Ethics bb

Question 1

How is death verified?

Answer 1

No response to verbal or painful stimulus
No palpable carotid pulse
No heart sounds (2 minutes)
No breath sounds (2 minutes)
Pupils fixed and dilated (non-responsive to light)

Document in medical notes (date and time)
Notify
- consultant (discuss cause of death for certificate)
- family (arrange for this to happen, may not be you doing it)

Question 2

Who has a statutory duty to issue a medical certificate of the cause of death (MCDD)?

Answer 2

The doctor attending during the last illness of a person who has died

• conversely, if you were not present for the deceased, you cannot write the death certificate

Question 3

What format is used for writing the cause of death?

Answer 3

1a, 1b, 1c, II format

1a = ultimate cause of death
1b = caused 1a
1c = caused 1b

II = other diseases related to cause of death but not related to 1a-c

You would not include other diseases if they did not contribute to cause of death

Question 4

What are the following forms of?
a) Form 4
b) Form 5
c) Form 6
d) Form 7
e) Form 11

Answer 4

a) 4: Medical certificate
b) 5: Confirmatory certificate (being phased out)
c) 6: Medical referee certificate
d) 7: Following anatomy dissection
e) 11: After autopsy certificate

Question 5

Types of autopsy

Answer 5

Consented (hospital)
- MCCD issued
- determine disease outline, support teaching/training

Medicolegal
- MCCD cannot be issued

Question 6

Types of medicolegal autopsies

Answer 6

1. Forensic
   - coroner’s rules
   - forensic pathologist
   - police involvement
2. Coroner
   - coroner’s rules
   - general pathologist

Question 7

What does a coroner do?

Answer 7

Concerned with who died, when they died, where they died, and how they died

Will instruct doctors to carry out autopsy/examination and determine MCCD on the balance of probability

Question 8

When must you refer to the coroner?

Answer 8

1. Unknown cause of death
2. Not seen by a doctor during last illness or last 28 days
3. During or within 12 months of pregnancy
4. Death in custody
5. While detained under the Mental Health Act
6. Death due to:
   - suicide
   - accident/trauma
   - industrial disease
   - medical/surgical treatment
   - abortion
   - anaesthetic care
   - lack of medical care
   - murder
   - self-neglect
7. Any hx of violence
8. Any element of suspicion
9. Any allegation of medical negligence
10. Any other unusual/disturbing feature

NOTE: time of death in relation to the above DOES NOT EXPIRE

IF IN DOUBT = CONSIDER REFERRAL

Question 9

What competency must a doctor have to consent a patient?

Answer 9

a) They themselves can carry out the procedure
b) They have received specialist training in advising patients about this procedure, have been assessed, and are aware of their own knowledge limitations

Question 10

When is a person unable to make a decision?

Answer 10

If they cannot:
1. Understand the information relevant to the decision
2. Retain that information
3. Use or weight that information as part of the process of making the decision, or
4. Communicate their decision

Question 11

What does the Human Tissue Act (2004) do?

Answer 11

Deals with consent, performance of autopsies and storage of material retained, as well as collection and retention of material taken from the living

Came into effect September 2006, established by Human Tissue Authority

Question 12

Who can give consent for removal, use of storage of tissue after death?

Answer 12

The person before death if competent
Nominated representative
Consent from an adult in a qualifying relationship (according to Human Tissue Authority hierarchy of consent)

Question 13

What is the hierarchy of consent in the Human Tissue Authority act?

Answer 13

1. Partner/spouse
2. Parent/child
3. Sibling
4. Grandparent/grandchild
5. Nibling
6. Step parent
7. Half sibling
8. Friend of longstanding

Question 14

What is the Organ Donation Act 2019?

Answer 14

Consent for organ/tissue donation will be deemed if:
a) there was no expressed consent/refusal prior to death
b) no nominated representative

Deemed consent may be rejected if the family provide reasonable reason to believe that the potential donor would not have given consent

Question 15

What are justifications for breaking confidentiality?

