Death Certification

1. Death Certification Dr. Judy Melinek Assistant Medical Examiner San Francisco

2. San Francisco Medical Examiner We get called when someone dies at home or if the death is violent or unexpected.

3. Coroner vs. Medical Examiner Citizen Training varies by jurisdiction Administrator or Law enforcement Elected or appointed Predominantly rural

4. REPORTABLE DEATHSDefined by CA H&S Code 10250 and Gov Code 27491 Violent, sudden, unusual, or unexpected. Unattended by physician (20 days) or no medical history. Related to accident or injury, either old or recent. Acute intoxication, Falls, Motor vehicle collisions... Time elapsed is of little relevance Homicide, suicide, or suspicious: criminal acts. Public health concern: infectious diseases

5. DEATH CERTIFICATIONReporting Requirements The ME/C must be notified for those types of death specified in CA Gov Code 27491. The only requirement is for the ME/C to investigate. The ME/Coroner has a right to the medical record (HIPPA exempt). Permission of next of kin NOT required for ME/C autopsy. Hospital physicians can only certify NATURAL deaths (due to disease/old age) before allowing a hospital autopsy.

6. My patient died: What next? Nurse will give you a �morgue pack�: checklist ? You will fill out the Death Certificate Worksheet Do not write �See dictated note�! Some time later Attending will sign Death Certificate: what you tell the Medical Examiner and what the attending signs has to match! Body will be released from the hospital to funeral home for burial: funeral home checks in with ME.

7. What can go wrong? You forget to call the ME/Coroner�s office on a reportable case. You sign out a death certificate that does not have an acceptable cause of death. You omit to mention trauma or surgery on the death certificate yet the patient clearly has trauma or surgical interventions.

8. So I made a mistake: who cares? Family of deceased Decedent affairs Funeral Home staff Medical Examiner/Coroner�s Office Risk Management at the hospital Other housestaff/attending who have to deal with fixing the DC & placating the above.

9. Typical CA Death Certificate

10. Cause of Death The etiologically specific disease or injury which starts the lethal sequence of events without sufficient intervening causes.

11. Mechanism of Death A description of the physiologic derangement (set in motion by the cause of death) that results in the cessation of: the pumping of the heart breathing cellular energy metabolism.

12. Good Natural Causes of Death Atherosclerotic cardiovascular disease. Myocardial infarct due to CHF due to HTN. Hypertensive stroke. Ruptured cerebral aneurysm. Chronic alcoholism. Complications of diabetes mellitus. Infectious complications of chronic substance abuse.

13. NOT GOOD AT ALL! Cardiorespiratory arrest Cardiac arrhythmia Respiratory failure End stage liver /kidney disease Pneumonia Multi-organ system failure Sepsis

14. BETTER! Cardiac arrhythmia DUE TO Rheumatic valve disease Respiratory failure DUE TO asthma/COPD ESLD DUE TO Chronic alcoholism ESRD DUE TO Diabetes/HCVD Pneumonia DUE TO Alzheimer�s dementia. Sepsis DUE TO complications of DM.

15. Evaluating Remote Injuries First you gotta ask! Did the injury compromise this person�s baseline? Immobility: they never walked again. Debility: they became a vegetable. It was a downhill course from their injury until their death. It�s a judgment call!

16. Therapeutic Complications Must be reported: Natural or Accident? Need to know: Dates of procedures. Indications for procedures. Co-morbidities and risk factors (including abnormal anatomy that made the complication more likely). Is this an expected or common complication of this procedure? (complications listed on consent form are not necessarily either!)