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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What Say You? Say It Isn’t So!

Attention Clinicians (and curious Georges and Georgettes) !

What do you tell families when their loved one has passed and the death has been reported to the Medical Examiner or Coroner (ME/C)?
Do you:
1. Tell the family that by law the ME/C must accept all deaths reported to them?
2. Do you say to the family that an autopsy will be performed because the ME/C is mandated by law to perform one on all reported and accepted deaths?
3. Do you say to them that an autopsy will be performed by the ME/C even when the ME/C has not taken jurisdiction over the death and their loved one will not be transported to the Office of the ME/C?

Because health care providers assume the answer to the above questions is ‘yes’, families of patients who have died at the hospital in which the death is reportable or has been reported are being told that an autopsy will automatically be done by the ME/C, because “it’s the law”. Then, when the family calls the ME/C to find out the results of the autopsy, they are surprised (and sometimes angry) to learn that an autopsy was not done.

The Medical Examiner or Coroner has jurisdictional authority (as mandated by state law) over sudden and unexpected deaths, violent deaths (suspected or obvious homicidal , suicidal, and accidental deaths), unattended deaths, deaths of unknown or uncertain causes, deaths in which a non-natural cause cannot be ruled out, and deaths of the unclaimed and unidentified. These are the reportable deaths and also include deaths occurring within 24 hours of admission or deaths occurring after several days or more of hospitalization from non-natural causes.

The ME/C will not automatically assume jurisdiction over all deaths originating from a medical facility, particularly those due to natural diseases and their complications, and those in which injury or the toxic effects of medications or drugs did not play a part. This would also include deaths in which there may have been a history of some type of remote injury not connected with the current death circumstances OR deaths in which there was a history of some type of recent injury followed by a return to baseline health in the setting of stable chronic natural disease with lethal potential, like certain heart or lung diseases.

Contrary to popular belief of those practicing clinical medicine and many others:
1. The ME/C will not assume jurisdiction over all deaths reported to them. The ME/C will not certify (meaning complete the death certificate on ) deaths for which jurisdiction was not taken. These are the deaths that resulted from natural disease and these are the ones that are certifiable by clinical practitioners BY LAW. 1,2
2. The ME/C will not have an autopsy done on every case for which jurisdiction has been taken. The decision to do an autopsy is made on a case-by-case basis. Even without an autopsy, an external examination of the body, review of medical and other records, and review of results of any postmortem testing are done. Determination of the cause and manner of death with completion of the death certificate will follow. A family, specifically the next-of-kin, may request an autopsy to be done and must do so in a timely manner . The honoring of that request is at the discretion of the ME/C.
3. The ME/C will not perform an autopsy on cases for which jurisdiction was NOT taken. This should be a no-brainer. Why would an ME/C do an autopsy on a non-ME/C case? For a hospital death, if the family (again next-of-kin to be specific) wants an autopsy done then the hospital pathologist would perform the autopsy at cost to the family unless the cost is waived by the hospital, especially at a teaching hospital. Otherwise families are on their own with the option to seek the assistance of a private autopsy service.

Medical Examiners’ and Coroners’ Offices are government agencies and have a very important public health-oriented mandate of timely cause and manner of death determination, funded by us taxpayers. They work with limited resources, staff, and budget strategically applied in order to meet that mandate which involves the investigation of approximately 500,000 deaths out of the approximately 1 million deaths reported per year 3,4.

References:
1. Information For Physicians Who Sign (Certify) Death Certificates . Available at : https://www.tn.gov/content/dam/tn/health/documents/BME_Note112105.pdf.
2. The Ohio Revised Code 3705-16. Statements in facts of certificates-death certificate. http://codes.ohio.gov/orc/3705.16.
3. Hickman MJ, Hughes KA, Strom KJ, and Ropero-Miller JD. Medical Examiners’ and Coroners’ Offices, 2004. Available at: www.bjs.gov/content/pub/pdf/meco04.pdf.
4. Armstrong EJ. 2017. Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner.

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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

Reporting for Duty.

Knowing when to report a death requires clinicians to dutifully exercise some medical forethought. It requires the knowledge that while the phrase sudden death is the common thread that defines many reportable deaths, not all sudden deaths actually need reporting to the Medical Examiner or Coroner (ME/C) and can be certified by a treating clinician of record. It further requires the consideration that causes other than that due to natural disease could have triggered a chain of clinicopathologic events leading to the patient’s demise, be they sudden or delayed in progression.