Answer 15

1. Best interest of patient or safeguarding the wellbeing of others
2. Statutory Requirements
   - Road Traffic Act 1988
   - Prevention of Terrorism Act 1989
   - Public Health (Control of Disease) Act 1984
3. Public Interest
   - public good vs obligation of confidentiality to patient
   - protection of confidence is a public interest

Question 16

Exceptions to keeping confidentiality after death in reality

Answer 16

1. Assist coroner/officer involved with inquest
2. National Confidential Inquiries
3. MCCD (death certificates)
4. Public health surveillance
5. Parent seeking information, i.e. child’s death
6. Insurance companies (lawfully)
7. Partner/close relative/friend if you have no reason to believe the patient would have objected

Question 17

Which of the statements are incorrect in relation to a doctor asked to complete a death certificate?

a) Needs to speak to Medical Examiner in all cases
b) Must raise any concerns known about the care given with the Medical Examiner
c) Should discuss the cause of death with the family prior to completing the MCCD
d) Is required to draw up the Medical Examiner’s notification paperwork before writing up the MCCD
e) When referral to the Coroner is clearly required needs to contact the Coroner without further delay
f) Does so to the best of their knowledge and belief which is not equivalent to the criminal standard of ‘beyond reasonable doubt’

Answer 17

c) Should discuss the cause of death with the family prior to completing the MCCD

e) When referral to the Coroner is clearly required needs to contact the Coroner without further delay

Complete paperwork asap and send to Medical Examiner who will discuss circumstances to you and this will enable you to complete MCCD or refer to Coroner for further discussion or more formal reasons

Question 18

Death follows from a recognised complication of a medical procedure for which appropriate and comprehensive written consent was obtained

Does this need a coroner referral?

Answer 18

Yes
= death due to medical/surgical treatment

Question 19

The cause of death is bronchopneumonia in a patient with metastatic ovarian cancer who was undergoing palliative chemotherapy without evidence of neutropaenia

Does this need a coroner referral?

Answer 19

No

Question 20

The death was due to massive pulmonary embolism in a patient with known deep vein thrombosis and very limited mobility following a motorcycle accident several months before (whilst working as a courier)

Does this need a coroner referral?

Answer 20

Yes
= death due to accident/trauma
= death due to industrial disease

Question 21

The patient died of an acute myocardial infarction with a history of coronary artery stenting two years before. The patient had undergone an apparently successful hip replacement the previous month.

Does this need a coroner referral?

Answer 21

No

Question 22

The patient was detained under section 3 MHA and died from a peritonitis following perforation of inoperable advanced colonic carcinoma.

Does this need a coroner referral?

Answer 22

Yes
= death occurred while detained under the Mental Health Act

Question 23

Which of the statements are correct in relation to the Coroner?

a) Is appointed by the local council and investigates deaths reported that appear violent or unnatural, or where the cause of death is unknown or where the deceased died whilst in “state detention”;
b) His or her officers are not required to have a medical background;
c) Will investigate some deaths with a post mortem examination and will hold a formal hearing when evidence is given in court (an Inquest) for all deaths
d) May decide not to investigate a referred death further where the cause of death notified to him is “uncertain” if the doctor has proposed a cause of death;
e) Needs to investigate any death where the family of the deceased have concerns about the medical care given.

Answer 23

a) Is appointed by the local council and investigates deaths reported that appear violent or unnatural, or where the cause of death is unknown or where the deceased died whilst in “state detention”;

b) His or her officers are not required to have a medical background;

d) May decide not to investigate a referred death further where the cause of death notified to him is “uncertain” if the doctor has proposed a cause of death;

Question 24

Patricia Liu is a 26 year old woman who has been estranged from her family for several years. She is brought into hospital, having been found unconscious in her flat, surrounded by used syringes and needles. Shortly after arriving in the emergency room, she has a cardiac arrest and dies. Her brother, Adam Liu, is traced and is her next of kin.

How should the ED doctor proceed?
a) The cause of death is uncertain so consent should be sought from Adam Liu for a hospital post mortem.
b) If the police confirm that Patricia Liu’s death is a suspected crime, then the case should be referred to the Coroner for a Coroner’s post mortem
c) The cause of death is uncertain so the team should request a hospital post mortem
d) The cause of death is uncertain so the team should refer to the Coroner for a Coroner’s post mortem
e) The cause of death is uncertain so the team should refer to the Coroner for a Coroner’s post mortem provided Adam Liu gives his consent

Answer 24

d) The cause of death is uncertain so the team should refer to the Coroner for a Coroner’s post mortem

= History of violence/element of suspicion/unusual or disturbing feature then REFER TO CORONER

Question 25

A 76 year old woman who suffers a fractured neck of femur after falling down some steps and is admitted to hospital for internal fixation of the fracture. The operation goes smoothly. Three days post operatively she suddenly becomes short of breath. CTPA reveals a pulmonary embolus (PE). She has a swollen tender left calf consistent with a deep venous thrombosis. She dies shortly after the PE is identified.

