DeathGertification
and
Registration
RffiilymaMock,mD
W] EMORY
At|anta,GA
\-/
UNIVERSITY
Goals of the Presentation
Afterthe presentation,
attendees
will be ableto:
Lecturelnformation
. Thishandoutwasdesigned
for a two-hour
presentation.
. An abbreviated
one-hourpresentation
has
beenprepared.
. Theslidesincludedin the one-hour
presentation
areindicated
withO in the
bottomleftcornerof the slide,as shown
below.
. Otherslidesare providedin the handoutas
an additional
sourceof information
The Problem....
. Understand how death certificate information
is processed and used
. Apply specific concepts to write cause-ofdeath statements of good quality
. Properly Complete the certifier's section of
the death certificate
. Appropriately use mechanismsof death
when writing cause-of-death statements
. Report appropriate cases to the coroner
o
TheResponse.
TheOutcome.
CardiacArrest
O
Anothercommonone...
Sepsis
It's Axiomatic.
. Physicians,
Coroners,and
Coroner'sPathologists
certify
deaths(theyare certifiers)
. Thesecertifiersare professionals
. Professionals
shouldproduce
professionalwork products
. The DeathCertificateis a work
product
a
o
Therefore......
Also to be considered...
j.
. Ethicalresponsibility
. End-of-LifeCare
. May be a legalduty
Certifiers
should
produce
professional
quality
DeathCertifications
The duty should not be shirked
o
a
EducationalResources
EducationalResources
Laminated
Guds
2
EducationalResources
EducationalResources
CAP Publications
l-800-323-4040
Gofllege
Fathoflognsts
ofAmnedcam
Hf,stry
Mamuafl
Disclaimer:The CAP derives revenue from sales but Hanzlick does not
&arh Cdtfr €te Complelion
umn*fim$amecg
On-line Tutorial
Origin of the DeathGertificate
"* . :
,-"::'l\rP
World Health Organization(WHO)
"-J iL-{""
W
'192Member "States"
The USA is one of the member "States"
Signatory States must follow the WHO rules
.:'
!
!
loP
r'jD/
State Vital Statistics Offices
Ndromafl
DahGoflhcted
Thmo@
Goqerffifumcememb
pantd GDG)
tsetweem
Sffies
aMNGHS
Why Accuracyis lmportant
Fam ily
r'tD/
Research
o
Statistics
Fundi ng
Programs
Responsibilities
-Compleles pa.ts ofthe death certificate
-Ensures certifier does his/her part
-Files certificate with Registrar
Certifier of Death
-ComDleles cause of death section
-Responds lo queries from Registrar
-Supplements or amendments, as needed
-Conducts queries
-Registe6 and assigns state file number
-Foruards data to NCHS
L
-Works with and assists states
-Complies data and generates reports
4onducts research
-Provides National leadershiD
Nebraska Mortality Data ryear2.o3l
. AllDeaths
. NaturalDeaths
. Non-Natural
MVA
Suicide
Acc Falls
Homicide
Acc Poisoning
Acc Drowning
Acc Fires
Acc Guns
OtherAccident
15,439
14.406
306
175
121
63
35
21
16
5
191
o
4
Nebraska Mortality Data ryear2oo3r
NebraskalnfantMortalityData
lYear20031
Heartdisease
3,948
Cancer
3,331
Cerebrovascular
1,090
ChronicLungDisease 785
Accidents
695
Alzheimer's
461
Diabetes
406
Pneumonia
404
. TotalDeaths 141
. Neonates
96
. Post-Neonates 45
. Low Birthweight 88
. Birthdefects
. SIDS
36
24
Nebraska's Death
Certificate is
based on a U.S.
Standard
Certificate of Death
2003 VeEion
F
The Cause-of-DeathStatement
PadI)
a.
Most recent condition
b. o*", An otder condition
certiner-F
C. o*o, An even older condition
d- '*.,
Oldest Condition (what started it all)
Pan II)
dt'
E
o
Something that contributed to death but did not cause
the ones listed above
A G o o dO n e . . . . .
Pad I
a.
Terminology
Paf I
Systemic sepsis
b. o*., Infected decubitus ulcers
C- -"",
Intermediary
Systemicsepsis'
I
b. o*", Infected decubitus ulcers
Bedridden state from previous stroke
c. o,",., Bedridden state from previous stroke
Cl.o*", Cerebral artery arteriosclerosis
d. o*", Cerebral artery arteriosclerolis
)ad II
)sc:
a.
lmmediate Cause
Pad II
osc:
Insulin-dependenldiabetesmellitus
tnsulin-dpent
diabetes mellitus
Other Significant Condition
o
Terminology
PaN I
a.
You can use all 4 lines in Par tI...
Pad I
lmmediatecause
c. -"", Intermediary
cause
c. o*", Bowel obstruction
d. o*",
Adenocarcinoma
of cecum
Pan lI
osc:
Other Significant Condition(s)
This is a "Sequential Part I Format"
o
Or 3, if appropriate....
Pad I
Peritonitis
b. o*", Ruptureof ileum
d. o*", Underlyingcause
osc:
A.
b. o*", Intermediary cause
Pad Il
a.
Or2,if appropriate......
Pad I
Ruptured esophagealvarices
a.
Acute myocardial infarction
b. o*., Cirrhosis of the liver
b. o*", Coronaryartery atherosclerosis
C. o*., ChronicAlcoholism
C- o*r
O, o*r
o
Underlying Cause
o
O. o*o
Pad U
Pan Il
osc:
OSCi
This is a "Sequential Part I Format"
a
This is a "Sequential Part I Format"
Or just one,if required...
