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Medical Cause of Certification of Death

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Slide 1:

District Programme Management Unit National Health Mission MCCD Dr. Anil Kumar. Korrapati

Intro:

Intro Mortality statistics is an integral part of vital statistics system. “Death certificates” shall provide perfect data regarding the health status of a community, state and country. Scientific evaluation of health trends, mortality rates, prevalence of diseases and causes of un-natural deaths are by large based upon the documentation of “ cause specific death certificates”.

Background:

Background Medical certification of cause of death “MCCD” was advocated by the Registrar General of India “RGI” as a scheme to implement the compulsory registration of births and deaths, under the registration of birth and deaths Act 1969, as “RBD Act.1969 .

Review:

Review The documentary record of cause of specific death in tabulated format “Form No.4/4A was introduced in early eighties. The scheme was implemented by all states by bringing all “govt. and private”, nursing homes, maternity homes, clinics, private medical practitioners under one umbrella in rural and urban areas. A physician manual was devised on 13 th of January 1983 and was circulated among all health Directorates of state governments for effective implementation of MCCD scheme in phased manner.

Why MCCD???:

Why MCCD??? Key indicator to evaluate the health status of the country/state Information from death certificates is used to measure the relative contributions of different diseases to mortality .

Need of MCCD:

Need of MCCD Reliable cause-specific mortality statistics is required on a regular basis by Administrators, Policy Planners, Researchers and other Professionals for evidence-based decision-making with regard to resource allocation , monitoring of indicators, identifying the priorities for programs and other related activities in the area of Public Health .

Why MCCD???:

Why MCCD??? Statistical information on deaths by underlying cause is important for monitoring the health of the population, designing and evaluating public health interventions , recognising priorities for medical research and health services, planning health services , and assessing the effectiveness of those services.

Why MCCD???:

Why MCCD??? Death certificate data are extensively used in research into the health effects of exposure to a wide range of risk factors through the environment, work, medical and surgical care, and other sources.

Why MCCD???:

Why MCCD??? Prevalence of the disease MCCD shall provide a data regarding the unnatural death as result of natural calamities like earth quakes. The rising trend to increasing trend of suicides , homicides , and accidents leading to increasing mortality and morbidity.

Why MCCD???:

Why MCCD??? Assessing the effectiveness of public health related schemes. MMR/IMR will be reduced effectively by way of suitable implementation of the MCCD. Future planning in health related issues. Research work

Legal Issues…:

Legal Issues… Compulsory registration is an integral part of RBD Act 1969 Under Section 10-(2) for certification of cause of death form 4A shall be available from the registrar Births and Deaths The copy of the abstract of the death certificate / birth certificate shall be disbursed to the applicant on request after payment of nominal fee/postal charges.

Legal aspects…:

Legal aspects… Section 10- (3) deals that a RMP attending the terminal illness of an individual for not less than 48 hours; when the case remains undiagnosed, cannot be compelled to issue the requisite death certificate. In all these case , autopsy becomes mandatory. In case where the exact diagnosis of the death is made, the RMP has no choice than to issue a certificate on Form 4/A. The body cannot be retained for want of payment of dues once the cause of death has been established. All the undiagnosed cases are required to undergo post mortem. The increasing trend in giving exemption to these cases by the executive magistrates also effects the validity of the death report.

Legal Status…:

Legal Status… Reportable deaths …………..all deaths are to reported for autopsy under Section 174 and 176 Obscure deaths or indeterminate cause of death ( 0.5 to 5%) ………………..exact cause not established Pending report cases …………..the I/O is required to make further investigation in order to establish the possible/probable cause

Death certificate:

Death certificate It is important document for the next kin's of the deceased an documentary evidence in the court of law ; particularly in with connection with medico-legal cases. To be issued on form No, 4/4A of the MCCD Scheme. The statistical wing of the municipality etc. shall issue the valid certificate. MCCD scheme are coded and grouped according to “ TENTH REVISION OF INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES ( ICD-10) RECOMMENDED BY W.H.O The Medical Superintendent under MCCD is required to avoid issuing death certificates. Instead of issuing death certificates; only information regarding the time and date of death should be given to the applicant with the directions to get the death certificate from the statistics division of Municipality

