Death Certification (needs to be checked)

Stopped @ slide 9, card 10

Under the Irish system, who may issue a medical certificate of cause of death (MCCD) when a death is natural with no suspicious or unusual features?

A doctor registered with the Irish Medical Council who knows the cause of death.

Within what time period before death must the certifying doctor have seen the patient to issue an MCCD?

Within one month prior to death.

Who issues the MCCD for deaths subject to coronial investigation and autopsy?

The Coroner (after an inquest, if necessary).

Who is the only person who may certify an unnatural cause of death?

The Coroner.

What must a doctor do if they are uncertain whether a death is natural?

Discuss the case with the Coroner.

What happens if a doctor writes an MCCD that refers to an unnatural cause of death?

The Registrar rejects it and the case is referred to the Coroner (these late referral causes difficulties for all concerned).

Which international body defined the standard format for certifying cause of death?

The WHO (the ONS format is now used in most countries).

What does Part I of the MCCD describe?

The condition(s) that led directly to death.

What does Part II of the MCCD describe?

Other conditions, not related to those in Part I, that also contributed to death.

Structure of information in Part I

They form a causal chain: (a) is due to (b), which is due to (c).

Which line of Part I is the most important, and why?

The lowest line, because it is the primary pathological condition or the start of the events leading to death. It is also the line used to compile mortality statistics.

Do all lines (Ib, Ic) and Part II have to be completed on every MCCD?

No, only if there are predisposing or other relevant conditions.

What is the advice about including the mode/mechanism of death (e.g. coma, heart failure, cardiac arrhythmia) on an MCCD?

Try to avoid it. It is not forbidden, but it doesn't provide useful information.

In which group of patients is Part II most often used, and why?

Elderly patients, who often have multiple co-morbidities that may have contributed to death.

Give examples of manner/means of death.

Homicide, suicide, accidental death, natural causes, misadventure, open verdict.

Is the manner of death usually recorded on the MCCD?

No. It is usually concluded through coronial investigation (inquest) or criminal investigation.

Who returns the verdict at an inquest?

The coroner (inquests without a jury) or the jury (where one is involved).

What does a properly completed MCCD communicate?

The same information that a case history would.

Good MCCD example: what is the full certificate for septic shock due to an infected decubitus ulcer due to cerebral infarction, in a patient with insulin-dependent diabetes?

Ia. Septic shock

Bad MCCD example: Ia pneumonia, Ib malnutrition. Why is this a bad certificate?

It doesn't explain what caused the malnutrition, so it is incomplete and ambiguous.

Within what time period must the relative register a death with a Registrar, and who must do so after that?

Within 3 months of death. After 3 months any other qualified informant must do so.

Which three "yes/no" questions on the death notification form must be answered in all cases?

Whether the deceased was seen after death by the doctor, and whether the deceased was known to be pregnant at the time of death or within the previous 42 days (the form also asks the date last seen alive).

Case 1: 48M, alcohol excess, 2-year history of recurrent epigastric pain, pancreatic calcification on X-ray, raised amylase, hypotension, death. Autopsy showed pancreatic fibrosis plus acute inflammation and necrosis. What is the MCCD Part I?

Ia. Acute exacerbation of chronic pancreatitis

Case 2: 75M with IHD, previous CCF, caecal adenocarcinoma (radiotherapy), died 2 days after admission with acute anterior MI. What is the MCCD?

Ia. Acute myocardial infarction

In Case 2, why is caecal adenocarcinoma placed in Part II?

It caused anaemia and weakened the patient, but was not part of the causal sequence leading to the MI.

In Case 2, why is congestive heart failure placed in Part II even though it was caused by coronary atherosclerosis/IHD?

It weakened the patient but was not part of the direct causal sequence that led to the acute MI.

What is the WHO definition of sudden death?

Death within 24 hours of the onset of symptoms.

In practice, how quickly do most sudden deaths occur after the onset of symptoms?

Within minutes or even seconds.

List the organ systems that cause sudden natural death.

Cardiovascular, respiratory, neurological, gastrointestinal, gynaecological.

When a natural death is very rapid, which system is the cause most frequently (though not always)?

Cardiovascular, as almost no other mode of death operates so quickly.

28-year-old collapses on a football field. What is the typical autopsy finding, and what is the certificate if HOCM is found?

No abnormal findings macroscopically or on histology (in a negative autopsy). Ia. Lethal cardiac arrhythmia, Ib. Hypertrophic obstructive cardiomyopathy.

