Medical Certification on the
Cause of Death (COD)
Medical Certification on Cause of Death
Objectives
1. Appreciate the significance of CRVS to the
h lth sector
health
t r
2. Appreciate the significant role of the medical
doctors
3. Understand the uses of CRVS
4. Provide a preview of the guidelines in medical
certification
5. Provide analysis
Vital Events
Vital
Events
Births
D h
Deaths
Disaggregated by:
• Age
• Sex
• Cause of death
• Geographic
g p level
• Administrative level
Pr d ti n
Production
•
•
•
•
•
Reporting
Registering
Recording
Compiling
Analyzing
Dissemination
Use
Sources of Data
Uses
Clinical diagnosis
Therapeutic decisions
Death
Death certificate
Family – legal and other purposes (personal)
Expert coding
National health authorities
WHO and the UN family
National program priorities, health planning
and policy, allocation of resources
International health statistics, international
program
p
g
priorities
p
Tree map of Causes of Death for Males aged 15-49 in 2010,
Philippines
(Pr m t r death)
(Premature
d th)
Leading Causes of Death Philippines 50-69 years old, 2013
Leading Causes of Death Philippines 70+ years old, 2013
Features of PhilCRIS
PhilCRIS - an information system that would address
the needs of the local civil registrars, hospitals,
churches attendants at births and deaths,
churches,
deaths solemnizing
officers, and those who are involved in the
preparation and recording of vital events.
Features:
• Enables
E bl encoding
di off relevant
l
iinformation
f
i ffrom civil
i il
registry documents
• Storage of vital data
• Query and retrieval of encoded records
• Maintenance of the local civil registry database
Urgent Action
• Advocacy
• Training for physicians
Overview of the Medical
Certification Process
Medical Certification on Cause of Death
Death
Certification
Medical Certification on Cause of Death
Death
» refers to the permanent disappearance of
all evidence of life at any time after live
birth has taken place,
place or
> the
h postnatall cessation
i off vital
i l functions
f
i
without capability of resuscitation
CRICOS Provider No 00025B
Fetal Death
» is death prior to the complete expulsion
or extraction from its mother of
a
product of conception, irrespective of the
d
duration
ti off pregnancy;;
> the death is indicated by the fact that after
such separation the fetus does not breathe
nor show any other evidence of life, such as
beati g of the heart,
beating
hea t pulsation
l atio
of the
umbilical cord, or definite movement of
voluntary
y muscles.
CRICOS Provider No 00025B
C
Concepts
on D
Death
hC
Certification
ifi i
The physician who signs his name becomes
the certifier of death.
death
The reported causes
ca ses of death represent the
physician’s best medical opinion.
Medical Certification on Cause of Death
C
Concepts
on D
Death
hC
Certification
ifi i
A death certificate is primarily a statistical
document.
document
Medical Certification on Cause of Death
The physician who completes and signs his
name in the Medical Certificate is attesting to
the best of his knowledge that the person
namedd on the
h certificate
ifi
di
died
d ffrom the
h cause
or causes of death stated.
Medical Certification on Cause of Death
When faced
Wh
f d with
ith the
th duty
d t off signing
i i the
th
certificate of death, first determine
whether the death is reportable or not;
secondly determine whether there is
secondly,
another physician more qualified to
complete the
h certificate.
f
Medical Certification on Cause of Death
Reportable deaths
1. Stab wounds
2 Gunshot wounds
2.
3. Suicide of any kind
4 Strangulation
4.
5. Accident resulting to death
6 Actual
6.
A t l physical
ph i l assault
lt rresulting
ltin to
t death
d th
7. Any other act or violence resulting to death
8 Sudden
8.
S dd death
d th off undetermined
d t
i d cause
Code on Sanitation of the Philippines (P.D. No. 856)
Medical
Certification on Cause of Death
If death is reportable you are duty-bound to
immediatelyy report
p the death to the authorities
of the Philippine National Police (PNP) or
the National Bureau of Investigation
(NBI) concerned.