Pad I
a.
T h eU n d e r l y i nC
g ause.....
Pad I
Metastaticadenocarcinomaof prostate
a.
Acute myocardial infarction
D. o*o
b. o-", Goronary artery atherosclerosis
C. mr,
c. o*u,
d. o*
d. o*,,
,/
/
Pan I
osc:
It is Underlvinqin 2 respects:
-Position in Part I
-Position in causal sequence
This is a "Single Line Part 1 Format"
a
lt is the "Bottom
j
One condition per line in Part I
Pad I
a.
Line" of both
Part II can have multiple
conditionslisted
Subarachnoid hemorrhage
Pad I
a.
Peritonitis
b. o*o, Ruptured berryaneurysm
b. o*", Perforatedgastric peptic ulcer
G. o*t
c. *"",
d. o*"
Helicobacter pylori infection
A
Pad II
osc:
Pad II
osc:
o
Ghronic gastritis, chronic alcohol use
a
No LaundryLists
Please
Limit it to conditionsthat
actuallycausedor contributedto
death.
a.
Right middle cerebral infarct
Pad II
osci
o
lschemic heart disease: diabetes mellitus
Let'stry doingone....
Oneway to do it....
Pan I
HISTORY:
A 56 year old malewith hypertensionis
admittedand diagnosedwith acuteMl.
4 days laterhe's found dead in his
hospital bed. Autopsy shows cardiac
tamponade,rupturedMl, recent
thrombus in the LAD, > 90o/o
stenosis
by ASCVD,and a 500gram heartwith
LVH.
o
Pad I
a.
C. o*., Coronaryarterythrombosis
Cl.o*", Atherosclerotic coronary disease
Pad Ir
osc:
Essential hypertension with cardiomegaly
There is often more than one acceptableway
Yet anotherwav to do it...,
Pad I
Cardiac tamponade
a.
Ruptured myocardial infarct
b. o*., Ruptured myocardial infarct
b. o*r, Atherosclerotic coronary disease
c. tub, Atherosclerotic coronary disease
C. o*o
d. *"
O, o*u
Pad II
osc:
Cardiac tamponade
b. o*", Ruptured myocardial infarct
o
Anotherway to do it....
a.
Pad lI
osc:
Essential hypertension with cardiomegaly
There is often more than one acceptableway
O
Essentialhypertension
There is often more than one acceptableway
o
What Happensto Your
Gause-of-DeathStatement?
What Happensto Your
Gause-of-DeathStatement?
Pad I
Hepatic cirrhosis
(K70.3) -l
o*", Chronic alcoholism (F10.2)
Pan ll
osc:
ACME (Automated Classification of Medical Entities)
SuperillCAR (Medical Indering. Classification,and Retrieval System)
TRANSAX
Underlying Cause of Oeath For "Single Cause" Moriality Data
Both recorded for "Multiple Cause" Mortality Data
8
GeneralRulesfor ICDCoding
Example
Pad I
. lf two or moreconditionsare reportedon a
linein Part| , thefirstone mentioned
will
be givenpriority,
usually
. Specificentitiesareusuallygiven
preferenceovernonspeciflc
ones
a. (Hypertensio)and coronary artery disease
b. o*. '
C. mr"
O. o* r'
Pad ll
. Keepthesethingsin mind,butdo notlet
theseprocedures
dictatehowyou certify
the death.
osc:
Preferenceis usually given to the first condition reported
Its better to reporl the most important in Part I and the lesser important in Part ll
Another Example
Pad I
a. Congestive Heart Failure
D, o*o
C. o*o
d. o*.,
Preferenceis usually given to the most specific condition
It would be better to reDortlhe coronary disease on Line B in Part l.
GeneralRules
. Alwaystry to includea specific
undedyingcauseof death
. Try to includethe immediatecause,
when possible
. Try to includeintermediary
causes
when reasonably
known
. Try to reportonlyone conditionper
linein Partl.
o
TheCauseof DeathStatement:
Let'stry anotherone....
. ls yourbestopinion
. ls notset in stone
. Canbe changedif needed
. Poseslittlelegalrisk
HISTORY:
While cleaninghis gutters,a 65
year old man falls off his ladder
and breakshis hip. Surgicalhip
repair is performed.One week
later,he has a massivepulmonary
embolismand dies.
o
o
Pad I
CoronerCases
a' * n^a'tdolil
k
- - . .
I
-^r. ,rdunldo8th
r- "- c. o"",.I lrrr
rrvu'
d "tDgath J€SulrEc
_- lrhrru
Pad II
osc:
o
r Gallthe
coroner!!
Many seemingly"Natural"deathsare not Naturaland
the Coronershouldat leastbe notifiedto determine
investigationand certificationstrategy.
.
.
.
.
.
Griminalmeans or violence.
Homicideor suicide.
By drowning.
lf sudden or unusual.
lf drug-related.
o
CoronerCases(cont'd)
GoronerCases(cont'd)
. lf sudden infant death syndromeis
suspected.
. When involvingthe suddenand
unexplaineddeathof a child
betweenthe ages of 1 week and 3
years,and when neglect,violence,
or any unlawful means are
possible.
. When death is not certifiedby
attendingphysician.
. When an individualhas died while
being apprehendedby or while in
the custody of a law enforcement
officer or detentionpersonnel.
. Any suspicious,unexplained,or
unattendeddeath.
a
o
OtherNebraska
Coronerlssues
Problemsarisewhen....
