Death is so final, whereas Life is full of possibilities

Medical Certification of Cause of Death

Dr Chetan KumarAssist. Prof., Forensic Medicine Dept.,Parul Institute of Medical Sciences & Research Limda, Vadodara

Definition of Death

• Total stoppage of circulation of the blood &

consequent thereupon cessation of the vital functions.

• Somatic death : complete loss of sensivity and the

ability to move and there is complete cessation of the

functions of the heart, the brain and the lungs.

• Molecular death : death of the tissue and the cells

individually.

Fact of life: Man is mortal & Death is inevitable Death certificate is permanent record of the fact of death

Legal definition • Death means the permanent disappearance of all

evidence of life at any time after live-birth has taken place.

(The Registration of Births and Deaths Act, 1969).

Legal definition

• “Deceased person” means a person in whom

permanent disappearance of all evidence of life occurs,

by reason of brain-stem death or in a cardio-pulmonary

sense, at any time after live birth has taken place.

• Brain-stem death” means the stage at which all

functions of the brain stem have permanently and

irreversibly ceased.

(the transplantation of human organs act, 1994).

Circulation stoppage tests1. Occulo-cephalic test : moving head on both sides.2. Vestibulo-ocular : using cold water.3. Eye examination : Light reflex & Corneal reflex.4. Apnoea test : put on ventilator with 100 % for 30

minutes.5. Magnus test : placing a ligature round the base of a

finger.6. Diaphanous test : looking through the web of the

fingers at a bright light.7. Icard`s test : injecting a solution of fluorescin.8. Application & withdrawal of pressure.9. Application of heat.10. Cutting a small artery.11. ECG tracing.

Respiration stoppage test

•Mirror in front of open mouth and nostrils.

•Feather or cotton fibers in front of open mouth and nostrils.

Test to certify brain-stem death

1. Pupillary reflex.2. Extra-ocular movements.3. Corneal reflex.4. Gag reflex.5. Cough reflex.6. EEG.

Death Registration & CertificationTo explain the importance of death

registration.To define what is meant by causes of death

and the underlying cause of death.To identify & properly complete the form of

the medical certificate of the cause of death.

Cause of Death Certification (definition)

It is the official recording of a person’s death.It usually include: name, age, sex of person,

date of death.It records the cause of death of a person as

stated by a doctor or another responsible heath worker.

Importance of Death Certificate

Useful in providing data for mortality statisticsUseful in surveillance of specific diseases particularly

in countries where registration is completeUseful in evaluation of disease control programsRise in certified deaths from a particular cause is an

indicator for a serious outbreak.The completed death registration form is a permanent

legal record of the fact of death of an individual.

Accurate cause-of-death information is important

•To the public health community in evaluating and improving the health of all citizens,

& Often to the family, now and in the future, and to the person settling the decedent's estate .

Data used by Govt. agencies, Researchers, clinicians, educational institutions for

• To assess the health status of the population and determine changes in status over time;

• To identify regional differences in death rates and investigate reasons for these differences;

• To monitor trends in public health issues such as infant and maternal mortality, infectious diseases, and accidents and suicides;

• To identify risks associated with environmental and occupational factors and lifestyle;

• To determine health research and health care priorities and allocate resources;

• To plan health facilities, services and manpower;

• To plan prevention and screening programmes and assess the results of these programs; and

• To develop health promotion programmes and evaluate their results.

Benefits of death registration to family•Hospital reimbursement•LIC claims•Settling Property claims•To obtain succession certificates•Releasing gratuity & Provident fund

claims•Deleting deceased’s name from ration

card, voter list etc.

Cause of death is defined as:

All those diseases, morbid conditions or injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced any such injuries.

Direct leading cause of Death.

Underlying cause of death is defined as:The disease or injury that initiated the

train of morbid events leading directly to death.

The circumstances of the accident or violence which produced the fatal injury.

Approximate interval between onset and death

Cause of death

………………… a)………………..due to( or as a consequence of)

Part1disease or condition directly leading to death

…………………. b)…………due to (or as a consequnence of)c) ………..due to (or as a consequnence of)d)…………

Antecedent causes Morbid conditions, if any, giving rise to the above cause, station undrlying condition last

…………………………… ……………………………………………………………….

Part IIOther significant conditions contributing to the death but not related to the disease or condition causing it,

Design and structure of Death Certification • Part I: Records (a) immediate cause and (b) the morbid condition, if any,

giving rise to the immediate cause.

In which the cause leading to death stated on line (a).

And also the antecedent conditions (reported on line (b),( c) &( d) that gave rise to the cause reported in line (a).

No entry is necessary in lines (b) and ( c) if the disease or condition directly leading to death, stated in line (a), describes completely the chain of events.

Cause A : Respiration or Brain or Circulation OR Heart arrest.

Cause B : Symptom or Sign that cause direct leading cause A.

Cause C : Pathology that lead to cause B.

•Part IIRecords any other significant condition ( if

important ) contributing to death but not related to the immediate cause of death.

