Alphabet Soup

The answer to the PPQ (Practice Pearls Quizlet) will be revealed. But first things first.

A surefire way to trigger a query from vital statistics officials is to commit one of several errors. One error is the use of medical abbreviations or acronyms and shorthand in the cause-of-death statement. Medical abbreviations while convenient are not necessarily universally understood by others less familiar with their many contextual meanings. So one way to avoid the inconvenience of the query, is to avoid the use of abbreviations, acronyms, and shorthand.

Consider the following possible translations for common medical abbreviations:

AMI: Acute Myocardial Infarct(-ion), Acute Mesenteric Ischemia

CHD: Coronary Heart Disease, Congenital Heart Disease, Chronic (Ischemic) Heart Disease

HLD: Hyperlipidemia, Hypersensitivity Lung Disease, Herniated Lumbar Disc

PE: Pulmonary Embolism, Pre-Eclampsia, Pleural Effusion

TAH: Total Abdominal Hysterectomy, Transfusion Associated Hepatitis

Each one of these conditions, if listed as the underlying cause of death, would be coded differently by nosologists, ultimately affecting mortality statistics. Many of them represent conditions with lethal potential. Others are not necessarily lethal if well-controlled or resolved.  Many of them also lack etiologic specificity and would not be appropriate to list as an underlying cause of death. Some of them may be associated with non-natural underlying causes which would require reporting to the Medical Examiner or Coroner. Still others may or may not be clinically significant enough to be listed in Part II. Indeed, nosologists are medical classification specialists, but they are not mind readers and they are not physicians.

…and not to omit: DVT– can’t quibble much with this one; Deep Vein Thrombosis especially in conjunction with Pulmonary Embolism or more specifically Pulmonary Arterial Thromboembolism would be the obvious choice. CHF– most would interpret as Congestive Heart Failure but Congenital Hepatic Fibrosis could apply in the right clinical context. Not much room to misinterpret NIDDM and CABG.

***And finally, the answer/explanation to the Inaugural PPQ from May 21st is: FALSE. Abbreviations are not acceptable.***

To illustrate, the sample presented in May 21st’s PPQ could be translated as:

Part I.

 

A. Pre-eclampsia/Deep Vein Thrombosis

Approximate interval: Onset to death

Days

Due to (or as a consequence of):

B. Acute Mesenteric Ischemia with Congenital Hepatic Fibrosis

 

Years

Due to (or as a consequence of):

C. Congenital Heart Disease

 

Years

Due to (or as a consequence of):

D. Hypersensitivity Lung Disease

 

Years

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I: Non-Insulin Dependent Diabetes Mellitus, status post Coronary Artery Bypass Grafting times 3, status post Transfusion Associated Hepatitis
Manner of Death

Natural

 

Aside from the fact this statement makes absolutely no sense, additional errors happen to be represented and are also ones that should be avoided when formulating a cause of death.

Most likely, the intended translation was as follows:

Part I.

 

 

A. Pulmonary Embolism arising from Deep Venous Thrombosis

Approximate interval: Onset to death

Days

 

Due to (or as a consequence of):

B. Acute Myocardial Infarct with Congestive Heart Failure

 

*Years

Due to (or as a consequence of):

C. *Coronary Heart Disease

 

Years

Due to (or as a consequence of):

D. Hyperlipidemia

 

Years

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I: Non-Insulin Dependent Diabetes Mellitus, status post Coronary Artery Bypass Grafting times 3, status post Total Abdominal Hysterectomy
Manner of Death

Natural

 

 

*Some tweaking of this statement may still be in order. For example, the time interval for line ‘b.’ makes more medical sense as “days” rather than “years”. For line ‘c’, Coronary Artery Disease or Atherosclerotic Coronary Artery Disease would be more specific. Finally, inclusion of Total Abdominal Hysterectomy in Part II is unnecessary.

For more examples of disastrous cause-of-death statements and how to avoid being caught in a query quagmire, consult Chapters 3 and 8 and take the Self-Assessment Test found in Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner available on Amazon.com .

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

 

Stay tuned for future PPQs and your next dose of Practice Pearls!

WHO’s on First and What’s Death Got to Do with It?