. The CountyAttorneyis the Coroner
. TheCoronerappointsCoronerPhysicians
to assistand certifydeaths.
. TheCoroner's
Physician
ensures
performance
of autopsieswhen requested
by the coroner
. Driversand Pedestrians
16 andoldermust
be examinedand havetoxtestsif theydie
within4 hours
. Autopsies
are requiredin certaincases
than age 19, death is sudden and not due to disease or accident)
O
lLess
10
TypicalProblemCases
Typical ProblemCases(cont'd)
.
.
.
.
. Peritonitisfollowing ruptured viscera
that may havehad a traumaticcause
. Complicationsof prolongedcoma
followinga drug overdoseor old injury
. Sepsisfollowingan injury (suchas a
burn)or poisoning
A fall with hip fracture or head injury
Post-traumatic seizure disorder
Complicationsof paralysisfrom an old injury
Subdural, subarachnoid,or epidural
hemorrhage that may have been due to injury
. Pulmonary embolism from immobility due to
an injury
. Pneumoniaas a complication of injury or
poisoning
o
o
"Unnatural"and MedicalGare
.
.
.
.
.
.
Medicaloroblem:
.
Fracturedhip
Pulmonary emboli .
.
Seizure disorder
.
Paralysis
Coma/Unresponsive.
.
Intracranial
hemorrhage
Thecoroner'sconcern:
Fall?
lmmobility from injury?
Post-traumatic?
From an injury?
Poisoning?
Head trauma?
lf uncertain. call the coroner!
Mannerof Death
.
.
.
.
Natural
Accident
Suicide
Hom icide
. Undetefmined
(courdnotbedetemined)
. PendingInvestigation
NOTE: lf you are not a coroner or are not acting on behalf of lhe coroner, afyou
are tempted to check any manner otherthan Natural, call the coroner.
O
11
"!n
Cardiac tamponade
6inutes
Other Checkbox ltems
Dueb dasaoe@@eol
Rupture of myocardium
DBb
l"_--**-i"
uNo I
d6acoss*d
Myocardial infarct
IUYES
tr".ry;"l@frl
7 days
ouab da6aMsa*ed
" Coronaryarteryatherosclerosis
Part
II
Years
IUYES
F"@"..fu;;l
sMomrd.d?_
/
I
luYEs
I
Interval Between Onset and Death
JII
" r".thl*lop"v
May indicate
"Partial"
or "Limited"
uNo
I
uNo|
I
/
Natural
a
lndicate YES even
tr;M;M;--_l
lrinutes
tr YEs D No tr PRoBABLYE uNKNowN
This applies lo fire
deaths and other iniury
cases as well
-Generic inlervals may be used, when necessary-
Other Gheckboxltems
lf Female
D
n
D
D
D
Not pregnantwithin past year
Not pregnairtat time of death
Not pregnant,but pregnantwithin 42 days
Not pregnant,pregnant43 days to 1 year beforedeath
Unknownif pregnantwithin the past year
Dates...
MM/DY^/R(03/05/05)
formatacceptablefor
mostinformation
items
(March3, 2005)for:
Use MONTH/DY^/EAR
. Dateof Death
. DatePronounced
. DateSigned
o
O
Except for Date Pronounced, you may
qualify a date as "Found" or "Approximate"
Times....
. Mifitary time is preferred (14421
. 0000 starts the new day
Physician
Certification
Natural Death
Except for Pronounced Time, you may
qualify a time as "Found", Approximate,"
or "Unknown" in SelectedCases
o
All Applicable
llems
Completed
o
12
GeneralRules
.
.
.
.
.
.
.
.
Makesure you use the current DC Form
Makeentrieslegible
Use permanentblackink
Do not abbreviate
Do not makealterations
Do not eraseor use whiteout
ForwardDC in timely fashion
Put decedentnamein margin
In Nebraska, this is on the bottom sstion
o
t1n
- Pneumocystispneumonla
to. b, or.s 5 d$+eE
SomeAdditional
Cause-of-Death
Statements
MakingSomelmportant
Points
Acquired lmmuns Deficiency Syndrome
Dialysis-dependentrenalfailure
3 years
d
, Essentlalhypertenslon
years
Human lmmunodefioiency Virus lnfecUon t0 yea^
D@b,n6a6EWed
OTHERSIGNIFICANT
CONDITIONS:
Parl
II
hdids6Mhob6slDl6@hhu@0@soredhPdl
Cryptococcal myocarditis
Natural
o
to. b or as a 6ne+de
,Veeks
d
D@b,d6a@sq€ror
_
O
"in
ofthe form
Cryptococcal myocarditis is a ccmorbid condition, in this case, clinically less
important than Fneumocyslis pneumonia, so it is placed on Part ll as an OSC
Parr ^ Heart dlsease requiring
t
implanted defibrillator
to6 b, or s . oe(wa
I 5 years
ol
, Chronicischemicheart disease
) weeks
, years
D@b.d * a@qE6ol
to.b,or.sa@retud
oueb das6onsoffid
OTHER
SIGNIFICANT
CONDITIONS
Part
II
OTHERSIGNIFICANT
CONDITIONS:
Part
II
Dcscnbc llow
bdbsmhbuhqb&sbrmtmi{'nhul@s@eor&dntonl
Atrial fibrillation, Diabetes Mellitus
lnjlryG(fr
D.sdb
Natural
1
This connotesthe end-stagenatureof causeof death
How
lrjrq
Ocdrd
Natural
O This illustrates the interplay between Part I and Part II
13
B e i n gG e n e r i c . . . .