Ultimately and for many important public health  and legal reasons, the goal is to ensure that deaths potentially occurring under non-natural circumstances are not missed and are otherwise identified, investigated, and certified by the ME/C.

Time out for a PPQ (Practice Pearls Quizlet) 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 all nicely documented in the EMR.

This death needs reporting. True or False?

2. 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?

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

This death needs reporting. True or False?

4. 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?

5. 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?

 

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 .

 

‘Til Death Do Us Part.

Clinical education focuses on the optimization of diagnosis, treatment, disease prevention, and quality of life for the patient. Establishment and maintenance of the physician-patient relationship is also an integral part of the clinical learning experience. Despite the best of all efforts, there are limitations in medical interventions aimed at saving lives and ultimately, the physician-patient relationship must dissolve.

The clinical care team must complete a number of complex tasks for the infrequent occurrence of an impending or unexpected, traumatic or natural hospital death in accordance with established hospital policy 1. These include clinical procedures with adherence to any advanced care directives, pronouncement of death, notifying family, providing family with the means for bereavement, notifying the organ/tissue procurement organization, providing education and obtaining consent from the family regarding a hospital autopsy where applicable, and fulfillment of legal requirements in homicidal deaths. Homicidal deaths will require notification of law enforcement, reporting the death to the Medical Examiner/Coroner (ME/C), and securing any evidence inclusive of the deceased’s body 2. While some variability exists, state law mandates the reporting of deaths that are sudden, unexpected or unnatural to the ME/C.

Fundamentally, clinicians must know not only when and how to report a death, but why. Understanding the “why” facilitates the whole process of reporting. The insufficiency of consistent, periodic education on this topic has fueled uncertainty, lack of knowledge, and lack of understanding 2 regarding:

  • state laws that mandate reporting and by whom 2,3
  • specific types of reportable deaths 2,3
  • specifics on how to report a death 2
  • the public health importance of reporting deaths 2
  • physician responsibilities for in-home patient deaths 4
  • the requirements and the role of the ME/C 2,3

Consistent and periodic education with assessment is necessary, as early as third or fourth year of medical school or at least starting early in the first year of residency. Various learning platforms such as textbook-based lectures, morbidity mortality review conferences, and online courses and tutorials can be utilized to ensure reinforcement and retention of knowledge throughout the years of clinical training and provide continuing medical education following training.

 

References:

  1. O’Malley P, Barata I, Snow S, et. al. Death of a child in the emergency department. Pediatrics. 2014;134:e313-e330.
  2. Armstrong EJ. 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. Charles A, Cross W, Griffiths D. What do clinicians understand about deaths reportable to the coroner? J Forensic Leg Med. 2017;51:76-80.
  4. Yang M, McNabney MK. Physicians’ responsibilities for deaths occurring at home. J Am Geriatr Soc. 2017;65(3):648-652.

 

Stay tuned for more Practice Pearls!

 

“Oh, What A Tangled Web…”

A true story…

Case Scenario: A middle-aged man dies in a nursing home of acute pneumonia with sepsis and respiratory failure. He had a recent history of a gunshot wound (site not specified), quadriplegia, and basocranial and facial skeletal fractures, all of unknown circumstance(s).

Surely this death was reported!-you exclaim.

In actuality… it was not.

Instead, nearly 2 weeks transpired until this death was reported, not by the nursing home, not by a first funeral home, but by a very astute second and final funeral home, luckily, prior to any further funeral proceedings such as a burial or a cremation of the body.  An autopsy was definitely needed followed by amendment of the heretofore completed death certificate.

When examined alone, the terminal disease conditions of the case scenario are suggestive of natural disease sequelae. The risk: The death will be not be reported but instead certified by the clinician as such with classification of the manner of death as natural. When examined in the context of his overall health status and medical history, the realization should be that a connection could exist: That the terminal disease conditions actually represent the delayed complications of prior injury.  A death in which the terminal clinical course could represent delayed complications of injury, regardless of the time interval, is a reportable death, an important point for all clinical practitioners to keep in mind. A medicolegal autopsy which includes review of all pertinent medical records is necessary to either confirm or discount a connection between disease and injury.

Furthermore, autopsy findings and medical record information may reveal circumstances suggestive of foul play or homicidal violence or otherwise unknown non-natural circumstances requiring further investigation by law enforcement. If circumstances suggestive of foul play or homicidal violence are discovered, a potentially crucial time period has already transpired during which there may have been loss of vital evidence, investigative leads, and access to potential witnesses to the death circumstances.