IRR of P.D. 856, “Code on Sanitation of the Philippines”
Medical Certification on Cause of Death
Death with Medico-Legal
g Implications
p
Local Health Officer
Local Civil Registrar
Medical Certification on Cause of Death
Understanding the Certificate of Death
The Certificate of Death (Municipal Form No.
No
103, Revised 2007) conforms to the
I
International
i lF
Form off Medical
M di l Certificate
C ifi
recommended by WHO with some
modifications.
For fetal deaths, the Certificate of Fetal Death
(Municipal Form No.
No 103A) is used.
used
Medical Certification on Cause of Death
Medical Certification on Cause of Death
Medical Certificate Portion of the Certificate of Death
Medical Certification on Cause of Death
Figure 4. Medical Certificate portion of Certificate of Death for children aged 0-7 days
Medical
Certification
on Cause of Death
CRICOS Provider
No 00025B
The causes of death refer to all those
diseases, morbid conditions, or injuries
j
which
either resulted in or contributed to death and
the circumstances of the accident or violence
which produced any such injuries.
20thh World Health Assembly (1967)
Medical Certification on Cause of Death
Physicians are expected to use medical
training,
g knowledge
g of medicine, p
patient
symptoms and available medical history,
diagnostic tests, and autopsy results, if
available, and verbal autopsy result to
determine the cause of death.
death
Medical Certification on Cause of Death
Causes of Death Portion of the Medical Certificate
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death
I I di t
I. Immediate cause : a. _________________________________ ____________________________
Antecedent cause : b. _________________________________ ____________________________
Underlying cause Underlying cause
:c
: c. _________________________________ ____________________________
II. Other significant conditions contributing to death: __________________________________________________
Medical Certification on Cause of Death
The most recent condition written on top
line of the certificate that directlyy leads to
death is the immediate cause.
Medical Certification on Cause of Death
Other intervening cause (or causes) of death
occurring between the underlying and
immediate causes is called the antecedent
cause.
Medical Certification on Cause of Death
The underlying cause of death is the
disease or injury which initiated the train of
morbid events leading to death,
death or the
circumstances of the accident or violence
which
hi h produced
d d the
h ffatall injury.
i j
UC
AC
C
AC
C
AC
C
Medical
Certification on Cause of Death
(WHO, 1994)
AC
C
AC
C
IC
C
Entries to Part I must show a sequence of events
leading to death reported in causal order, one cause
per line, starting with the most recent condition or
event on the top line and going backward in time
on progressively lower lines until the underlying
cause is reported on the lowest line.
Medical Certification on Cause of Death
The most effective public health objective
is to p
prevent the underlying
y g cause from
operating, hence the importance of
accurately identifying the underlying cause.
cause
From the standpoint of prevention of
death, it is necessary to break the chain of
events or to effect
ff a cure at some point.
i
(WHO 1994)
(WHO,
Medical Certification on Cause of Death
Sample Cases
CRICOS Provider No 00025B
Case Sample
p 1. ((When there is onlyy one reported
p
cause of death in the certificate.)
A 56 year old man dies from acute myocardial infarction within 3
hours of its onset. He did not have any other illnesses.
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. ACUTE MYOCARDIAL INFARCTION 3 HOURS Antecedent cause : b Underlying cause : c. II. Other significant conditions contributing to death: Medical Certification on Cause of Death
Case Sample
p 2. ((When there are onlyy two reported
p
causes of death in the certificate.)
A 65 year old person dies from abscess of the lung, which resulted
from lobar pneumonia of the left lung.
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. LUNG ABSCESS 5 DAYS Antecedent cause : b. LOBAR PNEUMONIA LEFT LUNG 2 WEEKS Underlying cause : c. II. Other significant conditions contributing to death
g
g
Medical Certification on Cause of Death
Case Sample
p 3. ((When there are three causes of
death reported.)
A 32 year old man dies from hypovolemic shock after sustaining
multiple fractures when he was hit by a truck.