Pad l
Qualifyinga cause....
a. Natural causes associated with old age
Pad I
b. o*"
a.
Probableintra-cerebralhemorrhage
b. o*.,Hypertension
C. o*u
C. o* ro
O. o* ro
A
Pad n
osc:
Pad ll
osc:
When generic statements are used but another
specific condition is reported, the specific condition
will be coded as the underlying cause of death
1
o
Its Okay to use the word "probable" or " presumed"
CaseScenario
Pad I
HISTORY:
A 23-yearold male becamequadriplegic
after an automobileaccident.He livedfor
severalyears but developedrecurrent
urinarytract infections.His most recent
admissionto the hospitalfor UTI was 2
weeks ago, and he died of systemicsepsis
while still in the hospital.
u' * n^n'|doifl
b' "*."-..- t- -^t' "afuraldo8th
r- '-' c, o*" ! lllg
--
!-:rr"u
d."*t,Dean lGsurrw
oi"' *
saffthecaraner!!
Injuryor PoisoningDeaths
Pan I
a.
Fatal derangement
b. "*," Bodily Trauma
InjuryDeaths
c. "..,., lnjury Event
O. o*o
(External
Causes)
Pad Il
osc:
CAVEAT: 1) Do not certify such deaths unless the coroner requests il
2) Some knowledge of injury death certification is helpful.
o
Similar to lmmediate, Intermediary,and Underlying Causes
o
14
For our "Fall" Scenario
InjuryDeath
Pad I
a.
lFell off of ladderwhile cleaning gutte6, died laler of pulmonary embolisml
Pad I
Intra-thoracichemorrhage
a.
Pulmonary embolism
b. o,,,",Penetratinglung injury
b. o*", lmmobility from hip facture
c. o*", Stab wound of left chest
c. o*", Fall from height
O, o* ro
Pad lI
osc:
Pad II
Similar to lmmediate,Intermediary,and Underlying Causes
a
PoisoningDeaths
Pad I
osc:
Pneumothorax
a.
Similar to lmmediate,Intermediary,and Underlying Gauses
But there's more when external causes occur......
tin
Probable cardiac dysrhythmia
, Chlorinated hydrocarbon toxicity
b. o*", Chlorinated hydrocarbon toxicity
DPro
osc:
a6acdqE@d
. Inhalationof paintfumes
C. o*", Inhalation of paint fumes
Paf ll
Probable cardiac dysrhythmia
oueb o,ass@nse*d
Part
II
Dcsci&
Similar to lmmediate,Intermediary,and Underlying Causes
The futal derangement, bodily t.auma, and iniury event scheme may be used
DescribeHow InjuryOccurred
Accident 1
I
O
How lnjuryGcurd
Huffing. Sprayed paint into plastic bag
and inhaled painl fumes.
+
Manner of Death
How injury'occurred
Examples:
Describe How Iniury
Describe How Iniury Occurred
Huffing. Sprayed paint into plastic bag
a n d i n h a l e dp a i n t f u m e s .
Shot self in head with .38 caliber revolver
Describe How
. Be complete
. Avoidcitingindividual
peopleor
individualentities/businesses
. ln Homicides,
be a littlemoregeneric
Unrestraineddriver of sports utility vehicle which
veered off interstate highway and struck a tree.
How
Shot by other(s)
15
OtherInjurylnformation
lnterstale Highway Exit Ramp
u
E
d
tr
Be Specific but Genericl
Typical Examples:
ln Own Home
Parking Lot
Fast Food Restaurar*
Wooded Area
Lake
2-Lane City Street
Car in Driveway
unveiluperator
Passenger
Pedestrian
other(specify)
E*4;--]G;ff;
t
(found,
These
maybeaualified
approx,
etc)
I oelosios ll tgzo I .
125 Second Hand Avenue, North Platte, NE 69103
Injuryat Work?(=Yes)....
Injuryat Work?(=No)....
.Working or in vocational training on
job premises
.While on break or at lunch or in parking
lot on job premises
.Working for pay or compensation,
includingat home
. Working as a volunteer law enforcement
official etc.
. While traveling on business, including
to/from business contacts
. Engaged in personal recreational activity on
job premises
. While a visitor (not on official work business)
to job premises
. Homemakerworking at homemaking activities
. Student in school
. Working for self for no profit (mowing yard,
repairing own roof, hobby)
. Commuting to or from work
tin
, systemicsepsis
Due b. o' as a @nscds
Catheter-associated bladder infecUon
Coroner
Ce,tification
2 weeks
0€ ro. o 6 a cosq€Eol
Quadriplegia from cervical spine injury
3 years
0Fb,o'.sa@neamedl
Iniury Death
, Motor vehicle accident
A Lot More
lnformation
Needed
tf
Non-Natural
Several
ol
3 years
Parl
II
Dcscd$How
Accident
hj!ryocdRi
Passenger in car that left roadway,
rolled over, and ejected the vicUm.
Remember! Medical complications may result from injuries which can make you
forget that it's a coroner's case. Always keep this in mind.
16
Mannerof DeathPrinciple
Combinations
of
lnjuryand Disease
CAVEATS: 'l.There a.e exceptionsto every rule
2.There is often more than one acceptable way to do things.
CaseScenario
.
.
.
.
.
.
Natural
Accident
Suicide
Homicide
Undetermined
notbedetemined)
Pending Investigation (coutd
NOTE: A general rule is that if an extemal cause (injury or poisoning) combined
with natural disease to cause death, preferen@ is given to the non-natural manner
"lf
Anotherway of looking at it: the injury had not o6urred, would death likely have
occured when it did?" lf no, then the manner will prcbably be other than Natural.