Slide 21:

Thanatology is the branch of medical science dealing with the study of death. or The scientific study of death, dying and bereavement or In other words it means the subject which deals with scientific study of death, types of death, the various events or changes that occur in the cadaver and their medicolegal significance. TO LIVE WITH DIGNITY IS THE FUNDAMENTAL RIGHT OF AN INDIVIDUAL. RIGHT TO DEATH OR EVEN THE RIGHT TO DIE WITH DIGNITY IS NOT THE FUNDAMENTAL RIGHT OF AN INDIVIDUAL. Study of death

Study of death:

Study of death The diagnosis of death is a difficult task and sometimes may be embarrassing for the medical fraternity. With the advent of ventilators , heart lung machines and other life saving devices, the issue of declaration of death has become more perplexed . To add more fire to the medical practitioners ; The Human Organ Transplantation Act of 1994 , the declaration of death is complex and the doctors have become more focussed and tend to declare the death time after a delay…………… PLAY SAFE

Signs of death:

Signs of death For medico-legal purposes; death is defined as Complete Permanent Perfect Persistent and Irreversible cessation of functions of the tripod of life i.e. three vital functions of body BRAIN, HEART AND LUNGS The signs of death can be classified as Immediate changes Early changes Late changes Remote changes

Types of death:

Types of death Somatic, systemic, or clinical Molecular

Somatic death:

Somatic death WHEN THE THREE TRIPODS, BRAIN, LUNG AND HEART STOP COMPLETELY, IT IS CALLED SOMATIC DEATH. SALIENT FEATURES ARE:- The person irreversibly loses its sentient personality Unable to be aware of (or to communicate with) it’s environment Unable to appreciate any sensory stimuli Unable to initiate any voluntary movement

Molecular Death:

Molecular Death WHEN INDIVIDUAL TISSUES AND CELLS DIE, IT IS TERMED AS MOLECULAR DEATH. SALIENT FEATURES ARE:- State in which the tissues and their constituent cells are dead They no longer have metabolic activity It follows ischemia and anoxia upon cardio respiratory failure Is a process, not an event? Different tissues die at different rates. It occurs piece meal, e.g . nervous tissue die rapidly, say within five minutes, while muscles survive up to about 3-4 hours after somatic death when the individual cells and tissues start dying and the decomposition signs start showing.

DIAGNOSIS OF SOMATIC DEATH IS NOT ALWAYS EASY IN THE FOLLOWING CONDITIONS:- :

DIAGNOSIS OF SOMATIC DEATH IS NOT ALWAYS EASY IN THE FOLLOWING CONDITIONS:- Soon after death when the body is likely to be warm Suspended animation Coma following excessive doses of sedatives or hypnotics especially barbiturates Hypothermia, particularly in elderly Electrocution and lightning accidents Drowning particularly in cold water The distinction between Somatic and Molecular death is important for two reasons:- Disposal of the body Transplantation

Late signs:

Late signs Appear along with the progress of the early signs, till the disintegration of tissues, resulting in putrefactive changes in the body. The modification of the like mummification and saponification are also significant changes which depict the late signs of the death during two weeks or so.

Remote signs:

Remote signs After 2 weeks after death, signs lead to gross disfiguration, disintegration, fragmentation and skeletonisation of the body are essential landmarks for giving time since death since death after two weeks

Physician’s responsibility:

Physician’s responsibility

Physician responsibility:

Physician responsibility The RMP has to play an important role in certification of death, before the format No, 4 of the MCCD is filled up. The death certified so compiled on the format is to be send to the Registrar Births and Deaths through the MS of the hospital in hospital deaths or private institutions, the same is send in Form 4/A by utilising his/her own resources. The physician is primarily responsible to complete the medical part of the certificate making it clear that the disease or any unnatural circumstances which led to the death, are to be clearly entered in the form No.4 Form No4/A. The cause of death are classified, code and grouped according to the “ TENTH REVISION OF INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES ( ICD-10) RECOMMENDED BY W.H.O

Method of certification:

Method of certification Certification of death document is an important document to be filled as per Form No,4/4A of MCCD Scheme. This standard format is to be filled as per the State rules. It is to be filled by the RMP after declaring a person dead, once the cause of death is established. The cause of death are as result of disease (natural death) or resulting from any other abnormality other than disease, like violence, poisoning or similar other conditions which contribute directly or indirectly to the death of an individual. (unnatural causes) Death often result from the combined effect of two or more conditions. In many cases, the conditions may be completely unrelated and may give rise to a new third condition.