Did you know? The World Health Organization (WHO), an agency of the United Nations (UN), publishes the International Classification of Diseases currently in its tenth edition (ICD-10). This is a medical classification system for disease (and injury) of not only patients but also decedents. Further, the ICD coding system is the international standard created for the reporting of disease and health conditions allowing researchers, health care providers, policy makers, and insurers to analyze health trends and derive mortality statistics. The WHO World Health Statistics Annual Report compiles mortality statistics from more than 70 signatory countries further facilitating international comparisons and is available online. The international medical certificate of causes of death is also a product of WHO and the basis of the death certificates used by the signatories inclusive of the United States Standard Certificate of Death.

In the United States, the National Center for Health Statistics (NCHS) an arm of the Centers for Disease Control and Prevention (CDC) compiles and extracts data from death certificates used by the States based on the US Standard Certificate of Death. Nosologists, employed by the Division of Vital Statistics (DVS) under NCHS, are an integral part of this process with the creation of ICD codes  which are based on cause-of-death information entered by physicians on death certificates. Statistical and epidemiological data arising from further analysis of ICD codes have many uses on the city, county, state and national levels and are the source of the ranking for leading causes of natural death by NCHS.

Suffering from Acronym Delirium Disorder (ADD)? Ask a nosologist.

Let me illustrate further by introducing….Practice Pearls Quizlet! (AKA PPQ).

Just one question for today’s Quizlet.

  1. The following cause-of-death statement is acceptable. True or False?
Part I.

 

A.  PE/DVT

Approximate interval: Onset to death

Dys.

Due to (or as a consequence of):

B.  AMI w/ CHF

 

Yrs.

Due to (or as a consequence of):

C.  CHD

 

Yrs.

Due to (or as a consequence of):

D.  HLD

 

Yrs.

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

NIDDM, S/P CABG x3, S/P TAH

Manner of Death

Natural

 

The answer will appear in the next entry.

For more information on WHO, ICD coding, NCHS mortality ranking, and nosology, consult Chapters 2 and 8 in Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner available on Amazon.com .

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

Stay tuned for your next dose of Practice Pearls!

Expect the Unexpected: The Lethal Potential of Disease

Scenario 1: A 62 year-old man with a history of hypertension, hyperlipidemia, coronary artery disease, a remote myocardial infarct, and a triple coronary artery bypass grafting procedure performed 10 years ago has a witnessed collapse at home. Assessment by medical first responders reveals absence of vital signs and the man is pronounced dead by the medical control physician.  According to his spouse, he takes his medications as prescribed and has had no recent health complaints. He was last seen by his internist and cardiologist within the preceding 12 months with no new health problems found.  His history is negative for psychiatric illness, substance use disorder, or injury of significance.

Police are in attendance and report the death to the local Medical Examiner’s Office. A death investigator from the office responds to the death scene and finds no signs of foul play or trauma, drugs of abuse, or prescription medication discrepancies. Contact information for the decedent’s internist is found in his wallet and the physician is called and briefed on his patient’s death and the benign death circumstances.  The death investigator asks if the physician is willing to sign the death certificate, to which he replies: “I will not sign the death certificate because I don’t know why he died and I did not attend the death.”

Scenario 2: A 62 year-old man with a history of hypertension, hyperlipidemia, coronary artery disease, a remote myocardial infarct, and a triple coronary artery bypass grafting procedure performed 10 years ago has a witnessed collapse at home. Assessment by medical first responders reveals an unresponsive, breathing man in ventricular fibrillation. Resuscitative efforts are promptly initiated and continued en route to the hospital and continued further by emergency room medical personnel. Despite all efforts, the man expires and is pronounced dead by the emergency physician 40 minutes after arrival. No signs of trauma are found. According to his spouse, he takes his medications as prescribed and has had no recent health complaints. He was last seen by his internist and cardiologist within the preceding 12 months with no new health problems found. His history is negative for psychiatric illness, substance use disorder, or injury of significance.

The emergency physician reports the death to the local Medical Examiner’s Office along with the decedent’s medical history and contact information for his internist and cardiologist obtained from the electronic medical record. The death investigator taking the report of death asks the emergency physician if he is willing to sign the death certificate, to which he replies: “I will not sign the death certificate because I don’t know why he died and I am not his regular physician.” The investigator then contacts the internist and asks if she is willing to sign the death certificate, to which she replies: “I will not sign the death certificate because I don’t know why he died and I did not attend the death.” In a final effort, the investigator contacts the cardiologist and asks if she is willing to sign the death certificate to which she replies: “I will not sign the death certificate because I don’t know why he died and I did not attend the death.”