Does this woman’s death need to be referred to the coroner?
a) Yes
b) No
c) maybe

Answer 25

a) Yes

= any allegation of medical negligence needs referral

Question 26

A 76 year old woman who suffers a fractured neck of femur after falling down some steps and is admitted to hospital for internal fixation of the fracture. The operation goes smoothly. Three days post operatively she suddenly becomes short of breath. CTPA reveals a pulmonary embolus. She has a swollen tender calf muscle consistent with a deep venous thrombosis. She dies shortly after the PE is diagnosed.

What is the correct cause of death?

a) 1a Pulmonary embolus, 1b Deep venous thrombosis
b) 1a Pulmonary embolus
c) 1a Deep venous thrombosis, 1b Pulmonary embolus
d) 1a Fractured neck of femur (operated on, date), 1b Deep venous thrombosis
e) 1a Pulmonary embolus, 1b Deep venous thrombosis, 1c Fractured neck of femur (operated on, date)

Answer 26

e) 1a Pulmonary embolus, 1b Deep venous thrombosis, 1c Fractured neck of femur (operated on, date)

Question 27

A 78 year old man with longstanding type 2 diabetes and a previous history of pulmonary embolus and recently diagnosed squamous cell carcinoma of the lung is admitted unconscious following a generalised seizure and reduced conscious level. A brain CT shows a massive cerebral metastasis with midline shift and cerebral herniation. A few hours later he suffers a cardio-respiratory arrest and dies.

What is the correct cause of death?

a) Part 1a should state pulmonary embolus and Part 1b squamous cell carcinoma of the lung. Part 2 should state Type 2 diabetes
b) Part 1a should state cerebral metastasis and Part 2 squamous cell carcinoma of the lung
c) Part 1a should state squamous cell carcinoma of the lung and Part 1b Type 2 Diabetes
d) Part 1a should state cerebral metastasis, Part 1b should state squamous cell carcinoma of the lung and Part 1c should state pulmonary embolus

Answer 27

b) Part 1a should state cerebral metastasis and Part 2 squamous cell carcinoma of the lung

Question 28

When may ‘old age’ be used as a cause of death on MCCD?

Answer 28

Unusual in an acute hospital setting as patients are generally admitted with a disease/condition/injury

Thus more likely in the general practice setting and need to –
a) Have cared for Deceased over a long period
b) Have noticed a gradual decline in the Deceased’s health and functioning
c) Not aware of any identifiable disease/injury that contributed to death
d) You are certain the death should not be reported to the Coroner

Question 29

A 76 year old nun dies suddenly in the convent. Dr T, consultant pathologist, conducts a Coroner’s post mortem on the deceased. A haemopericardium is noted associated with a ruptured left ventricle secondary to a myocardial infarction. Dr T is currently conducting research on post mortem kidney tissue and this post mortem provides an excellent opportunity to restock his supply of post mortem kidney tissue.

What should Dr T do?

a) Give the cause of death to the Coroner and take kidney tissue for research, you do not need consent as it is a Coroners post mortem
b) Provided only a small amount of tissue is needed, further consent is not required
c) Give the cause of death to the coroner and ask the family for consent to take kidney tissue for research
d) Await toxicology before giving a cause of death
e) Refer the case for a forensic post mortem

Answer 29

c) Give the cause of death to the coroner and ask the family for consent to take kidney tissue for research

= Human Tissue Act (2004): You need consent for examination, removal, storage and ANY type of use – teaching, research, audit, clinical governance etc

Question 30

John Johnson is a 24 year old single man with known cystic fibrosis and severe learning disability (mental age of 4 years) who is admitted to hospital with a severe pneumonia. He dies on day 10 of his admission. His mother died over 10 years previously. His stepfather, who has been his main carer since his mother died, has requested a post mortem but John Johnson’s older brother is deeply opposed to this.

How should you advise his medical team in relation to the post mortem request?

a) John Johnson’s stepfather, as the main carer, is the official next of kin and therefore the post-mortem can be performed with his consent.
b) The post mortem cannot be performed in this situation as there is family disagreement
c) The post mortem cannot be performed in this situation as the brother is refusing
d) If there is family a disagreement a post-mortem cannot be legally performed
e) If there is family disagreement, the decision regarding a post mortem should go to the Court of Protection

Answer 30

c) The post mortem cannot be performed in this situation as the brother is refusing

= Hierarchy of consent from Human Tissue Act (2004)