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death HYPOVOLEMIC
SHOCK
I. Immediate cause : a. HYPODERMIC SHOCK __ 1 HOUR Antecedent cause : b. MULTIPLE FRACTURES 5 HOURS Underlying cause : c. PEDESTRIAN HIT BY TRUCK 5 HOURS II. Other significant conditions contributing to death: Medical Certification on Cause of Death
Case Sample 4. When there are more than
th
three
reported
t d
causes
off
d th
death
A 10 year old boy with a past medical history of
Thalessemia for the past 4 years developed severe
anemia leading to high output cardiac failure 2
weeks ago. 3 days PTA, he developed cough and
dyspnea with RR of 44/min.
44/min CXR showed lobar
pneumonia.
Despite antibiotic coverage and
blood transfusion,
transfusion his condition deteriorated and
he died the next day.
CRICOS Provider No 00025B
Case Sample
p 4. ((When there are more than
three reported causes of death.)
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. LOBAR PNEUMONIA 4 DAYS HIGH OUTPUT CARDIAC FAILURE Antecedent cause : b. DUE TO SEVERE ANEMIA 3 DAYS; 2 WEEKS Underlying cause : c. THALASSEMIA 4 YEARS II. Other significant conditions contributing to death: g
g
Medical Certification on Cause of Death
Part II of the Medical Certificate includes all
other significant
g
or contributoryy co-existingg or
pre-existing diseases or conditions that
contributed to death but do not directly lead
to the underlying cause of death listed in Part
I.
Medical Certification on Cause of Death
Case Sample
p 5. ((When there is reported
p
condition
contributing to death.)
A 68-year old man who is a known diabetic died from lung abscess
due to lobar pneumonia of left lung.
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. LUNG ABSCESS __ 5 DAYS Antecedent cause : b. LOBAR PNEUMONIA LEFT LUNG 2 WEEKS Underlying cause : c. : c II. Other significant conditions contributing Medical Certification on Cause of Death
Type 2 Diabetes mellitus
Interval Between Onset and Death
The spaces to the right of lines (a), (b), and
(c) correspond to the entries for recording
the interval between onset of the cause,
andd ddeath.
h
Medical Certification on Cause of Death
General intervals such as seconds,
minutes,, hours,, days,
y , weeks,, months,,
and several years are also acceptable. A
range such as seconds to minutes,
minutes
minutes to hours, or terms such as
“k
“known
ffor fi
five years”” may be
b used.
d
Medical Certification on Cause of Death
As a rule, the underlying cause
occurred first in the sequence of events
and would logically have the longest
time
i
iinterval.l
Medical Certification on Cause of Death
Case Sample
p 6: A 65-year
y old man has longg historyy of on and
off hemoptysis and weight loss has been diagnosed to have
advanced pulmonary tuberculosis for six years. After a bout
off massive
i hemoptysis
h
i while
hil working
ki iin the
h ffarm, the
h patient
i
died at home six hours later.
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. PULMONARY HEMORRHAGE SIX HOURS Antecedent cause : b. ADVANCED PULMONARY TUBERCULOSIS SIX YEARS Underlying cause : c. y g
II. Other significant conditions contributing to death: Medical Certification on Cause of Death
Ill Defined Conditions
Medical Certification on Cause of Death
Ill Defined Causes of Death
The ill-defined
Th
ill d fi d causes off death
d h under
d
ICD-10 are vague
g categories
g
and
conditions that include signs and
symptoms and abnormal clinical and
laboratory findings.
Medical Certification on Cause of Death
Sample Ill Defined Conditions
- Disseminated Intravascular Coagulopathy
- Pulmonary edema
- Congestive heart failure
- Ventricular tachycardia
- Volume depletion
- Pulmonary embolism
- Cardiovascular disease, unspecified
- Heart disease, unspecified
- Hypotension, unspecified
Medical Certification on Cause of Death
As a rule, ill-defined conditions should
not be reported
p
on a Certificate
f
off Death
unless nothing else is known about the
deceased and unless a more specific
underlying cause is also reported.