In which any other significant condition that unfavorably influenced the course of the morbid process and thus contributed to fatal outcome is written.

Duty of the doctor

Who attended the person in last 7 days.

Fill the prescribed format form 4.

No refusal / no delay.

No fee.

Forward to the registering authority.

Symptomatology or modes of death should not be recorded

as cause of death without mentioning the underlying

pathological cause.

Duty of the doctor

In any of the domiciliary deaths not attended by a

medical person before death, a statement from the

relatives of the deceased should be obtained in writing

to that effect, clearly mentioning the morbidity

condition with sign and symptoms prevailed preceding

death, with duration of such illness so that the most

possible cause of death could be entered.

‘Medical Certificate of Death’ should be

• prepared accurately• legible, typed whenever possible or

printed clearly using permanent ink• an original, not a reproduction, of a

current version of the Medical Certificate of Death

• Any alterations or errors are initialed; • Abbreviations are to be avoided;

• No copies are made after the medical certificate has been completed and certified and

• The original, not a reproduction, accompany the body of the deceased upon transfer to the funeral /cremation place to be provided to the funeral incharge.

• Terminal events like circulatory failure, respiratory failure etc. and modes of dying should be avoided as they are no more than signs of death and provide no useful information as to the underlying disease process.

• If at all entered, the disease which led to them must be entered in the next line. They can not be the sole entries.

Old age•Death due to old age is also a natural

death and the underlying cause of death then is entered as Senility under I (a). However, senility as underlying cause of death is to be entered only when no other disease or its complication has caused death.

When not to issue

1. The injured is brought dead

2. A crime has already been registering by the police.

3. The police has already been informed about the case.

4. The cause of death is unknown.

Points to be kept in mind by the M.O concerning the issuance of medical certificate of cause of death

• (a) He should not delay, for any reason, issuing the medical

certificate of cause of death, once he is sure of the cause of

death.(The death report (Form 4) and MCCD (Form 8/8A) should reach the registrar with

in 14 days of occurrence of death. )

• (b) He cannot charge any fees for issuing this certificate.

• (c) He should not withhold issuance of medical certificate of

cause of death even if his dues have not been cleared by the

relatives.

• (d) No medical officer should sign medical certificate of cause of

death in advance (i.e. before the individual has died) or without

viewing and examining the dead body personally.

Special circumstances

• For organ donation cases.

• For withholding life support in terminally ill person in ICU

settings.

Who will certify

• Board of medical experts consist of four doctors.

• Examine the person on two occasion.

Procedure to be followed• The bottom portion of the medical certificate of cause of

death is to be filled up by the certifier, detached and handed over to the relatives.

• This document enables them to get the municipal permission for cremation as well as acts as reference to obtain the extract of the death register (Death Certificate) from the registering authority.

• It may be noted that this portion, handed over to the relatives does not mention the medical cause of death.

• Even the Death Certificate issued by the registering authority does not mention the medical cause of death

• This procedure is adopted to maintain confidentiality of information of the cause of death in accordance with section 17(1) (b) of Registration of Births & Deaths Act of 1969

The dilemma

Are there circumstances in which you would agree to a request to omit HIV from a death certificate from a patient or a relative?.

Example

I - a) Septic shock b) Infected decubitus ulcers c) Complications of cerebral infarction d) Cerebral artery atherosclerosis II - Insulin-dependent diabetes mellitus

This above cause-of-death statement is complete:

• If not completed properly, information may be missing from the cause-of death section, so someone reading the cause of death would not know why the condition on the lowest used line developed.

• For example: I a) Pneumonia

• b) Malnutrition• c) __________

• II ___________

• This example does not explain what caused malnutrition. A variety of different circumstances could cause malnutrition, so the statement is incomplete and ambiguous.

Indian Medical Council

•If a serious communicable disease has contributed to the cause of death, you must record this on the death certificate.

Why is accurate information on MCCD important?Death certificate or medical certificate of the cause of death (MCCD)

Statistical information on deaths by underlying cause is important:

• for monitoring the health of the population.

•designing and evaluating public health interventions.

•recognising priorities for health services and medical research,

•planning health services and assessing the effectiveness of those services.

Health risk state

• You will need to make decisions on a case by case basis, taking account of the context, the views of others where appropriate, and using your clinical judgement.

• It is important to note that failure to disclose information concerning notifiable infectious diseases and body contamination may be regarded as a criminal offence.

Avoid the following…• Avoid “NATURAL CAUSES” alone with no specification of any disease.

Natural causes is not a cause of death, it is a manner (classification) of death.

• Specify “natural causes, exact cause unknown” only if a medical or surgical condition that may have contributed to the death is also mentioned in Part I or Part II.

• ORGAN FAILURE - Avoid reported organ or (multi)system failure alone (e.g. congestive heart failure, renal failure, respiratory failure). If an organ or system failure is listed as an immediate cause of death, always report its etiology on the line(s) beneath.