52-year-old with high BMI, left arm pain, collapse in a car park. What are the autopsy findings and the MCCD?

Severe coronary artery stenosis, with fibrosis and infarcted tissue on histology. Ia. Myocardial infarction (if confirmed on histology), Ib. Severe coronary artery disease, Ic. Atherosclerosis.

How does coronary artery stenosis cause sudden death?

It causes chronic myocardial ischaemia, leading to electrical instability and increased risk of arrhythmias.

Does the myocardium need to infarct for coronary artery stenosis to cause a lethal arrhythmia?

No. The ischaemia only has to be severe enough to initiate a lethal arrhythmia.

What is critical coronary stenosis? (not defined in the slides)

Narrowing of a coronary artery severe enough to significantly restrict blood flow to the myocardium (generally taken as roughly 70-75% luminal narrowing).

Name the three complications of atheromatous plaques that can worsen coronary stenosis.

Plaque haemorrhage, plaque rupture, coronary thrombosis.

How does plaque haemorrhage appear at autopsy?

As subintimal haemorrhage.

What happens to the contents of a ruptured atheromatous plaque?

The extruded cholesterol, fat and fibrous debris are washed downstream in the coronary artery and impact distally.

Which is more common: coronary thrombosis or simple critical stenosis as a cause of death?

Simple critical stenosis is more common (coronary thrombosis is common, but less so).

In what time window after an MI is the myocardium weakest, and what is the risk?

Between 3 days and 1 week post-MI. Rupture and subsequent cardiac tamponade are most likely at this time.

56-year-old, 5 days post massive MI, collapses in hospital; autopsy shows 500 mL blood in the pericardial sac. What is the MCCD?

Ia. Cardiac tamponade

67-year-old with poorly controlled hypertension and left-sided heart failure, sudden collapse at home. Heart 570 g, LV wall 16 mm. What is the MCCD?

Ia. Lethal cardiac arrhythmia

Why is hypertensive heart disease an important cause of sudden death?

It causes LVH and lethal arrhythmias.

What is the normal left ventricular wall thickness? (not stated in the slides)

Approximately 1.0-1.5 cm (so 16 mm is hypertrophied).

76-year-old with a known heart murmur, previous light-headedness, and aortic stenosis at autopsy. What are the two acceptable MCCD formats?

Ia. Lethal cardiac arrhythmia, Ib. Aortic stenosis; or just Ia. Aortic stenosis.

In which patients does aortic stenosis typically occur, and in whom rarely?

Typically older people with tricuspid aortic valves. Rarely younger people with congenitally bicuspid aortic valves.

What cardiac change does aortic stenosis cause?

Left ventricular hypertrophy (LVH).

25-year-old collapses on a run 2 weeks after flu-like symptoms. Heart is grossly normal; histology shows lymphocytes+++ in the myocardium. What is the MCCD?

Ia. Lethal cardiac arrhythmia

Why must histology be taken when infective myocarditis is suspected?

Because the heart can appear grossly normal at autopsy and the diagnosis is made on histology (lymphocytes in the myocardium).

Which age group is affected by primary myocardial disease, and how common is it relative to other CV causes?

Younger people. It is much less common than coronary artery disease, hypertensive heart disease and aortic stenosis.

Name the cardiomyopathies listed as causes of sudden death.

HCM (hypertrophic cardiomyopathy) and ARVD (arrhythmogenic right ventricular dysplasia).

Name the conduction defects that cause sudden death with a negative autopsy.

Long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia.

38-year-old smoker with a family history of sudden death collapses at home; autopsy shows pale conjunctiva, distended abdomen and 2 L blood in the abdominal cavity. What is the MCCD?

Ia. Hypotensive shock

Which arterial diseases are listed as causes of sudden natural death?

Abdominal aortic aneurysm (AAA) and aortic dissection.

78-year-old collapses mobilising 5 days post total hip replacement; autopsy shows right calf larger than left and an adherent thromboembolus in the pulmonary artery. What is the MCCD?

Ia. Pulmonary embolism

What is the major cause of sudden death within the respiratory system?

Vascular, i.e. pulmonary embolism.

Why is PE highlighted clinically?

It is the most clinically under-diagnosed cause of death.

What proportion of PEs have a predisposing cause, and what are examples?

About 80%, e.g. fractures, recent surgery, immobility.

In whom do the remaining PEs (without a predisposing cause) occur?

Normal, ambulant people who were previously asymptomatic.

Which respiratory conditions can cause massive haemoptysis leading to sudden death?

Lung tumour and cavitating TB.