"gut fol,
the injury, death would not have @urred when it did.
Oneway to do it......
":n
. A 65-year-old
ladywith previousMl has
chestpainwhiledriving.Shepassesout
and losescontrolof the car and hitsa tree
. Shelivesseveralhoursin the hospital.
. Autopsyshowsmultiplerib fractures,
pulmonary
lacerations,
andan old
myocardialinfarctwith no acutechanges
in the heartor coronaryarteries.
^
Rlb fractur€ with lung lacerauons
OTHERSIGNIFICANT
CONDITIONS:
hdids
6hbln9
b dd
br id Eshng
Dcscdh
tlow
Injq
D h. ui&ilE
c&e
d 4il
ii Pd I
&@ed
Driver ofcar. Had acute cardiac event. Losl
control and ran into rear ofanother car.
Anotherwavto do it....
Another way to do it.
tin
^ Bluntforce injuryofchest
Motor vehicle colllslon with tree
Descnb
Ilow
Injury Ocdred
Driver ofcar. Had acute cardiac event. Lost
and ran into rear ofanother car,
Descnhllow
Accident
InjrqGdd
Driver of car. Had acute cardiac event. Lost
control and ran into rear of another car.
17
Another way to do it.....
Part
I
tin
^ Bluntforce chesttrauma complicating
coronaryarteryatherosclerosis
to.b,d$aoscled:
1
Motor vehicle collision with tree
tub
^
I hours;
Intracerebral hemorrhage
Minuie!
to6b,ds€@r@d
u
'
Hours
Acute cocaine lntoxlcation
HouB
0€b,d6s6W@ol
aEsmswd
toeb,nad@'twed
dl@ffi i
toeb,d6aoiew.d
:p,retrqtrgn:
Part
OTHERSIGNIFICANT
CONOITIONS
$E"S]
t;
Part
,:
OTHERSIGNIFICANT
CONDITIONS:
hdls6ffi6gbdblrcl.d@nhun@hgc.6ol6dhn
II
Desdh
Accident
Ho* rdry
Dedb
Driver of car, Had acute cardiac €vent. Losl
control and ran into rear ofanol her car.
0F b, d ds r @ne{@
How
Injq
Ocffid
e(id
Accident
Smoked illicit crack cocaine. Dev€loped a
Hemorrhase in the brain,
Some intoxications
can causean otherwise"natural"event
This method makes the story clearer
".
Pd I
Hypertension
t"t r-fr:"
Il
d
Acute cocalne Intoxlcallon aggravaUng
ischemic heart disease
Dc*ib
How
Injq
Deaths
of
The Elderly
ccid
Srnoked illicit crack cocaine which aggravated
Usingwords such as "complicating"or "aggravating"can be helpful
":n
^ Chronicaspirationpneumonia
Weeks
o
"in
0Fb,d6a6isQ@d
,
"
h6
Senile Dementia
Environmentalhypothermla
b,
or as a 6ieae@
"
l5 years
0Eb,ssrcrymol
0€b,d6
DFb
Hours
d
Cold exposurecomplicating
AlzheimerDementia
15 yeaF
sms{Erol
dasadisQmed
D€b,d6a@tr4deol
Part
tl
OTHERSIGNIFICANT
CONDIlIONS
OTHERSIGNIFICANT
CONDITIONS
Part
IT
D*db
Ho* lrj0ry ocord
Dc$ne
Natural
I
Specify the immediate cause and the type of dementia
Accident
O
Ho$ rijury Go,rd
Wandered away from home in cold weather.
Inadequately dr€ssed.Died ofcold exposure
Note that the Manner corresponds to underlying cause
1B
"?n
^ Pulmonaryembolism
Due b, or 6 s @r'wo
Or.,...
"in
^ Pulmonaryembolism
Minutes
d
0@b o,ossonse#dl
" lmmobility
0€b
Minute!
6 days
d6adsB@0,
. Hip fracture aggravaung senile demenua
, lmmobility
i days;
Years
6 days
Dblo d6acss#rol
. Hip fracture aggravating senile dementia
i days;
Years
DFb.dsa@nw*6ol
Dueb 6rasB@eae@d
6 days
Fall while walking
OTHERSIGNIFICANT
CONDITIONS
Pa.t
II
Part
OTHERSIGNIFICANT
CONDITIONSi
II
Descnb Ilow ljury&dtu
De*nb
Unstable on feet. Fell while walking.
Fractured left hip.
Accident
Accident
o
How
lnjury
ocdwd
Unstable on feet. Fell while walking.
Fractured left hip.
o
Or.....
"?n ^ Seniledementia
"!n
Years
^ Fat embolism
Due b. { 6s a @nws
D!€ b.orasa6n*tu*eoj
, Pathologicfracture of right femur
D€b,d
tub
Minutes
ol
2 days
6 acdseqEdor
d6o@s4€eol
Years
, Osteoporosis
ouab.o.asaonsQmed
OTHER
SIGNIFICANT
CONDITIONS:
OTHER
SIGNIFICANT
CONDlTIONS
Parl
II
Pulmonary
embolism
followinghipfracture
De*Dh
Accident
rlow
I tDry
Part
II
66!o66nhbdn0bedh
Des6&
{}qwd
Unstable on feet. Fell while walking.