Codes of diseases:

Codes of diseases According to ICD-10, the following codes are allotted Infection and parasitic diseases --- A00-A09. Tuberculosis A15 – A19. Zoonotic bacterial diseases A 20-A28 Bacterial diseases A30-A49. STD A50-A64. NOTE: THE LIST IS LONG

Forms of certification:

Forms of certification To be filled as per the guidelines laid down by WHO i.e. Form 4/4A In institutional deaths, Form 4 In non institutional deaths, Form 4 A

Slide 35:

CASE HISTORY On 03.01.1977, a 60 year old female was admitted with a “strangulated Femoral Hernia” which had started 4 days earlier. She came complaining of abdominal pain and fecal vomits. Apparently, the small intestines were perforated even before. On 4th January, she underwent a release of hernia and the recession of the intestines, with an end to end “ Anastomosis ”. On 5 th January, she started developing signs of “peritonitis”, and following that dies on 14.01.1977. 9/9/2015 Dr.Anil Kumar. Korrapati

Cause of death:

Cause of death A cause of death is disease, abnormality, injury or poisoning that contributed directly or indirectly to death . A death often results from the combined effect of two or more conditions. These conditions may be completely unrelated, arising independently of each other; or they may be casually related to each other, that is, one condition may lead to another, which in turn leads to a third condition and so on

Slide 38:

Where there is a sequence, the underlying cause, i.e., the disease or injury which initiated the sequence of events will get selected for the purpose of tabulation.

Slide 39:

The underlying cause of death is: (a) The disease or injury which initiated the train of morbid events leading directly to death; Or (b) The circumstances of the accident or violence which produced the fatal injury. All these morbid conditions or injuries consequent to the underling cause relating to death are termed as antecedent and immediate cause.

Form of medical certificate:

Form of medical certificate

Slide 41:

PART – I OF THE CAUSE OF DEATH STATEMENT Only one cause is to be entered on each line of Part I. The underlying cause of death should be entered on the lowest line used in this part. The underlying cause of death is the condition that started the sequence of events between normal health and the (direct) immediate cause of death .

Line (a): Immediate cause:

Line (a): Immediate cause The direct or immediate cause of death is reported on line (a). This is the disease, injury or complication that directly preceded death. It can be the sole entry in the statement if only one condition was present at death. There must always be an entry on line (a).

Immediate cause:

Immediate cause The mode of dying (e.g. heart failure, respiratory failure ) should not be stated at all since it is no more than a symptom of the fact that death occurred and provides no useful information. In the case of a violent death, enter the result of the external cause (e.g. fracture of vault or skull, crushed chest).

Immediate cause:

Immediate cause The mode of dying e.g. Coma, Syncope and Asphyxia should not be stated as cause of death because it is no more a cause but a symptoms of the fact that occurred and provides a layman information only.

Slide 45:

The sequence of events between normal health and the death should be given as, DIRECT, IMMEDIATE AND EXACT CAUSE OF DEATH. The direct or immediate cause of death is to be reported on line (a). This is exactly the disease, injury, poison or any complication which directly proceeded the death . In majority of cases it can be the sole and ; one entry in the statement, if one condition terminating life was diagnosed at the time of death. As such, the entry on line (a) should be made carefully giving the exact cause of death.

Line (b): Due to (or as a consequence of):

Line (b): Due to (or as a consequence of) If the condition on line (a) was the consequence of another condition, record that in line (b). This condition must be antecedent to the immediate cause of death , both with respect to time and etiological or pathological violence or circumstances of accident is antecedent to an injury entered on line (a) and should be entered on line (b), although the two events are almost simultaneous (e.g., automobile accident, fall from tree). An antecedent condition might have just prepared the way for the immediate cause of death, by damage to tissues or impairment of function, even after a long interval.