Medical Certification on Cause of Death
CRICOS Provider No 00025B
Examples
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death
S i
Sepsis
1 day
d
I I di t
I. Immediate cause : a. _________________________________ ____________________________
Complicated urinary tract infection ____________________________
1 week
Antecedent cause : b. _________________________________ Underlying cause Underlying cause
:c
: c. _________________________________ ____________________________
II. Other significant conditions contributing to death: __________________________________________________
CRICOS Provider No 00025B
Table 1 Terms that imply mode of dying rather than the cause of death* Table 1. Terms that imply mode of dying rather than the cause of death* Asphyxia Asthenia Brain failure Cachexia C Coma Exhaustion Heart failure Hepatic failure Hepatorenal failure Kidney failure R l f il Renal failure Shock Syncope Uremia Vagal inhibition Vasovagal attack V t i l f il Ventricular failure * From Medical certificate of cause of death. Southampton University Hospitals NHS Trust Medical
Certification
on Cause of Death
CRICOS Provider
No 00025B
Examples
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death
Ch i respiratory
Chronic
i
ffailure
il
1 month
h
I I di t
I. Immediate cause : a. _________________________________ ____________________________
Chronic obstructive pulmonary disease
2 years
Antecedent cause : b. _________________________________ ____________________________
Underlying cause Underlying cause
:c
: c. _________________________________ ____________________________
Tobacco use
20 years
II. Other significant conditions contributing to death: __________________________________________________
CRICOS Provider No 00025B
Ill Defined Conditions = Garbage Code
The so-called “garbage code” includes all illdefined conditions or residual categories of
major disease groups that do not provide
meaningful
i f l iinformation
f
ti on the
th underlying
d l i
disease or injury that caused death.
Medical Certification on Cause of Death
Mechanistic terminal events are
terminal pathophysiologic or
biochemical derangements that are
common final
fi l pathways
h
that
h explain
l i
how a cause of death exerts its lethal
effect.
Medical Certification on Cause of Death
In ggeneral,, mechanistic terminal events
have an almost limitless differential
diagnoses and should NEVER be reported
in the Certificate of Death as one of the causes
off death.
d th
Medical Certification on Cause of Death
Mechanistic terminal events include the
following:
g
1. Respiratory arrest
2
2.
Cardiac arrest
3. Cardiopulmonary arrest
4
4.
A t l
Asystole
Medical Certification on Cause of Death
CRICOS Provider No 00025B
Relevant entries that MUST be filled out by the Certifier
19b. Causes of death entry containing three lines marked (a), (b),
andd ((c)) with
i h the
h corresponding
di lilines for
f the
h entry off
interval between onset and death, and a line for other
significant conditions contributing to death.
19c. Maternal condition, if the deceased is female aged
15-49 yyears old
19d Death by external causes which include manner of
d th andd place
death
l off occurrence off external
t
l cause,
when applicable.
CRICOS Provider No 00025B
Relevant entries...
20.
Autopsy, whether done or not
21a Attendant
Attendant, whether by a private
physician, public health officer, hospital
authority, if any
21b. Dates for duration of attendance, if deceased
was attended before death.
22. Certification of Death – affix signature
General Guidelines on
Filli
Filling-out
t and
d Completing
C
l ti a
Certificate of Death
Medical Certification on Cause of Death
- Use the current form of Certificate of
Death or Certificate of Fetal Death
Medical Certification on Cause of Death
- Complete each item legibly using a
computer
p
p
printer with high
g resolution or
typewriter with black ribbon, or print with
pen using permanent black ink.
ink
Medical Certification on Cause of Death
- Do not make alterations or erasures.
Obvious changes
g could affect the validityy of
a certificate and altered certificates may be
rejected by the Local Civil Registrar.
Registrar
Medical Certification on Cause of Death
- Do not use abbreviations or medical
symbols.
y
- Record only one cause per line in the
cause-of-death portion. Line (a) must always
h
have
an entry.
t
Medical Certification on Cause of Death
- If the condition on line (a) resulted from
another condition,, put
p this other condition
on line (b), and so on, until the full sequence
is reported.
reported Always enter the underlying
cause of death on the lowest used line in
P t I.
Part
I Never
N
skip
ki lines.
li
Additional
Additi l lines
li
may
be added if necessary.
Medical Certification on Cause of Death
- Never report signs and symptoms or
abnormal clinical and laboratoryy
findings as causes of death.
