Medical Death Certification

1
Medical Death Certification Ontario's
Coroners System What do you need to know and do?

• Dr. Barry McLellan
• Chief Coroner
• Associate Professor, Department of Surgery
• University of Toronto
• Dr. Bart Harvey
• Coroner, City of Toronto
• Associate Professor
• Department of Public Health Sciences
• University of Toronto

2
Learning Objectives

• After this session, participants will be able to
• Describe a physician's roles following a death
• Describe the steps involved in and importance of
  accurate death certification
• Accurately complete a death certificate
• Describe the role and operation of Ontarios
  Coroners system
• Report applicable deaths to the local coroner

3
Case

• 58 year old woman dies in the Neurosurgical ICU
  due to sustained raised intra-cranial pressure
• Presented to hospital 3 days earlier after being
  found unconscious in her home after friends could
  not reach her by phone
• EMS provided on-scene resuscitation, but the
  patient never regained consciousness
• Raised ICP a result of a block in her
  ventriculoperitoneal shunt, inserted because of a
  head injury from a fall as a teenager
• Family requested that only supportive care be
  given

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What is Done Now?

• Pronouncement of death
• Medical staff notification
• Communication with the family
• Determine the cause of death
• Report the death to the local coroner?
• Candidate for organ donation?
• Postmortem examination?
• Complete the death certificate
• Additional follow-up?

5
What is Done Now?

• Pronouncement of death
• Medical staff notification
• Communication with the family
• Determine the cause of death
• Report the death to the local coroner?
• Candidate for organ donation?
• Postmortem examination?
• Complete the death certificate
• Additional follow-up?

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Pronouncement

• Fact that the person has died
• Not a medical act
• Determines the time of death

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What is Done Now?

• Pronouncement of death
• Medical staff notification
• Communication with the family
• Determine the cause of death
• Report the death to the local coroner?
• Candidate for organ donation?
• Postmortem examination?
• Complete the death certificate
• Additional follow-up?

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Medical Staff

• Who can certify death?
• In Ontario, MD or RN(EC)
• Who should be notified?
• Ideally, those with greatest familiarity (with
  the patient, with the family)
• Can/should any physician agree to certify a death?

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What is Done Now?

• Pronouncement of death
• Medical staff notification
• Communication with the family
• Determine the cause of death
• Report the death to the local coroner?
• Candidate for organ donation?
• Postmortem examination?
• Complete the death certificate
• Additional follow-up?

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Communication

• Depending on circumstances, establish effective
  communication with the family
• Over the course of care (also patient)
• As the clinical course deteriorates
• Surrounding the death
• Follow-up after death?
• Be careful what you say/promise
• Dont worry, hell be fine

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What is Done Now?

• Pronouncement of death
• Medical staff notification
• Communication with the family
• Determine the cause of death
• Report the death to the local coroner?
• Candidate for organ donation?
• Postmortem examination?
• Complete the death certificate
• Additional follow-up?

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Cause of Death

• What chain of events led to this persons death?
  Your best medical opinion
• Reflects the patients case history
• Keep asking, What was that due to?
• Underlying cause should be as specific as
  possible to reduce 'etiologic ambiguity
• Use 'probable' 'unknown' if necessary

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Causes of Death

• Immediate Cause
• Intermediate Cause(s)
• Underlying Cause
• Significant Contributing Cause(s)
• Mechanisms of Death

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Contributing Causes

• All other significant diseases, conditions, or
  injuries
• that contributed to death
• but are not in the direct chain of events
  initiated by the underlying cause of death

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Mechanisms of Death

• Cardiopulmonary Arrest
• Congestive Heart Failure
• Renal Failure
• Never an underlying cause of death
• May not be needed on the death certificate
• What was this due to?

