Death Certificate Flashcards
(2) pathognomonics of death
- hypostasis → accumulation of fluid or blood in the lower parts of the body or organs under the influence of gravity, as occurs in cases of poor circulation or after death
- rigor mortis → stiffening/rigidity of the limbs of the corpse caused by chemical changes in the muscles postmortem
In what case should the death be reported to the coroner?
- cause of death unknown
- unnatural causes of death
- unknown identity of the deceased
- no attending doctor to complete MCCD
- poisoning (even by normally benign substance e.g. salt) → both accidental or deliberate
- exposure to toxic substance
- use of medical product, controlled drug, psychoactive substance, herbal/legal highs
- death due to a person undergoing treatment or medical procedure
- violence, trauma inury (includes also self-inflicted)
- self-harm
- neglect and self-neglect
- occupational injury/disease
- death in custody or detention
- if attending doctor has not seen a patient for more than 14 days
Within what timeframe a verification of death should be done in:
A. Hospital
B. Community
A. Hospital → 1 hour
B. Community → 4 hours
When can nurses & paramedics verify death?
Nurses and paramedics can verify death if it is:
- expected
- no suspicious circumstances
- occurs in a private residence, hospice, residential home, nursing home or hospital
- DNACPR is in place
- does not require reporting to coroner
*but they can refuse to verify and a doctor/ police would need to do this
(2) elements of death verification
- confirm cardiopulmonary arrest
- confirm brainstem death
How long for do we observe the patient during death verification?
- minimum of 5 minutes
- spontaneous return of cardiac or respiratory activity during this period → further 5 minutes observation
How to establish irreversible cardiorespiratory arrest during verification of death? (3)
Observe for 5 minutes:
- absence of a central pulse on palpation (minimum 1-2 minutes)
- absence of heart sounds on auscultation (minimum 1-2 minutes)
- absence of breath sounds on auscultation (minimum 1-2 minutes)
*maybe supplemented by other monitoring (e.g. ECG, echo, intra arterial pressure monitoring)
Death verification
What to do after 5 minutes of cardiopulmonary arrest observation?
Confirm brainstem death
How to confirm brainstem death? (3)
(after 5 minutes of irreversible cardiopulmonary arrest observation and confirmation)
- absence of pupillary responses to light
- absence of corneal reflexes
- absence of motor response to supra-orbital pressure
When to record a time of death?
The time of death is recorded as the time when we verify death (when we confirm cardio-pulmonary arrest and brainstem death)
Who verify expected deaths in the community?
- GP or district/nursing home nurses/paramedics
- GP to issue MCCD (must have seen patient within 14 days)
Who verifies unexpected deaths in the community?
- GP to verify + report to coroner
- If police/ambulance service in attendance → Forensic Medical Examiner to examine and verify
Elements of referral of the death to the coroner? (2)
- inform family of the referral and that coroner’s office will contact them
- inform coroner’s office in writing → online portal
Possible outcomes of coroner referral (3)
- coroner’s office will ring referring doctor back to discuss the case and ask for further information (if needed)
- referral may lead to:
- post-mortem +/- inquest OR
- inquest without post-mortem OR
- no investigation required (=permission to issue MCCD)
The role of Medical Examiner (ME)
ME will be introduced in autumn 2020
- all deaths not referred to coroner to be discussed with ME by a doctor before MCCD
- ME will then:
- agree what a doctor wants to put on MCCD
- suggest something different to put on MCCD
- suggest coroner referral
What’s MCCD and what’s its role?
MCCD = Medical Certificate of Cause of Death
- notifies the Registrar of births and deaths of the cause of death
- it is given to patient’s next of kin, who take it to register the death (within 5 days) → the registrar will then issue a certificate for burial/cremation and certificate of registration of death
*if Registrar has any concerns they can discuss them with a coroner
How to complete MCCD in the following example
Patient had diagnosis of:
- bowel Ca 2010
- liver metastasis 2012
- disease progression (leading to death) 2014
I a Metastatic carcinoma (to liver) 2012
b Ca Bowel 2010
c
OR
I a carcinomatosis 2014
b metastatic
c Ca bowel
*carcinomatosis = effects of cancer
What’s cause 1 and cause 2 on MCCD?
Cause 1 → reverse order (immediate cause first, followed by underlying conditions) 1a 1b 1c
Cause 2 → Conditions unrelated to 1 but contributing to death (not all conditions but the ones that contributed to death)
Can we put frailty or old age as the cause of death on MCCD?
No - we need to be specific
Can we put organ failure alone as a cause of death on MCCD?
No - we need to be specific
e.g. 1a chronic renal failure
1b diabetic nephropathy
1c diabetes mellitus
Who completes Cremation Form 4?
Doctor looking after the deceased at the time of death
Who can complete Cremation From 5? (3)
Cremation Form 5 → corroborates the medical circumstances of death as stated by the doctor in Form 4
- doctor of no less than five years’ experience
- not a relative of deceased, or a partner of the doctor who have done Form 4
- should not complete Cremation Form 5 for the GP practices where the doctor regularly / recently worked
Fill in the following MCCD
- Mr GS 64 y old with a history of poorly controlled HTN and cholesterol
- Diagnosed with angina in 2018
- Patient presented to Blackpool Victoria Hospital with chest pain and had ST elevation on ECG
- Patient went into cardiac arrest with an unsuccessful resuscitation
1a ST elevation myocardial infraction
1b Cardiovascular disease
1c Hyperlipidaemia and hypertension
OR
(instead of 1c)
II hyperlipidaemia and hypertension
Fill in the following MCCD
- 93 y old patient with type 2 diabetes, HTN, osteoarthritis, polymyalgia rheumatica and cataracts
- frail and poor mobility
- patient became drowsy, confused and unwell and was admitted to the hospital → sepsis diagnosed → urine sample grew E.Coli
- failure to respond to medical treatment → deterioration and death
1a Sepsis
1b Urinary tract infection (E.coli)
1c ———–
2 type 2 diabetes
Fill in MCCD for:
- 78 y old patient with extensive smoking history
- COPD diagnosed in 2014 and gradually worsening
- frail and poor mobility
- patient developed productive cough and fever
- patient deteriorated despite treatment and died
1a Lower respiratory tract infection OR Exacerbation of COPD
1b COPD
1c ——-
2 Tabacco misuse
Issue MCCD for:
- 87 y old patient
- retired builder with history of asbestos exposure
- presented with worsening SIB and haemoptysis
- found to have pleural thickening and a biopsy confirmed mesothelioma
- admitted to hospice for symptom control where deteriorated further and died
We can’t issue MCCD as death linked to condition due to occupational exposure
*refer to coroner