• MODE OF DEATH- Modes of dying should not be entered as the sole entry in Part I or used as the underlying cause of death. These include terms such as cardiac arrest, respiratory arrest, hypoxia, asphyxia, syncope, shock etc.

• Also avoid very vague statements such as cardiovascular event/incident, asthenia, debility or frailty.

Wherever applicable report/Include ..

• Use of alcohol and/or other substances

• Smoking history

• Environmental factors, such as exposure to toxic fumes, history of working in the mining industry, etc.

• Recent pregnancy, if believed to have contributed to the death

• Late effects of injury

• Surgical information, if applicable

• Any iatrogenic underlying cause.

• Any disease, abnormality, injury or late effects of poisoning, believed to

have adversely affected the decedent should be reported

EXAMPLE• The casualty officer on-call receives a 68 year-old female who

was diagnosed 6 months ago with carcinoma of the lung. She has a 45-year history of smoking 2 ppd, a 5 year history of COPD with frequent bouts of pneumonia and bronchitis. She stops breathing and dies bedside.

• Part I …(a) Respiratory Arrest ______________________ hours due to (b) Metastases to abdomen and pleura ___ 2 months due to (c) Bone metastases _____________________ 2 months due to (d) Carcinoma of lung (primary) __________ 6 months

• Part II Smoking, 45 years COPD, _______________ 5 years

Smoking is reported in Part II as a contributing factor. When reporting neoplasms always indicate the organ or part FIRST affected (the primary site) and secondary sites if they are known.

EXAMPLE 2

• A 79 year-old female has suffered a right hip fracture due to a fall at home four months previous. Since the date of the injury, her health declined to the point that it rendered her bedridden and immobile. She has a long history of osteoporosis.

• Part I (a) Respiratory arrest..............................................minutes due to (b) Pneumonia.......................................................10 days due to (c) Immobility….....................................................4 months due to

(d) Right hip fracture………...................................4 months

• Part II Osteoporosis..............................................................years

Where a cause of death is an injury or fracture reported in Part I or in Part II, you are required to complete the accidental or violent death section in the DC.

EXAMPLE 3

• A 59 year-old female with a history of hypertension for 10 years was admitted to hospital for investigation following complaint of persistent headache for weeks. Exploratory craniotomy revealed she was suffering from an inoperable tumor of left temporal lobe. Biopsy showed tumor to be an astrocytoma. Patient wished to die at home. Palliative care was instituted through discussion with family and physician. Patient died after 2 months.

• Part I(a) Astrocytoma of left temporal lobe..........Months

• Part II Hypertension (benign) ........................10 years

• In some cases a single disease or cause of death which describes completely the sequence of events or may be wholly responsible for the death may be reported alone in Part I.

• The death may have been expected and occurred at home but not witnessed by anyone. In such cases line 1(a) can serve as both the underlying and immediate cause of death.

• A 33 year-old male was diagnosed HIV positive five years ago. He was transferred to a hospice for palliative care after he developed AIDS and diagnosed with Pneumocystis Carinii Pneumonia.

•Part I(a) Pneumocystis carinii pneumonia…1.5 weeks

due to (b) AIDS...............................................4

months due to

(c) HIV infection ....................................5 years

•Part II Kaposi’s sarcoma...............................4

months

A lady was admitted with 80% suicidal burns injuries died of septicemia after 3 days of admssion

Part I(a) Septicemic shock ------------------3 days (b) Burn(80% superficial & deep)- 3 days (c) Intentional self harm by fire & flames-3

days back Part II ..............Nil

Manner of death1. Natural 2. Accident 3. Suicide 4. Homicide 5. pending investigation

• A diabetic man who had been under insulin control for many years developed ischemic heart disease and died suddenly from a myocardial infarction. Depending on the physician’s documented medical diagnosis, the following certifications are possible and would be acceptable:

1. If the physician considered that the heart condition resulted from the long-standing diabetes, the sequence would be:

• Part I (a) Myocardial infarction..........................1 hour due to • (b) Chronic ischemic heart disease..........5 years due to • (c) Diabetes mellitus..............................12 years

2. If the physician considered that the heart condition developed independently of the diabetes, the certification would be:

• Part I (a) Myocardial infarction................................................1 hour due to • (b) Chronic ischemic heart disease..............................5 years

• Part II Diabetes mellitus….............................................12 years

• If the man had instead died from some other expected complication of the diabetes, such as nephropathy, the heart condition playing only a subsidiary part in the death and the physician being uncertain that it arose from the diabetes at all, the sequence would be:

Part I (a) Acute renal failure..................1 week due to (b) Nephropathy........................... … 4

years due to (c) Diabetes mellitus…...................12

years Part II Chronic ischemic heart disease

Further reading

• Handbook on Medical Certification of Death (http://www.publications.serviceontario.ca/ecomlinks/016600.pdf)

• http://medind.nic.in/maa/t04/i3/maa• http://www.mlam.in/pdf/medicalcertificates/

mccd.pdft04i3p261.pdf

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