Medical Certification on Cause of Death
- If an organ failure (e.g. congestive heart
failure)) is reported
p
as a cause of death,, the
underlying condition responsible for the
failure should also be reported (e
(e.g.
g liver
failure due to hepatitis B infection).
Medical Certification on Cause of Death
- Mechanistic terminal events (e.g.
cardiopulmonary
p
y arrest)) should NEVER be
reported as one of the causes of death.
Medical Certification on Cause of Death
- If there is uncertainty in the entries for
causes of death,, it is acceptable
p
to use
qualifying terms such as “probable” or
“presumed
presumed.”
Medical Certification on Cause of Death
- For deaths without medical attendance, a
verbal autopsy
p y mayy be conducted to
determine cause.
- Use pen with permanent black ink for
signatures.
i t
Rubber
R bb stamps
t
or facsimile
f i il
signatures are not acceptable.
Medical Certification on Cause of Death
- File original copies of the Certificate of
Death with the Office of the Local Civil
Registrar. Reproductions or duplicates are
not acceptable.
acceptable
- Complete
C
l t allll relevant
l
t portions
ti
off the
th
Certificate of Death.
Medical Certification on Cause of Death
Guidelines for Reporting Causes of
D th iin S
Death
Specific
ifi G
Groups or
Conditions
Medical Certification on Cause of Death
Death Involving Women of Child-Bearing
Child Bearing
Age
For women aged 15 to 49 years of age, indicate
under item 19c the maternal condition whether
pregnant not in labor, pregnant in labor, <42 days
after delivery,
delivery 42 days to one year after delivery,
delivery or
none of the above.
Medical Certification on Cause of Death
Maternal death refers to “death of a woman
while pregnant or within 42 days of
termination of pregnancy, irrespective of the
duration and the site of pregnancy,
pregnancy from any
cause related to or aggravated by the pregnancy or
its management,
management but not from accidental or
incidental causes.”
Medical Certification on Cause of Death
The fact that a woman died during pregnancy
or within 42 days of the termination of
pregnancy should
h ld b
be clearly
l l iindicated
di t d in
i
under Maternal Condition.
Medical Certification on Cause of Death
Case Sample 8:
A 36
36-year
year old G5P3A1 woman who delivered a full
fullterm baby boy at home was brought to the ER
because of p
placental retention. The woman
apparently had severe bleeding and was hypotensive
on her arrival at ER. She was transfused whole blood
and manual extraction of the placenta was
performed. However, the woman died four hours
after delivery.
Medical Certification on Cause of Death
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death
I Immediate cause : a. _Postpartum hemorrhage____________ I. Immediate cause : a Postpartum hemorrhage
_Approximately 4 hours________
Approximately 4 hours
Antecedent cause : b. _Retained placenta__________________ _ Approximately 4 hours________
Underlying cause Underlying cause : c. __________________________________ :c
____________________________
II. Other significant conditions contributing to death: __________________________________________________
19c9c. Maternal Condition (if the deceased is female aged 15 –
9 M l C di i (if h d d i f l d 15 49 years old) 49 ld)
____a. pregnant _X_ b. pregnant ____ c. less than 42 days ____ d. 42 days to 1 year ____ e. none of the not in labor in labor
i lb
i lb
after delivery
f d li
after delivery
f d li
choices
hi
Medical Certification on Cause of Death
Fetal death
Fetal death is a death prior to the
complete expulsion of a product of
conception, irrespective of the period of
pregnancy.
pregnancy
Medical Certification on Cause of Death
For all fetal deaths, a different death form
called Certificate of Fetal Death (Municipal
Form No. 103A)) must be prepared
p p
and the
causes of death completely filled out by the
certifier.
certifier
*report even spontaneous abortions or those
with AOG < 20 weeks
Medical Certification on Cause of Death
19. CAUSES OF FETAL DEATH a. Main disease/condition of fetus ______________________________________________________________
b. Otherdi
Other diseases/conditionsofthefetus
ns of the fetus _________________________________________________________ c. Main maternal disease/condition affecting fetus _________________________________________________
d. Other maternal disease/conditionaffecting fetus ________________________________________________
ee.Otherrel
. Other relevant vantcicircumstances cumstances ________________________________________________________________
Medical Certification on Cause of Death
Case Sample 10.