The serious disservice to society is for a death involving homicidal violence or resulting from reckless or negligent acts to escape adjudication because of a failure to report.

 

Now to unravel the mystery of the last PPQ:

The death certificate was flagged for many, many reasons and furthermore, the death was reportable.  The reasons:

  1. Use of non-specific terminology with possible non-natural (traumatic) causes: septic shock, bacteremia, wound, acute kidney injury
  2. Listing of more than one condition and competing conditions per line (line a.)
  3. Use of abbreviations (CHF)
  4. Lack of medically known cause-and-effect relationship between lines a-d: examples- acute kidney injury does not cause severe aortic stenosis and severe aortic stenosis does not cause severe pulmonary hypertension
  5. Listing a range of calendar dates in “Approximate interval: Onset to death” box (Use of terms such as seconds, minutes, hours, days, weeks, years, and decades with or without specific numbers, inclusion of qualifiers such as “approximately”, or if interval not known “unknown” are permitted. Boxes with corresponding cause of death information cannot be left blank.)

Stay tuned for a future Practice Pearls!

 

 

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The Patient Died from Complications of Paralysis, Naturally? The perils of forgetting about etiology and why it matters.

The following cause-of-death statement is from an actual death certificate certified the by decedent’s attending physician. It was flagged by the local Vital Statistics agency and sent to the local Medical Examiner’s office for investigation for many glaring reasons, some discussed previously. It is also representative of a reportable death. It will be familiar as it appeared in August 13th’s entry as a PPQ question:

Part I.

 

 

A. Hospital-acquired pneumonia

Approximate interval: Onset to death

< 1 week

Due to (or as a consequence of):

B. C-6 quadriplegia

 

>  1 year

Due to (or as a consequence of):

C. Mucous plugging

 

>  1 month

Due to (or as a consequence of):

D. Cardiac failure

 

>  1 month

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

Natural

 

With the advancements in medical care, paralyzed patients are living longer lives but are at risk acquiring a number of disease complications in the interim period that can lead to death. Losing sight of the initial cause of the paralysis will result in a death that does not get reported to the Medical Examiner or Coroner (ME/C). Trauma must be ruled out in patients who die of delayed complications of spinal cord injury with paralysis. If trauma is a known or suspected etiologic factor, then the death is reportable to the ME/C who will investigate the circumstances under which the trauma (injury) was acquired and properly classify the death as accident, suicide, or homicide. Recommendations for the approach to the investigation of these types of deaths are outlined in the 1954 Model Postmortem Examinations Act and have been adopted by most US jurisdictions to varying degrees 1. It is important to also note that the original “trauma” or “injury” may not be physical and thus would include sequela of prolonged cardiopulmonary arrest following a drug or medication overdose or certain types of asphyxia (like chemical/gas or choking). Classification of non-natural manners of death provides valuable information used in fatal injury databases such as the CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS) 2 and in publications by the National Safety Council 3.

There are many chronic medical conditions that represent “red flags” for possible underlying non-natural causes including venous thrombosis, encephalopathy, cerebral infarcts, recurrent infections, and contractures.

So you’ve been wondering what else is wrong with the cause-of-death statement?

  • an overall lack of cause-and-effect relationship between conditions listed in Part I (cardiac failure does not cause mucous plugging and mucous plugging does not cause C-6 quadriplegia)
  • ‘Cardiac failure’ is a non-specific, mechanistic, sometimes terminal process and should never be listed as an underlying cause of death which is what belongs on line ‘D’
  • the manner of death can’t be listed as natural if the quadriplegia was due to a spinal cord injury subsequent to a remote gunshot wound or a mechanical fall regardless that the proximate cause of death was pneumonia

 

References:

  1. Hanzlick RL. A synoptic review of the 1954 “Model Postmortem Examinations Act”. Acad Forensic Pathol. 2014; 4(14):451-54.
  2. WISQARS. Scientific Data, Statistics, and Surveillance. Available at: www.cdc.gov/injury/wisqars/dataandstats.html.
  3. National Safety Council. Injury Facts. The Source for Safety Data. Available at: www.nsc.org/learn/safety-knowledge/Pages/injury-facts.aspx.

 

You’ll find more on why etiology really does matter in death reporting (and certification) in Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available through this link: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

More pearls for practice are in your future, so stay tuned for the next installation of Practice Pearls!