Fractured left hin.
o
tormrrcu[ns
nhun4nscaleolddhh
Pdl
Seniledementia
How Injury OccDnd
Natural
a
Pad I
a. Natural causes associated with old age
ti*
^
Unspecifiednaturalcauses
Due b or as a onewme
d
D. n.u
DEro n6a(oseG@dl
d. o*"
Pan II
osc:
OTHERSIGN]FJCANT
COND!TIONS
Part
II
I)J(nh
o
When generic statements are used but another
specific condition is reported,the specific condition
will be cbded as the underlying cause of death
IIo!''ifryrn{rql
Natural
a
Although"Senescence"is probablyOK, it is not needed.
Do not do this unlessyou have no likelycause.
19
The importantthings....
Deathsof
Neonates
and
Infants
. Usually more than one way to certify
. Getthe major conditionson the DC
. Put conditionsin a logicalorder
: Correctlyclassify manner
. Completethe injury informationas needed
. Use the various "tricks"
. Reportappropriatecasesto the Goroner
o
o
"1^ ^
Necrotlzing enterocolitis
Extremeprematurity
3 Days
2 week!
Maternalplacental abruption
Neonates
DBb
28 Daysor Younger
or.r.Meee€d
Part
u
D€db
low
lnjury
Gcffid
Natural
O
"in
^
0Db
"
tub
Hypoxic cerebral hemorrhage
Hours
Try to includethe underlyingmaternal/gestational
condition
lnfantS
to 1year]
[1monflr
orrs.oi$amedl
Premature onset of labor
I day
dsadqEEd
Undeterminedspecific cause
toeb,aroso@rwd
Part
II
Descih
Uow
Injury
Gdnd
.
.
.
.
Glear-cutcause(s)
SIDS-L|ke
Not SIDS,but no cause known
Inadequateinvestigation
(Hopefully,these will be non-existentl
Natural
This let's a reader know you thought about it
20
Clear-cut
causesarehandled
as usual....
Clear-cutcausesare handledas usual....
OTHER
SIGNIFICANT
CONDITIONS
Desdb
Hov
lDj!ry
Ocerd
Injuries inflicted by another person(s)
SIDSOID
Cases...
'ad .
Undetermined
. Consistentwith SIDS
. SIDS plus disease
. SIDS plus external stressor
. Not consistent with SIDS;
no cause identifiable
. Inadequate investigation
'ad
n
&i,.,of
I
|
oTHER
StGNtF|CANT
CONDTIT0NS
,"fu,.-*".""
l
D.ih
Undetermined
*.",-,
l*,"'"'
I
There are better ways to certify such deaths
" T r i p l eR i s k M o d e l " . . .
Uncomplicatedcase
Each would be coded
as R95 SIDS
The Manner
does not matter
Some might be non-natural
o
21
GrayZone Case with Disease
p:d
Gray Zone Case with External Stressors
^ Sudden Unexplained lnfant Death
Pad
lI
I
OTHERSTGNFTCNTCONoITONS
I
cl.q4a@htuu
I
p1d
Upperrespira!0rybactviral infeclior
I D.*nh
t
ln.l€ternined
lb$ r,iB
Sudden Unexplained lnfant Death
u
o..h,
lk"r.
I Undeternin€d
ifexrernst
H*
b!ry tuMd
I
Undetermined Undctermincd
ifcxtcrnal causcs*erc involvcd.
I
I Bed sharing wilh 4 aduhs.Found facedosn.
catrses w€ru involved
This would be codedas SIDS
This would be codedas SIDS
Zone Case with ExternalStressorand Disease
"1n
pad
Sudden Unexplained Infant Death
SuddenUnexplainedlnfant Death
OT}IERSIGNIFICANT
CONDITIONS
Pad
n
n
Bedstrarinswitb 2 edults .F
t
Indetermined
Undercrmincd ifexternal cauxs were involved.
I
I B{d sharins wilh 4 adulls. Found facc down.
Undeterrnined
ljndrtcrrnincd
if cxtcrnalcause$
wcrc inrol*d.
AnotherFormatOption(wouldbe coded as SIDS)
This would be codedas SIDS
Part
I
^
Sudden Unexolained Infant Death
associated with bedsharino with adults
O T H E RS I G N I F I C A NC
TO N D I T I O N S
tsan
II
Undetermined
AnotherFormatOotion(wouldbe
erc involved.
:11"1""1o:
l
Stressors....
.
.
.
.
.
.
.
.
.
.
Bedsharing
Unsafe or soft sleep surface (if found face down)
Previous unexplained infant death of sibling
E x c e s s i v eb l a n k e t i n go r w r a p p i n g
Face down position when found
Intoxication (defined as detection of a substance in
infant's system)
Abrupt change in sleep position
Abrupt change in sleep location
Abrupt change in sleep surface
Injuries ofunknown significance (specifying the type)
In many settings, after investigation and autopsy, SIDS-like deaths account
for about 53% of infanl deaths, and 70% ofthose have gray zone findings.
22
lnadequateInvestigation
Not SIDS: But no cause identified after complete investiqation
"in
^
tin
Unexpectedand UndeterminedCause
^
Unclassified Infant Death
OTHER
SIGNIFICANT
CONDITIONS
Pan
u
I Undetermined if external cruss were involvcd.
