Monday, January 19, 2009

Official Cause of Death

A question recently hit my inbox about what the official cause of death would be listed as on a death certificate of a person who died of cancer. As I don't deal much with that end (pun not intended) of the health care spectrum, I did a bit of digging and found out that writing the "cause of death" statement is surprisingly complex and yet also a thing of simple beauty. Ok, so I'm a bit morbid.

A typical cause of death statement might read:

Acute Myocardial Infarct

Now, if you aren't an MD or a nurse, that might look like a load of gibberish, but really it just says "heart attack". Simple, right? er... not quite as simple as that. Actual cause of death statements are written in two parts. The purpose of these statements is to allow tracking bodies to develop statistics on diseases and processes that kill people, and the things that put us at greater risk for these conditions. So if a coroner or MD writing a death certificate has more information (ie from medical history or an autopsy), they are going to fill this section in with as much data as possible.

Part I

The purpose of part 1 is to determine the series of medical events that lead up to the death, in reverse order, starting from the most recent condition and working backwards to the oldest relevant condition that lead directly to the death. So that very basic heart attack up there would become something more like heart attack due to hardening of the arteries that feed the heart, or in medical jargon:

Acute myocardial infarct
due to or as a consequence of Athrosclerotic coronary artery disease

As another example, if you had someone die of a pneumonia because they had AIDS, their cause of death statement would look like:

Klebsiella Pneumonia
due to or as a consequence of Acquired Immune Difficiency Syndrome
due to or as a consequence of Human Immunodeficiency Virus infection


If there isn't a lot of data on what lead up to the death, or if the person was terminally ill from a known disease but there isn't a way to determine what complication of that terminal disease exactly killed the patient, you can sort of guess or just leave it off. As below:

Acute myocardial Infarct
Due to or as a consequence of Probable Atherosclerotic coronary artery disease

Or simply:

Adenocarcinoma of the prostate

Part II

Part II is to list risk factors that lead to the sequence of events that lead to the death. These can include other diagnoses, like high blood pressure (hypertension) or diabetes (diabetes mellitus type I or type II), or behaviors, like alcohol abuse, IV drug abuse, etc..

Do's and Don'ts

Don't report signs or symptoms as the cause of death

So a person cannot be said to have died of a cough, fever, or elevated blood alcohol level. They can die of pneumonia (that caused the cough), or a specific infection (that caused the fever), or alcohol toxicity (with the high blood alcohol level would diagnose, but the blood alcohol level itself is a test, not a diagnosis).

Don't report mechanistic causes of death

Mechanistic causes of death are the physical process that stopped or failed due to disease or trauma, rather than the disease or trauma itself. As in cardiac arrest caused by a heart attack, or respiratory arrest caused by pneumonia. Other examples of things that shouldn't be reported in this class include heart arrhythmias like asystole (flat line), or ventricular tachycardia (V-tach, a fatal change to the electrical impulses in the heart. See photo).


Do be specific and exact

Don't oversimplify or under-report. For instance, a doctor wouldn't write that high blood pressure killed anybody. High blood pressure may have lead to stroke that killed someone, or it could have lead to hardening of the arteries and a heart attack. It's better to include too much information rather than too little.



Relevant for fiction?

Depends on your fiction. If you have a doctor or coroner talking about a cause of death, then this statement is going to be very important. Doctors are trained to analyze cause of death in this pattern, and so it's going to be this pattern that they are most comfortable with when reporting cause of death at trials, to reporters, to family members who want more specifics, etc.. They will also use this basic pattern of understanding to ask for permission to do an autopsy on cases where they don't understand exactly what progression led to the death. ie "We believe your aunt died of an overwhelming urinary tract infection, but we would like to be sure/we need to understand what caused this infection to be so severe."
Why is cause of death important?

In my particular line of work, (in a NICU with newborn, premature, and young babies) the official cause of death can be very important. Information like genetic or infectious reasons for the death can help us council families who wish to have more children. Information also needs to be gathered to prove that everything was done as it should have been, that the death was not do to medical error (either ours or the birth hospital's), or some other process that can be prevented or mitigated in future pregnancies.

Cause of death statements also allow us to track which diseases and problems are killing us, and thereby allow us to work harder on cures, treatments, and solutions to those same diseases and problems. Keeping mortality and morbidity statistics is one of the best ways to start tracking the impact of disease and death. Of course, the cost of disease and death can't just be measured in death. Quality of life, healthcare costs, the costs to survivors, and other factors must be weighed as well.

Autopsies and how they help us understand death




Autopsies are frequently requested when children or young people die and the exact cause of death was not well understood. Autopsies can be requested by the hospital, the coroner, or the family, though the latter option can be prohibitively expensive for the family. Autopsies can be done even if the deceased was an organ donor.

There are also legal reasons why an autopsy would be required. If there is suspicion of abuse, murder, or death by unnatural causes, the family might not have a say as to whether or not an autopsy takes place. In these cases, cause of death statements must be exact and as complete as possible because they might effect future prosecution. Cause of death statements can be amended if new evidence later comes to light in these situations.

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