up to the terminal admission which importantly includes any clinical assessment performed by paramedics.

The reasons proffered for refusal to perform this end-of-life patient care duty run the gamut:

  • “I am not obligated to sign the death certificate.”
  • “I am not the patient’s regular physician or primary physician.”
  • “I’m the pronouncing physician not the attending physician.”
  • “I don’t know the patient’s history.”
  • “I have not seen the patient in ‘x’ number of weeks, months, or years.”
  • “The patient’s chronic medical condition has been stable.”
  • “I’m only the cross covering doctor.”
  • “The patient just arrived to the nursing home and I don’t have all the medical records.”
  • “I don’ t know the cause of death.”
  • “If I’m wrong, I might get sued.”

It is apparent that those who are uninformed also believe that the cause of death cannot be determined unless an autopsy performed, certification of a patient’s death has nothing to do with patient care, and when the ME/C refuses to certify a death, their just passing the buck 1 . It is also apparent that the many “messages” that have been sent to the contrary are not being received by all  2,3 . Message not received. For those still in doubt, your state medical board can surely clear that up!

Families who experience delay in receiving the death certificate generally are not privy to all of the steps required to generate a death certificate but will and do suffer many real-life consequences that result when getting one is delayed (See “On the Edge” entry from 10/22/2017).  Thoughts of doubt, suspicion of substandard care, and suspicion that someone’s trying to cover up a medical mistake also may surface.

It is important to remember that the clinician is not required to be 100% correct when listing the cause of death, just greater that 50% certain, or that in all probability, more likely than not, the patient died of ‘x’. It is the clinician’s opinion put forth in good faith and is otherwise legally defensible. This requires review of the patient’s medical history and history of present illness, exercising clinical judgment, and applying one’s knowledge of the lethal potential of many natural disease entities that can present with sudden unexpected death.  A reasonable cause of death can be opined without results from a battery of tests in patients with little or no medical history including patients with recent exertional chest pain presenting in v-fib arrest, shortness of breath in the setting of obesity, peripheral edema with a history of cardiomyopathy, or other tell-tale signs of a rapidly decompensating disease condition, who expire after brief hospitalization. Use of qualifiers such as “presumed” or “probable” are permitted on death certificates to indicate uncertainty (because of lack of clinical evidence) in those instances. A hospital autopsy could be beneficial in attaining a higher degree of certainty of the cause of death and requires consent from the legal next-of-kin 4 . It may be necessary to list “pending” in the cause-of-death section while awaiting results of the hospital autopsy. Once final results are received and reviewed, a supplemental death certificate listing the etiologically specific cause of death reflective of the autopsy findings must promptly follow.

 

References:

  1. (author not listed)Who Should Sign Death Certificates? Emergency Physicians Monthly. Available at: http://epmonthly.com/blog/who-should-sign-death-certificates/ .
  2. Philips J. 2013. Coroner says office burdened because doctors won’t sign death certificates. The Columbus Dispatch. Available at: http://www.dispatch.com/content/stories/local/2013/02/04/cause-of-death-hard-to-reach.html .
  3. Cina SJ. Death Certification: A Final Service to Your Patient. Available at: http://www.cmsdocs.org/news/death-certification-a-final-service-to-your-patient .
  4. Armstrong E J. 2017. Chapter 5: Hospital versus Forensic Autopsies. 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/ref=sr_1_1?ie=UTF8&qid=1488731535&sr=8-1&keywords=death+certification .

Now, for the answers to the last PPQ:

The case was of a 59 year-old female clinically diagnosed with a hypertensive intracerebral hemorrhage with subsequent death and pronouncement within 24 hours of hospitalization. It is based on a true case.

True. This is a reportable death (death within 24 hours of admission).

False. As there was no suspicion of foul play, findings of trauma, history of signs of substance use disorder, or concerns for suicidality, and  further, with a negative urine toxicology screen test, this death did not need a medicolegal death investigation.

It should be remembered that a medicolegal death investigation entails personnel and resources that exist as a result of appropriation of tax-payers’ money, including yours and mine, the use of which is perpetually under intense scrutiny by the public. News Flash: There are no deep pockets as it pertains to the governments, especially local ones!

Furthermore, several physicians were involved at some point in this patient’s care, any of whom would be eligible to sign the death certificate. But mysteriously, none could be located to do so. Ideally, a proverbial climb up the “chain of command”, even to the level of Chief Medical Officer, could have been rightly done. But alas, Tag, the ME became It!

 

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