I Found dead ia bassin€s€. No autoDsv was Derformed
Undetermined
Would NOT be coded as SIDS
Gomplications
of Treatmentor
Diagnostic
Procedures
o
Category of Complication or Outcome
Suggested Manner
l. Malfunction of(or a defective) medical devicq tool, or
diasnostic/theraDeutic asent (malfunctionins thermostal)
Accident
2. Itrconet use ofa medical deyice, tool, or
diagnostic/theraDeutic asent (wrons dore of drus)
Accident
3. Rarely occuring complication with a reognizd
untoward Dotential (anaDhylaxis after dye)
Variable*
4. Utranticipated complication oigating wroDg artery)
Variable*
5. Reasonably anticipated outcome of a indicated medical
ther.Dv or Drocedure (disoxitr ioxicitv)
Natural
6. InhereDt and accepted risk ofan invasive procedure or
surgery (yery ill and can't wean from pump)
Natural
7. Nonspecific strEses ofr procedure or therapy
(high risk patient who di6 during hip replacement)
Natural
8. Periprocedural death not otheryise classilialrle
(healthy man di6 during henia reDairi no caus)
Undetermined
O'*'-":l?;["Tft.;mfi:Pds'ondjdsmdbdd
"in
tin
^ Bilateral pneumothoraces
^ Digoxlntoxicity
Deb.daa6iea*ed
Treatment of refractory heart failure
, Complicationof ventilatorysupport
Delo a6adqe@d
Chronic ischemic heart dlsease
Pneumocystispneumonia
to.b
orrsadneQdedl
Acquired immune deficiency syndrome
Pail
II
Mmdol
)an
tl
OTHERSIGNIFICANT
CONDITIONS
D.dh
Natural
Descdb
I
How lnjnry&e'rd
Natural
23
'ad
^ Pseudomonasburnwoundsepsis
, Cutaneousscald burns
, Whirlpool therapy for leg contractures
Complications of cerebrovascular stroke
turdof&db
lhcnbUNltriu*Occud
ACCident
waterin a whirlpool.
I Scaldedin overheated
I
o
C o n s i d earl lo f t h e s e . . . .
.
.
.
.
Ageand underlying
condition
of patient
Was the procedureelective?
Emergentnatureof the procedure
Inherentdifficultyand reasonablyknown
risksof the procedure
. Acceptability
of the untowardoutcome
-TerminalEvents-Nonspecific
Processes-Mechanisms-
These issues have to do with manner of death classifi€tion.
Regardless ofthe manner, be sure to include the complication in
the Cause-of-Death Statement.
o
"Mechanisms" of Death
O
For the Cause-of-DeathStatement:
NO Terminal Events should be used
. TerminalEvents
(e9.,asystole,cardiopulmonaryarrest)
. NonspecificAnatomic Processes
(e9.,cirrhosis,DAD,peritonitis)
. NonspecificPhysiologicDerangement
(e9.,hyperkalemia,
hypoglycemia)
o
dissociation
OK to use if certain conditions are met:
. Nonspecific Anatomic Processes
. Nonspecific Physiologic Derangements
o
24
&s@ss
Abdomlnal
khesions
hemorhag€
I Carclnomatosis
| Cadiac dy3rhythmia
lcardiomyopathy
ftult
ultrospiratorydistr€ss
rospiratorydistr€ss lCellulitis
I Cellulitis
svndrome
| &rsbral dema
kute
my*ardial
Atered mental status
tu€nia
tuoxla
tuoricencephalopathy
I Cerebrovascular accident
Cerehllartonsillar
I hemiation
bdridden
state
I Chronic bedridden
lclrrhosis
I Disseminated intra
I vascular
I coasulopalhy
GeneralRules:
lDyErhythmla
I End-staoeliver di*rse
lnclude NAP or NPD in GOD Statement if:
. lts a recognized potentially fatal complication
of the underlying cause of death
. lts NOT a symptom or sign
. lt was involved in the cause of death
sequence in the case in question
. lts existence in the patient would not be
known unless reported in the COD statement
. lts inclusion is not an oversimplificationor
redundant
. A specific underlying cause is also reported
I Ehd-stage renat disase
lEDiduralhematoma
Exsang!ination
t thrive
II Failure to
lFractur€
Gangrene
lGastrointestinal
I hemorrhage
I Haad failuro
I HemothoEx
I Hepatic failure
Hepatitis
II Hepalitis
| Hepatorenalsyndrcme
Aspiration
Atrial fibrillation
Bacteremia
&dddden
Biliary obstruction
Bowelobstruction
lbasulopathy
&mDresstontractur€
Congestiva head hilure
I Cohwlsions
I Decubiti
I D€hydration
hmentia
(wheh
I &mentia
{when not
I otheruise srifid)
lDiarrhea
Braininjury
|
HyFrulyemia
lHyrrkalemia
|
| Hypvolemlc
Arrhythmia
Erain stem herniation
shock
...ptus many more
Nonspecific Processes and Derangements (M&hanisms)
O
These need to have an g!ggl!y!!g
cause reported.
o
An example:
Possiblecandidatesfor the DC
History:
A chronicalcoholicdeveloped
cirrhosis,portalhypertension,
hyperammonemia,
hepaticcoma,
asterixis,respiratoryarrest,and
thenasystole.
.
.
.
.
.
.
.
.
o
a
Applying the rules....
'-nSyStete-
Oneway to do it....
Pad I
TerminalEvent
@Terminal
. Hepatic encephalopathy
!4lrperclmmeFemia-rA€*€fD€i*
Event
a.
Hepatic Encephalopathy
b. *",
Portal hypertension
c. o*", Cirrhosis of liver
tmplicit
d. "*", Chronic alcohol abuse
Sign
Pad tr
. Portal hypertension
. Cirrhosis
. Ghronicalcoholabuse
o
Asystole
Respiratoryarrest
Hepaticencephalopathy
Hyperammonemia
Asterixis
Portal hypertension
Cirrhosis
Chronicalcoholabuse
osc:
O
25
Another way to do it....