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Manners of Death

• In Ontario
• Natural
• Accident
• Suicide
• Homicide
• Undetermined

17
Case Revisited

• 58 year old woman dies in the Neurosurgical ICU
  due to sustained raised intra-cranial pressure
• Presented to hospital 3 days earlier after being
  found unconscious in her home after friends could
  not reach her by phone
• EMS provided on-scene resuscitation, but the
  patient never regained consciousness
• Raised ICP a result of a block in her
  ventriculoperitoneal shunt, inserted because of a
  head injury from a fall as a teenager
• Family requested that only supportive care be
  given

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Cause of Death?

• Immediate cause?
• Intermediate cause(s)?
• Underlying cause?
• Significant contributing cause(s)?

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Causal Chain?

• Immediate cause?
• Raised intracranial pressure
• Intermediate cause(s)?
• Blocked ventriculoperitoneal shunt
• Underlying cause?
• Head injury from a fall (40 yrs ago)

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What is Done Now?

• Pronouncement of death
• Medical staff notification
• Communication with the family
• Determine the cause of death
• Report the death to the local coroner?
• Candidate for organ donation?
• Postmortem examination?
• Complete the death certificate
• Additional follow-up?

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Coroners

• Physicians who apply for the position based on
  the community need
• Training course
• 350 in Province
• Legislation Coroners Act of Ontario

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Team Coroner

• Investigating Coroner
• Regional Supervising Coroners
• Deputy Chief Coroners
• Chief Coroner

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The Bigger Team

• Coroner
• Police
• Pathologist
• Ministry of Labour Investigator
• Fire Marshal
• Centre of Forensic Sciences
• Forensic Odontologist
• Forensic Anthropologist
• Forensic Entomologist

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Case

• 84 year female dies on Orthopedic ward with
  pneumonia
• Originally presented to hospital 4 weeks previous
  with inter-trochanteric hip fracture (post fall
  at home)
• Surgery day 2 uncomplicated
• Past history of NIDDM, coronary artery disease
  (angina), CHF
• Deteriorating on Orthopedic ward daughter, RN at
  hospital, had requested supportive care only

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Case Contd

• Family have no issues with care provided
• Diagnosis (pneumonia) not in question
• How do you complete the Medical Certificate of
  Death?

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Questions

• Is this a coroners case?
• Why/why not?

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Issues

• You recognize that this is a Coroners case and
  the Coroner is notified
• During discussions, family tell you they want an
  autopsy what do you do?

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Case

• A 32 year old female dies from MODS in the CrCU
  two weeks after initially presenting with an
  acetaminophen overdose
• Presented to hospital two days following
  ingestion developed progressive liver failure

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Case Contd

• Cause of death is clear
• Family have no issues
• Previous history of depression no other past
  medical history
• How do you complete the Medical Certificate of
  Death?

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Case

• You are caring for a 25 year old male in the CrCU
  who was shot once in head following a dispute
  over a pharmaceutical transaction
• Four days after admission he is declared
  neurologically dead

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Case contd

• The family wish to proceed with organ donation
  (single GSW to head work-up has ruled out other
  injury that may preclude organ donation)
• What do you do?
• Is organ donation ever considered for Coroners
  cases?

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Relevant Legislation
Coroners Act

• Section 10 (reporting of cases)
• Section 11 (interference with body)
• Section 18 (who is entitled to information)
  

Trillium Gift of Life Network Act

• Section 6 (imminent deaths)

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Cases Requiring Investigation

• Section 10 of the Coroners Act
• Accident, Suicide, Homicide
• Sudden and Unexpected
• Special Circumstances

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Reporting 'Myths'

• Death within 24 hours of presenting to hospital
• Death within 28 days of a surgical procedure

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Section 11

• No person . shall interfere with or alter the
  bodyuntil the coroner so directs

36
Release of Information

• Section 18(2) of the Coroners Act dictates who is
  entitled to receive records of the investigation
  (Coroners statement, autopsy report, toxicology
  report, consultant (anonymous) and/or committee
  report)
• To clinical team to advance public safety