10
A 38-year
38
old
ld G3P2 was admitted
d itt d att a
birthing facility while 34 weeks pregnant.
After six hours of premature labor, she
delivered a stillborn babyy boyy with cord
around his neck. The fetus is cyanotic with
no gross fetal movement and no heartbeat.
Medical Certification on Cause of Death
19. CAUSES OF FETAL DEATH CAUSES OF FETAL DEATH a. Main disease/condition of fetus SINGLE CORD COIL AROUND NECK b. Other diseases/conditions of the fetus ASPHYXIA; PREMATURITY c. Main maternal disease/condition affecting fetus PREMATURE LABOR; 34 ld
d ff f
WEEKS OF GESTATION d. Other maternal disease/condition affecting fetus /
g
e. Other relevant circumstances ___________________________________________________________ Medical Certification on Cause of Death
Medical
Certification
on Cause of Death
CRICOS Provider
No 00025B
Infant Death
For deaths
F
d th involving
i l i infants
i f t aged
d 0 to
t 7
days, the same form of Certificate of Death
is used as in other deaths from the general
population
p
p
except
p that the Medical Certificate
f
portion (item 19a) found at the back of the
form is filled out instead of the one in front.
Medical Certification on Cause of Death
Instead of reporting the underlying and/or
immediate cause of death, with or without
antecedent
t d t cause, the
th certifier
tifi has
h to
t reportt
the main disease or condition of infant,
the main maternal disease or condition
affecting
g the infant, as well as for other
diseases or conditions.
Medical Certification on Cause of Death
Medical Certificate portion for infant deaths
0 to 7 days found at the back of Certificate of
Death Form 103
19a. CAUSES OF DEATH a. Main disease/condition of i
a Main disease/condition ofinfant _____________________________________________________________ fant
b. Other diseases/conditions of infant ___________________________________________________________ c. Main maternal disease/condition affecting i
c Main maternaldisease/condition affectinginfant ________________________________________________ fant
d. Other maternal disease/condition affecting infant _______________________________________________ e. Other relevant ci
e Otherrelevant circumstances ________________________________________________________________ cumstances
Medical Certification on Cause of Death
In reporting causes of infant deaths, the
certifier should fill out in lines (a) and
(b) the diseases or conditions which in
his opinion had contributed to the death
j like in fetal death.
of the infant,, just
Medical Certification on Cause of Death
The single most important or main
di
disease
or condition
diti in
i the
th infant
i f t should
h ld
be entered in line (a) and the remainder,
if any, in line (b).
Medical Certification on Cause of Death
The mode of dying (asphyxia, heart
failure, anoxia), including prematurity,
should not be entered in line (a) unless
it was the
th only
l known
k
condition.
diti
Medical Certification on Cause of Death
IIn lilines (c)
( ) andd (d),
(d) recordd allll diseases
di
or
conditions in the mother which had
some effect on the infant. The main
maternal disease or condition should be
entered in line (c) and the rest, if any, in
line (d).
Medical Certification on Cause of Death
Line (e)
Li
( ) is
i for
f reporting
i off other
h relevant
l
circumstances which have bearing on the
death of the infant but cannot be identified as
a disease or condition of the infant or the
mother (e.g. home delivery or delivery
attended by untrained hilot)
hilot).
Medical Certification on Cause of Death
There are other items in the Certificate
of Death that must be filled out for
infant deaths. These are: the age of
mother, method of delivery, length
of pregnancy, type of birth, and
order
d off child,
hild if multiple
l i l birth.
bi h
Medical Certification on Cause of Death
CRICOS Provider No 00025B
Case 12.
A 38-year
y old G3P0A2 was admitted at a birthingg
facility while 24 weeks pregnant. She has been
havingg premature
p
labor for six hours. She
subsequently delivered 700g infant who was
treated at the intensive neonatal care unit but
subsequently died after 24 hours. Chest x-ray of
the infant shows dense lungg fields consistent with
severe hyaline membrane disease.