Are severe chest infections usually a sudden cause of death?

No, usually not so sudden.

What is notable about asthma deaths in relation to sudden death?

Asthma is associated with rare unexplained sudden and unexpected deaths, even with no evidence of status asthmaticus or a history of a particularly severe episode.

29-year-old with epilepsy found dead in bed, no abnormal autopsy findings. What is the MCCD?

Ia. Sudden unexplained death in epilepsy (SUDEP).

What special action should be taken at autopsy for suspected SUDEP?

Retain the brain.

What clinical presentation suggests subarachnoid haemorrhage?

Sudden "thunderclap" headache, "worst headache of my life", "feels like I've been kicked in the head".

What is the main risk factor for intracerebral haemorrhage causing sudden death?

Hypertension.

Is cerebral infarction typically a very sudden cause of death?

No, it is not so sudden.

Which epilepsy-related causes of sudden death are listed?

Status epilepticus and sudden unexpected death in epilepsy (SUDEP).

45-year-old with alcohol dependency, cirrhosis and liver failure vomits blood and collapses; autopsy shows jaundice, 2.5 L blood in the stomach/duodenum, no ulcer, prominent oesophageal vessels. What is the MCCD?

Ia. Hypotensive shock

What is the major cause of sudden death within the gastrointestinal system?

Vascular causes.

List the GI causes of sudden death that are acutely sudden.

Ruptured oesophageal varices, perforated peptic ulcer, bowel infarction from strangulated hernia or bowel torsion (adhesions), and peritonitis (ruptured diverticulum or tumour).

Which GI causes of death are described as "not so sudden"?

Bleeding peptic ulcer and mesenteric thrombosis/embolism leading to bowel ischaemia/infarction.

34-year-old woman with sudden severe lower abdominal pain and collapse; autopsy shows a ruptured left fallopian tube mass with haemorrhage into the abdomen. What is the MCCD?

Ia. Hypotensive shock

Which two gynaecological causes of sudden death are listed?

Ruptured ectopic pregnancy and PE.

When a death is due to Covid, who is informed?

The coroner.

During the pandemic, what was the rule on informing the local coroner of hospital deaths?

The local coroner was informed about every death in hospital to determine whether Covid played a role.

Where is a death "with but not from" Covid recorded on the MCCD?

Usually in Part II.

List the autopsy findings of Covid.

Thrombotic complications, direct lung damage (exudative and proliferative diffuse alveolar damage, alveolar neutrophils, organising pneumonia), heart failure (HTN as co-morbidity), lymphadenopathy and splenomegaly, renal damage (diabetic nephropathy as co-morbidity).

What type of lung damage is seen in Covid at autopsy?

Exudative and proliferative diffuse alveolar damage (DAD), alveolar neutrophils and organising pneumonia.

Which complications of Covid vaccination are important to recognise at autopsy?

Thrombocytopenia and thrombosis, and myocarditis.

How common are these vaccine complications and vaccine-associated deaths (WHO)?

Complications occur in 4-6 per million vaccinated. Associated deaths are less, approximately 1 per million.

What principle must be remembered when assessing vaccine-related (and Covid) deaths?

Association does not equal causality.

What are the four steps of the AEFI causality assessment checklist after COVID-19 vaccination?

Order of incidence, temporal proximity, grounds for other causes, published evidence.

In the AEFI checklist, what time window defines temporal proximity?

Symptoms occurring within 21 days following vaccination.

Case: 85-year-old woman, fall at home, left neck of femur fracture, hip replacement 5 days later, post-op pneumonia and respiratory failure, died 10 days post-surgery. What is wrong with the intern signing the death certificate as "natural causes"?

The death involves trauma (the fall and fracture), so it must be reported to the coroner. Only the coroner can certify it, so the intern shouldn't have signed it as natural.

In the 85-year-old hip fracture case, what is the suspected cause of death?

Pneumonia, but trauma played a role.

Will the hip fracture case be reported to the coroner, and why?

Yes, due to the trauma aspect.

Will the hip fracture case have a post-mortem and an inquest?

A post-mortem is probable but depends a little. If referred for post-mortem, then yes, there will be an inquest.

Who signs the death certificate in the hip fracture case?

The Coroner.

What is the MCCD in the hip fracture case?

Ia. Bronchopneumonia (not respiratory failure, though that may appear in a narrative description)

List the possible inquest findings.

Natural, misadventure, suicide, unlawful killing, lawful killing, industrial disease, stillbirth, narrative, open (depends on the details of the fall).