Many natural diseases other than cardiovascular disease also have the potential to cause sudden decompensation and death even while under treatment.  Recognition of this will help to allay the reluctance that some physicians may have in regards to certification of sudden, unexpected natural deaths. While medical examiners or coroners often certify these types of deaths, clinicians, including emergency medicine physicians, are better equipped to certify them because chances are they either knew the patients clinically or otherwise have ready access to their medical records. In certifying the death, the clinician makes a determination based on the patient’s history and/or medical knowledge that in all probability, more likely than not, the patient died of “X”. One-hundred percent certainty is not required for this determination.

Which of the physicians, the internist, the cardiologist, or the emergency physician is qualified to certify the death? The answer is: all of them.

How would Doc4N6 certify both deaths, you ask?

Part I.

 

 

A. Sudden cardiac death

Approximate interval: Onset to death

Minutes

Due to (or as a consequence of):

B.  Remote myocardial infarct

 

Years

Due to (or as a consequence of):

C. Atherosclerotic coronary artery disease

 

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  Hyperlipidemia, Hypertension
Manner of Death

Natural

 

You’ll find numerous examples of diseases and disease conditions with lethal potential and more information on who qualifies as a certifier of death in Chapters 6, 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

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

 

Stay tuned for your next dose of Practice Pearls!

Not My Job: Misconceptions of Death Certification

Amongst the ever-expanding demands on the clinical practitioner, death certification may seem like just another onerous task to tick off the long list of duties that have little to do with real patient care. The assumption may be that it’s just optional and nothing will happen if a death is not certified. Or perhaps that the certification of death is really not that important and therefore not a priority. The fact is, death certification is an important patient care duty and so much more.

Aside from serious financial and emotional distress that a family may be forced to endure, a delayed or uncompleted death certificate triggers a cascade of real-life consequences that ultimately affects us all. So important is mortality data for the global optimization of health that the World Health Organization (WHO) has standardized the way it is to be collected by the participating nations for the purpose of international health comparisons. In the US, the Centers for Disease Control and Prevention-National Center for Health Statistics (CDC-NCHS) along with the National Vital Statistics System (NVSS) provide oversight and guidance for the standardized collection of mortality data from death certificates.  A multitude of federal, state, and other local agencies utilize statistical data derived from death certificates to facilitate epidemiological study, health monitoring, healthcare fund allocation, law-making, and social and medical research.

Certain misconceptions regarding death certification exist amongst clinical practitioners that lead to unnecessary delay which is a disservice to the bereaved family or the legal representative of the deceased and to public health surveillance efforts. Some of the more prominent ones follow:

  • Only the Attending Physician or the decedent’s primary care physician is authorized to complete and sign the death certificate
  • The physician will be penalized for listing an incorrect cause of death
  • The Medical Examiner or Coroner is responsible for completing and signing all death certificates clinicians fail to complete and sign

More myth-busting information on this topic can be found in Chapter 8 of Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available at Amazon.com.

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

 

Stay tuned for your next dose of Practice Pearls!

Death Reporting and Certification: The Missing Link in Clinical Resident Education and Why It Matters

As Match Day has come to pass and with the approach of the new academic year, intense focus will soon turn to the training of new 1st-year medical residents in the many ways of competent care and management of the patient. The goals: optimization of health, prolongation of a quality life, and prevention of premature death. Understandably, the efforts towards these goals consume the bulk of resident education leaving little room for concentrated instruction on death reporting and certification. Death, however, is an eventuality and a reality, even after the best of clinical efforts.

This necessitates the inclusion of formalized education on the topic of death reporting and death certification with the ultimate goal of optimization of public health through enhanced diagnosis, treatment, and prevention of disease and injury. Some training programs may already have a curriculum in place and others may be actively looking for a place to begin. Residency training programs can enhance the curriculum pertaining to death reporting and certification by:

  • providing traditional or online tutorials and lectures
  • utilizing morbidity and mortality conference as the platform for reviewing terminal clinical events and autopsy results along with the cause of death listed on the death certificate
  • scheduling visits by residents to the local coroner or medical examiner office to observe the triage process and the workup of jurisdictional deaths

More on this topic can be found in Chapters 3 and 6 of the new textbook Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available on Amazon.com.

Click on the following link and take a look inside! https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408/ref=sr_1_1?ie=UTF8&qid=1

 

Stay tuned for future Practice Pearls posts!