Medical Certification on Cause of Death
19a. CAUSES OF DEATH a. Main disease/condition of infant NEONATAL RESPIRATORY DISTRESS SYNDROME b. Other diseases/conditions of infant PREMATURITY ‐ 24 WEEKS OF GESTATION c. Main maternal disease/condition affecting infant PREMATURE LABOR d. Other maternal disease/condition affecting infant PREVIOUS SPONTANEOUS ABORTIONS e. Other relevant circumstances Medical Certification on Cause of Death
Death Involving External Injuries
A useful approach to writing causes of death
involving external injuries is to report the external
cause or events as the underlying cause and identify
the bodily trauma caused by the external event and
report it as antecedent cause, and lastly report
the fatal derangement resulting from the bodily
trauma as the immediate cause.
Medical Certification on Cause of Death
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. _(Fatal
( derangement)_________________
)
____________________________
AAntecedentcause
ntecedent cause : b. _(Bodily trauma)
trauma)_____________________ ____________________________
Underlying cause : c. _(External event)_____________________ ____________________________
I . Other significant conditions contributing to death: __________________________________________________ Medical Certification on Cause of Death
Case 15
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I I di t cause : a. SUBARACHNOID HEMORRHAGE I. Immediate SUBARACHNOID HEMORRHAGE MINUTES Antecedent cause : b. BLUNT TRAUMA OF HEAD MINUTES Underlying cause : c. PEDESTRIAN HIT BY A MOVING MOTORBIKE MINUTES II. Other significant conditions contributing to death: 19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. INTRA‐ABDOMINAL HEMORRHAGE 2 HOURS LACERATIONS OF LIVER DUE TO Antecedent cause : b. BLUNT FORCE TRAUMA OF ABDOMENT 2 HOURS Underlying cause : c. FALL FROM HEIGHT 2 HOURS II. Other significant conditions contributing to death: CRICOS Provider No 00025B
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. PERFORATING BRAIN TRAUMA 30 MINUTES Antecedent cause : b. GUNSHOT WOUND OF HEAD 30 MINUTES U d l i : c. HANDGUN DISCHARGE Underlying cause HANDGUN DISCHARGE II. Other significant conditions contributing to death: CRICOS Provider No 00025B
30 minutes
When ddeath
Wh
h iis a result
l off underlying
d l i externall cause,
item 19d must be completed by the certifier:
manner off death
d th whether
h h h
homicide,
i id
suicide, accident or legal intervention;
place
l
off occurrence off external
t
l cause
whether at home, farm, factory, street or sea.
Medical Certification on Cause of Death
Death from Infections
Forr deaths
F
d th due
d to
t infections,
i f ti
the
th certifier
rtifi r has
h to
t
report the manifestation or body site (e.g.
pn m ni pyelonephritis,
pneumonia,
p l n phritis m
meningitis,
nin itis hepatitis).
h p titis)
If the causative agent is known, it should be
noted on the certificate;
certificate if unknown,
nkno n write
rite “cause
“ca se
unknown.”
Medical Certification on Cause of Death
Also indicate the source and route of
infection (e.g. food poisoning,
contaminated blood product, health
care associated
i d iinfection),
f i ) if know
k
n.
Medical Certification on Cause of Death
Specify also any underlying disease
that may have suppressed the
patient’s immunity that made him
susceptible
tibl tto the
th infection
i f ti that
th t led
l d to
t
his death.
Medical Certification on Cause of Death
CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. Pnemocystis carinii pneumonia 3 WEEKS Antecedent cause : b ACQUIRED IMMUNE DEFICINECY SYNDROME MONTHS Underlying cause : c HIV INFECTION 10 YEARS Underlying cause : c. HIV INFECTION 10 YEARS II. Other significant conditions contributing Medical Certification on Cause of Death
Death from Neoplasm
It is
i iimportant to iindicate
di
or report the
h
specific site of neoplasm because public
health prevention strategies differ markedly
from one type
yp of neoplasm
p
to another.