37
Organ/tissue donation in Coroners Cases

• Under section 10 every person who has reason to
  believe that a deceased person died.shall
  immediately notify a coroner of the facts and
  circumstances.
• Section 11- no person who has reason to believe
  .. Under section 10..shall interfere with or
  alter the body or its condition in any way until
  the coroner so directs by a warrant

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Guidelines for Organ/tissue Donation

• Chief Coroners Office strongly supports organ
  donation
• Once death has been determined (or when death is
  imminent), the coroner must be notified and
  discussion should be undertaken about the area of
  organ donation

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Organ donors v. recipients
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Motto of Ontario Coroners
We speak for the dead to protect the living
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Not a Coroners Case...

• Now what?
• Communication with the family
• Postmortem examination?
• Complete death certificate
• Additional follow-up?

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Postmortem Exam?

• Family consent required
• Requested by medical team?
• Persistent questions about clinical course
• Requested (or wanted) by family?
• Assists some families with closure
• Want as full an understanding as possible

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What is Done Now?

• Pronouncement of death
• Medical staff notification
• Communication with the family
• Determine the cause of death
• Report the death to the local coroner?
• Candidate for organ donation?
• Postmortem examination?
• Complete the death certificate
• Additional follow-up?

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Death Certification

• Sole legal documentation of death--accurate?
• Last aspect of patients (and familys) care
• Part of the familys process of closure
• In Ontario, physicians and RN(EC)
• Guides estate insurance settlements--accidental?
  
• Used to gauge populations health and to guide
  health policy and funding decisions
• Reviewed by a coroner before a cremation or
  shipment out-of-province

45
Death Certification

• Tell as complete, accurate and precise a story as
  possible--patients case history
• Use 'probable' 'unknown' if necessary
• Will the patients clinical course be to a
  colleague reading the death certificate?

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Death Certificate

• Identifying information
• Who? Deceaseds name, age sex
• When? Date of death
• Where? Place of death
• Associated information
• Surgical procedure(s)
• Manner of death
• Cause of death (Parts I II)

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An Example

• I. Multi-system organ failure
• Is this a satisfactory death certification?
• Why or why not?

48
Another Example

• I. (a) Pneumonia
• (due to)
• (b) Malnutrition
• Is this a satisfactory death certification?
• Why or why not?

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One More Example

• I. (a) Pneumonia
• (due to)
• (b) Lung Cancer
• (due to)
• (c) Breast Cancer
• Is this a satisfactory death certification?
• Why or why not?

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Case

• 58 year woman dies on Surgical ward after
  developing pneumonia
• Admitted 2 weeks earlier with breast cancer for a
  mastectomy
• On post-op day 8 diagnosed with pneumonia and put
  on IV antibiotics
• Past history of 50-pack-years of tobacco use,
  COPD, CHD (stable angina)

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Cause of Death?

• Immediate cause?
• Intermediate cause(s)?
• Underlying cause?
• Significant contributing cause(s)?

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Death Certificate...

• I. (a) Pneumonia 1 week
• (due to)
• (b) Post-op complication 2 weeks
• (due to)
• (c) Breast Cancer 2 months
• II. Tobacco abuse/addiction COPD

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What is Done Now?

• Pronouncement of death
• Medical staff notification
• Communication with the family
• Determine the cause of death
• Report the death to the local coroner?
• Candidate for organ donation?
• Postmortem examination?
• Complete the death certificate
• Additional follow-up?

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Additional Follow-Up?

• Further questions or concerns
• Completion of insurance forms

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Other Resources

• Back of the death stillbirth certificates
• National Association of Medical Examiners
  (www.thename.org/CauseDeath/COD_main_page.htm)
• Centers for Disease Control and Prevention
  (www.cdc.gov/nchs/data/misc/hb_cod.pdf)

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Death Certification the Coroners System

• Further Discussion or Questions?

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reproduction in any manner, whether in whole or
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Coroner.