Pad I
a.
Hepatic Encephalopathy
b. "*", Cirrhosis of liver
c. ,,"", Chronic alcohol abuse
O, o*o
-Queries-Amendments-SupplementalReports-
Pad II
o
Queriesby Registrar
o
Amendments
& Supplements
[Changesl
. Registrar contacts Certifier
. To verify DG accuracy or obtain
missing information
. Extent of queries vary
regionally
. lf you are queried,you should
respond promptly
a
!.Jpdaiing a Pending Recordl
Certifier:
. Writes to registrarspecifying needed
changesor updates(in a pendingcase)
FuneralDirectoror Nextof Kin:
. A specific form is used
. Documentaryevidenceis required
. A fee is chargedfor the process and for
each new copy ofthe correctedDC
a
An
ldea
a
26
The "HospitalGertifier"Goncept
Mostare Easy....
ffi*@f=oc
o
l
@HW
o
"in
Some
Final
Examples
^ Uppergastrointestlnalhemorhage
touB
kb,d$.ffiq€md
, UndetermlnedNaturalCause
Db b, d 6 ,6qE@
d
DEb,d6rco|wd
Part
II
Ddb
How
Injq
&c@d
Natural
Making Natural Causes Evident
t?n
^ Upper gastrointestinal hemorrhage
tos b or r. a MeQme
d
. Presumedgastric ulcer
0Fb
"i*
Hours
. Probableberryan€urysm
Daysto
DEb,d6€d5€@ol
0u.b dasa6iee*.ol
OTHERSIGNIFICANT
CONDITIONS
HouF
DEb,d6r6E@.d
c6ac(,rj.Grol
Part
II
" NontraumaUc subarachnoid hemorrhage
oue b, d as a onseffi
d
Part
II
Dcnnh Ilow lnjury&ord
Natural
D.*db
How rnjq
Gc&d
Natural
Let the history guide you
Let the history and medical knowledge guide you
27
tin
Part
Pneumonia
, Cerebralcontusions
5 days
. Blunt force trauma of head
5 days
, Motor vehicle collision
5 days
Mm.rof
4 yeaF
Humanlmmunodefi
ciencyVirus infection I
y€re
pneumonia
Intravenous
druguse,pneumocystis
I esihHwbjqkd
I Unrestraineddriver of sportsutility vehicle thal
I left the roadwavand srrucka tree .
Accident
ffi;
lh6hnwhiqc.*d
Part ll contains a risk factor and other sequel of HIV
Part ll contains other significant injuries
"in
. AcquiredlmmuneDeficiencySyndrome
Parl
II
Multiple
skullfraclures,subdural
hematoma
hrb
2 w6k
OTHERSIGNIFICANT
CONDITIONS
OTHERSIGNIFICANT
CONDITIONS:
Part
tr
Cryptococcal myocarditis
3 days
"ln
, Pyelonephritis
, Recurrent E coli bladder infections
2 yeaB
,
3 years
Indwelling urinary catheter
Perforating injury of head and brain
Minute!
, Contact gunshotwound of head
Muliiple sclerosis
OTHER
SIGNIFICANT
CONOITIONS
OTHERSIGNIFICANT
CONDIIIONS
Pan
n
Pad
n
Aspirationpneumonia
gastriccancer
Clinicalhistoryol depressiol metastatic
Derb
H@ b!ry edd
I
;;t'*t
lk;b'Nhtsrycdftd
Sequential history is evident by reading the cause
Pad
I
^
I Shotselfin headwith 38 caliberrevolver
SUiCide
Appropriate to include psych conditions and possible medical reasons
"i"
Oxycodone poisoning
Asphyxia
Ho!rs
Overmedication of degenerative disc disease
Days;
OTHERSIGNIFICANT
CONDITIONS:
Pad
n
Analgesicdependency
M.nnc'ofDcdh
lD.$nh.ENt'iurGcumd
ACCident
prescribedmedication.
I Took excessive
t
'
Specifiesunderlyingcause,acute poisoning,drug dependency
tr
Acutealcoholintoxication
Mini.rorD.5rh
ID.dkHovhjuryoauftd
Accident l:**gl*::::::::fl::*l::,"'r"..
Risk factor in Part ll
28
tin
"in
Intra-abdominalhemorrhage
, Bronchopulmonaryarterytistula
Delayedrupture of contused spleel
' Blunt force injury of abdomen
Fall from height
, Bronchopulmonaryhemorrhage
'
5 days
Squamouscell carcinoma, left lung
5 days
OTHERSIGNIFICNT MNDTNNS:
Ofr ERSIGNIFICANT
CONOITIONS
Pad
I
tr
&S&
Md\F,
Houts
or hh
e$,h
HN
Natural
Accidenrl)Yl:**:--{':l"ll"-l.o-1".:1T1"j1.:'j::"c'*d
Immediate,Intermediary,UnderlyingCause;SequentialPart I Format
Fatal derangement,bodily injury, injury event
"1n
llow bj!ry ftd
b,ry()ffid
I
Metastaticcarcinomaof prostate
l0 yean
ContactPoints
Randy Hanzlick,MD
Chief Medical Examiner,Fulton County, GA
Professor of Forensic Pathology
Emory School of Medicine, Atlanta, GA
II
Miiu
of &dh
De$dh
Hs
h!ry
tuud
I
Natural
I
Single Line Part I Format
430PryorSt SW
Atlanta,GA 30312
404-730-4400
randy.hanzlick@co.fu
lton.ga.us
o
29