Medical Certification on Cause of Death
The primary site must be stated on the
Certificate of Death even if it has longg been
removed before death. If a secondary
growth is included in the sequence of events
leading to death, state the site of secondary
growth
th as due
d to
t the
th site
it off primary
i
growth.
th
Medical Certification on Cause of Death
If the
h primary
i
site
i iis unknown,
k
record
d on the
h
Certificate of Death, “primary unknown.”
The certificate should always state the
primaryy site as this will help
p
p identifyy the
underlying cause of death. More often than
not the primary site is the underlying cause
not,
of death.
Medical Certification on Cause of Death
Aside
A
id ffrom the
h site
i off neoplasm,
l
the
h
certifier must also indicate on the
Certificate of Death the behavior of the
tumor (whether benign or malignant),
malignant)
and its nature or histological type, if
known.
Medical Certification on Cause of Death
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I Immediate cause : a
I. Immediate cause : a. SECONDARY ADENOCARCINOMA OF LIVER 1 YEAR Antecedent cause : b. PRIMARY UNKNOWN UNKNOWN Underlying cause : c. II. Other significant conditions contributing to death: Medical Certification on Cause of Death
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) Interval between Onset and Death I. Immediate cause : a. SECONDARY ADENOCARCINOMA OF LIVER 1 YEAR I Immediate cause : a Antecedent cause : b. PRIMARY ADENOCARCINOMA OF BREAST - Left
3 YEARS U d l i Underlying cause : c. II. Other significant conditions contributing to death: Medical Certification on Cause of Death
Assessing the quality of medical
certification
1.. Documenting
oc e t g multiple
t p e causes
ca ses per
pe linee
2. Incorrect/clinically improbable sequence of events
leadingg to death
3. Approximate interval between onset and death
4. Abbreviations used in certifying
y g the death
5. Illegible hand writing
6. Ill-defined condition entered as underlying
y g COD
7. Neoplasms
p
CRICOS Provider No 00025B
Summary
CRICOS Provider No 00025B
Review of Important Points
• Is the death reportable?
• Am I the physician most qualified to certify this
death?
• Cause of Death = Physicians best medical
opinion
• Minimum of 1 COD, maximum of 4 COD, one
cause per line except antecedent (max of 2)
• No skipping of lines, lowest line with an entry is
designated as the underlying COD
CRICOS Provider No 00025B
Review of Important Points
• Indicate time interval from onset to death,
death may
be approximated
• Underlying COD should have longest time
interval
• Avoid
A id ill defined
d fi d conditions;
di i
may use one ill
defined condition as long as more specific
underlying
d l i condition
di i iis iincluded
l d d
• NO mechanistic terminal events
CRICOS Provider No 00025B
Review of Important Points
• Fill out other pertinent items
– Maternal condition, death by external cause, autopsy,
attendant duration of attendance
attendant,
• Be specific when applicable – infections,
neoplasms etc
etc.
CRICOS Provider No 00025B
Other reminders
• Permanent black ink
• Write legibly
• No
N stamps, facsimiles
f i il – must be
b original
i i l
signature
• No abbreviations or symbols (not standardized)
– HPN, HTN, ARF
*only HIV, AIDS is internationally accepted abbreviation
CRICOS Provider No 00025B
Did we achieve our objective?
At the end of the training, the participants will be
ablee to properly
ab
p ope y aand
d accurately
acc ate y fill out
o t the
t e
Certificate of Death forms.
CRICOS Provider No 00025B
Pre-test
Pre
test (Brief Assessment) Results
• Based on number of errors (out of 21 certificates)
– Certificates with onlyy one error: 14%
– Certificates with two errors: 14%
– Certificates with more than 2 errors: 71%
• Based on types of errors (number of errors out of total
number of death certificates assessed)
–
–
–
–
–
–
–
Multiple causes per line: 10%
Incorrect/clinically improbable sequence of events: 48%
Interval between onset and death: 95%
Abbreviations: 76%
Blanks between lines: 5%
Illegible handwriting: 5%
Ill-defined conditions entered as UCOD: 48%
Medical Certification on Cause of Death