“Thou Shall Not Tamper with Evidence!”- The Fifth Commandment of Death Reporting and Death Certification

Case Scenario: A 25 year-old man sustains multiple homicidal gunshot wounds to the chest and extremities. He fails to respond to emergent surgical intervention and is pronounced dead intra-operatively. Family and friends request to see the decedent. In preparation for the viewing and in an effort to prevent potential contact with bodily fluids, the surgical resident wipes blood and debris from the hands of the decedent.

Medicolegal evidence comes in many forms both seen and unseen. The decedent or decedent’s clothing can harbor foreign hairs and fibers, foreign DNA-containing bodily fluids, drug paraphernalia and residues, weapons, gunshot residue, bullets, and bullet fragments, to name a few. In homicidal deaths, this evidence will be collected, tested, and later presented in a court of law affecting decisions of guilt or innocence, freedom or imprisonment. Care must be taken to preserve any potential evidence in its original state and to initiate and maintain the chain of custody.  The hands in particular are potentially high-yield body regions for foreign material thus the importance of securing paper (not plastic) bags over the hands in order to contain and preserve any adherent material. Paper bags may have been placed on the hands (and sometimes feet) prior to arrival to the hospital and should not be removed. Of course, the urgent need to access the hands (or feet) for application of life-saving measures is priority.

In homicidal cases especially, a no-contact policy should be enforced to prevent unintentional or deliberate alteration of any on-body evidence. This may require the assistance of hospital security and/or local law enforcement officers.

And what about the other 4 Commandments you ask?

Thou shall:

  • Recognize deaths reportable to the Medical Examiner/Coroner
  • Leave therapeutic devices in place
  • Promptly and properly certify non-jurisdictional deaths
  • Recognize the benefits of the autopsy and make use of the expertise of the autopsy Pathologist in the formulation of the cause-of-death statement

 

You’ll find more information on these Commandments and meaning of evidentiary value in the textbook Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner available on Amazon.com.

 

Now, time out for a PPQ!

  1. Ethylene glycol will be detected on routine hospital blood and urine screen tests. True or False?
  2. Identify errors present in the following cause-of-death statement.
Part I.

 

 

A. Hospital-acquired pneumonia

Approximate interval: Onset to death

< 1 week

Due to (or as a consequence of):

B. C-6 quadriplegia

 

>  1 year

Due to (or as a consequence of):

C. Mucous plugging

 

>  1 month

Due to (or as a consequence of):

D. Cardiac failure

 

>  1 month

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

Natural

 

 

Stay tuned for your next dose of Practice Pearls!

To Report or not to Report? That Is the Question.

Which of the following would you report to the Medical Examiner or Coroner?

A 62 year-old woman with ischemic heart disease develops progressive heart failure subsequent to a hip fracture sustained 6 months prior. She never returned to baseline and dies while in the rehabilitation care facility.

A 45 year-old woman is hospitalized for a severe asthma exacerbation triggered after smoking crack cocaine. The urine drug screen is positive for cocaine metabolites. She develops anoxic encephalopathy, acute bronchopneumonia, and respiratory failure and expires on hospital day 7.

A 55 year-old man dies of multisystem organ dysfunction due to polymicrobial urosepsis after a brief hospitalization. Fifteen years prior, he sustained a spinal cord injury from a fall with resultant paraplegia. He developed a neurogenic bladder requiring intermittent catheterization and has had recurrent urinary tract infections ever since.

In each of these scenarios, natural disease seems to be the proximate cause of death; however; they all involve non-natural triggers and are all reportable. Deaths due to the acute or delayed effects of injury or intoxicants are reportable regardless of the interval of time that has transpired.  A whole host of complications disguised as chronic medical conditions have potentially non-natural causes. Examples of these include bowel adhesions, decubital ulcers, and seizures. It is important to not lose sight of the root cause of chronic medical conditions as this may preclude reporting of a death that should be reported. The temporal association of the effects of injury and intoxication will be the determining factor in the classification of the death as a homicide, suicide, or accident which is done by the Medical Examiner or Coroner. Clinicians certify only purely natural deaths.

Examples of other reportable deaths include:

  • Deaths occurring within 24 hours of hospital admission (clinical definition of sudden death)
  • Peri-procedural or therapy-associated deaths
  • Deaths of group home or institutionalized residents

Reporting deaths to the Medical Examiner or Coroner requires communication of key pieces of information. The Medical Examiner or Coroner will take jurisdiction and investigate certain deaths as mandated by state law.

For more information, see Chapters 3, 7, and 8 of Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner.

For a direct link to this book, click on: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408/ref=sr_1_1?ie=UTF8&qid=1

 

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