death & death certification - wslhd
TRANSCRIPT
Death & Death Certification
Dr Andrew Baker (DPET)
2019 INTERN ORIENTATION
Aims • Understand the overall processes followed after a death occurs • Understand the timeframes, roles and responsibilities • Understand when you can issue a Medical Certificate of Cause of
Death • Understand what to do in when you cant issue a MCCD • Know how to complete a MCCD and how to avoid common errors
Test Run
• How many Death Certificates will you write as an Intern? • 0-5 • 6-10 • 11-20 • 21-40 • 40+
Overview 1. Verify that death has occurred 2. Decide if the death is reportable 3. Complete MDDC & Cremation Certificate OR notify coroner 4. Manage the body appropriately 5. Notify and support the family
Overview 1. Verify that death has occurred 2. Decide if the death is reportable 3. Complete MDDC & Cremation Certificate OR notify coroner 4. Manage the body appropriately 5. Notify and support the family
Verification of Death • Previously known as Certification of Life Extinct • Involves Clinical Assessment
• Absent Carotid Pulse • Absent Heart sounds • Absent Breath Sounds • Absent response to neurological stimuli • Fixed dilated pupils
• Entry in the medical record: • Documenting clinical findings • Verifying death
Management of the body • If notifiable, nothing should be done to the body • Leave all tubes, lines, drains in place
Notification of Family • Family should be informed of the coronial process, if the death is notifiable • Some families will object to a post mortem occurring, and they are entitled
to request this not be done –BUT this is a decision for the coroner - NOT the JMO
• Reporting to the coroner is a mater of law – and can never be the basis of a negotiation with the family
• The Family can object to an MCCD being written, in which case it should be reported to the coroner
When should the death be reported to the Coroner
• Yell out some answers!
When should the death be reported to the Coroner
• Patient not seen by a Dr for 6 months
• Patient died under suspicious, violent or unnatural circumstances
• Patient died while in or related to institutional care (e.g. mental health patients, children, prisoner, disabled)
• Patient died of an accident (unless > 72 and accident related to age)
• Cause of death unknown
• Death following a procedure was not the reasonable expected outcome
Death within 24hrs of an Anaesthetic • Is NO longer a mandatory reason for reporting to the coroner • Must be reported to SCIDUA • Requires a “form B” – to be completed by an anaesthetist/seditionist • May require reporting to the coroner (if death following a procedure
was not the reasonable expected outcome)
Coronial Checklist Required Actions
• Notify and discuss with AMO • Notify Police • Complete Form A
If Unsure • Discuss with senior member of team • Discuss with senior medical administrator • Discuss with Coroners office • Document discussions
Mrs Christie • 85yo lady with dementia absconds from nursing home • Trips and falls on the gutter and incurs #NOF • Dies of sepsis & pneumonia 2 days later
• Go to VoxVote to Vote
Mr Roberts • 85yr old man with abdo pain and vomiting and suspected
large bowel obstruction • Serious co-morbidities including IHD, AF and T2DM • No improvement with conservative management and after
long discussion with family, decision taken to perform laparotomy
• Ischemic bowel identified and resected • Dies in ICU 18hours post op with large myocardial infarct
Death Certificates*
*Medical Certificate Cause of Death
D-Cert • For individual interns, deaths are
not common
• Therefore we’ve put a pack together with flowcharts and checklists
• Be aware of the family bereavement pack
• Most information is now on line –
• Access Via APP
• Or: http://www.wslhd.health.nsw.gov.au/Education-Portal/Medical/Westmead-Orientation-Resources/Clinical-Processes
Who uses Death Certificates? Death Certificate vs MCCD? Uses of Death Certificates • Bureau of BD&M • Epidemiologists & Statisticians • Health Planners • Family
Getting this right and completed in a timely fashion is an extension of
your patient focus and patient care NOT another piece of tedious
paperwork
How Certain do you need to be? • Lets Vote
• 95% • 80% • 65% • 51%
Standard of Proof • Civil standard of proof
Saying something is proven on a balance of probabilities means that it is more likely than not to have occurred. It means that the probability that the event happened is better than 50%.
Who should write a Death Certificate and when
• After hours?
Can you write an MCCD if you have never seen the patient alive?
What you need to complete
Common Errors • Mechanism of death rather than underlying disease • Abbreviations • Non specific – remember Side/Site/pathology/Organism/Unknown • Bizzare Causal chains • Timing often wrong – can estimate
Example 1
Example 2
Example 3
Mrs Stephens • 82 Lady with Ca Breast & bony
Mets • # shaft femur getting out of
bed • Gets bronchitis then
bronchopneumonia & dies
Mr Joseph • 69yo man died 2 days after
massive embolic stroke • 5 year history of chronic AF • Had myocardial infarct 9 years
ago • Also diagnosed as alcoholic
and smoker for 40 years
How did you go? • Comments on Outcomes • +/- Common errors or both
Mr Gilmore • 78yo lady who had fall at home with multiple # ribs • Past medical History of IHD, HT & T2DM • Admission complicated by pneumonia and
hyperglycaemia • Improving and intending to be discharged when
had sudden deterioration and died due to Inferior STEMI.
Mrs Gilmore • High percentage listed Cardiac Arrest - and some listed Cardiac Failure as immediate
cause of Death • Of those who recorded a myocardial infarct, the majority were non specific; with
response varying between AMI, Inf AMI, STEMI & Inf STEMI • Many people listed Cardiac Risk Factors under section 21.1 rather than 21.2 • Some listed Hyper cholesterolaemia as a risk factor – basically making this up • Someone listed hypokalemia as a cause of the infarct • Some list Fall/# rib/pneumonia as the cause of the infarct • Some included old NSTEMI • Many durations were left blank
Mrs Gilmore • INFERIOR ST ELEVATION MYOCARDIAL INFACT due to 1 hour • ISCHEMIC HEART DISEASE many years
• Other significant conditions • Type 2 Diabetes Mellitus, hypertension and smoking Many years • Left lower lobe pneumonia (organism unknown), One week
secondary to fall with fractured ribs
Non –Coronial Post Mortem • Treating teams may sometimes request a non coronial post mortem • Requires permission by Next of Kin • Needs approval by a “Designated Officer” • Can only be performed if a MCCD has been completed
(NB: you may want to perform a post mortem to confirm your clinical impression of cause of death, but you still need to be 51% sure to start of with. If you were completely unsure the death would be reportable to the coroner)
5 Take-aways 1. When asked to write a Death Certificate you can refer to the D-Cert on
every Ward 2. Before Writing Death - Is it a coroners? (see Coroner’s Checklist) 3. When writing a Death Certificate we want to know the disease process
most responsible for the death – not the final mechanism of death (Avoid Cardiac or Respiratory Arrest/Failure)
4. Be Specific – Site/side/ pathology/ organism 5. Avoid Abbreviations