Antecedent cause_line {b}:

Antecedent cause_line {b} In line (b) the record is made as the antecedent cause to the immediate cause of death regarding the underlying cause or the resultant pathology or a sequence to the cause mentioned on line (a ). Although the two events are almost simultaneous, the Medical Officer/ RMP is required to specify the actual cause of death as mentioned in the line (a) subsequent to the specific entry made of the existing fact in line (b).

Line (c) ::

Line (c) : The condition, if any which gave rise to the antecedent condition on line (b) is to be reported here. The remarks given for line (b) apply here also. If the condition on line (b) is the underlying cause, nothing more be entered on this line. However, if the sequence of events comprises more than three stages, extra line (and entries) may be made in part I .

Line c:

Line c An antecedent condition might have prepared or precipitated the way for the immediate cause of death. In line (c) the condition if any which resulted to the antecedent condition on line (b) should be reported if so found. The remarks given for line (b) apply here also. If the condition on line (b) is the underlying cause, nothing more is required to be entered on this line. In case the sequences of events comprise more than three stages, extra line/ entries may be made in part-I of the statement . When many conditions are involved, full sequence i.e. starting from normal healthy condition to the last.

Line c:

Line c However, many conditions are involved; write the full sequence, one condition per line, with the most recent condition (immediate cause) at the top, and the earliest (the condition that started the sequence of event between normal health and death) last.

Slide 51:

Normally the condition or circumstance on the lowest line used in part I will be taken as the basis for underlying cause statistics, though classification of it may be modified to take account of complications or other conditions entered by special provisions of the ICD.

PART-II OTHER SIGNIFICANT CONDITIONS:

PART-II OTHER SIGNIFICANT CONDITIONS Enter, in order of significance, all other diseases or conditions believed to have unfavorably influenced the course of the morbid process and thus contributed to the total outcome but which were not related to the disease or condition directly causing deat h.

PART-II OTHER SIGNIFICANT CONDITIONS:

In certifying the causes of death for Part II, any disease, abnormality, injury or late effects of poisoning, believed to have adversely affected the decedent should be reported, including: • Use of alcohol and/or other substances. • Smoking history. • Environmental factors, such as exposure to toxic fumes, history of working in the some specific industry , professional exposure to toxins , specific animals etc. • Recent pregnancy, if believed to have contributed to the death. • Late effects of injury, including head injury sequelae • Surgical information, if applicable. • Any iatrogenic underlying cause. PART-II OTHER SIGNIFICANT CONDITIONS

INTERVAL BETWEEN ONSET AND DEATH:

INTERVAL BETWEEN ONSET AND DEATH Space is provided, against each condition recorded on the certificate for the interval between the presumed onset of morbid condition and the date of death . Exact period should be written when it is known; in other cases approximate periods like “from birth”, “several years” or “unknown” should be indicated. This provides a useful check on the sequence of causes as well as useful information abut the duration of illness in certain diseases.

INTERVAL BETWEEN ONSET AND DEATH:

INTERVAL BETWEEN ONSET AND DEATH The space is mentioned in this column against each condition recorded on the certificate, for the interval between the onset of the morbid condition and the hour and date of death. Exact period should be mentioned as per the history and other observations made regarding the various post mortem changes after death. Specific changes i.e. early changes ---- within 2hours, from two days to two weeks-----late changes and after that remote changes in the form of disfiguration, dismemberment, skeletonisation are seen in the body.

Manner of death:

Manner of death At the middle of the Form 4/4A, specific column have been included to specify the manner of death i.e. Suicidal Homicidal Accidental Natural Pending investigation Information regarding death due to pregnancy in case of child bearing age in women to be mentioned. Even if the pregnancy is not related; death should also be mentioned in the relevant column.

Slide 57:

Accidents If suicide or homicide is ruled out, how the fatal injury occurred should be explained indicating briefly the circumstances or cause of the accident. In case of medico-legal cases, the certificate has to be given by the police authorities. However, the Registrar should be informed of such cases, by the hospital.

Slide 58:

Female death Information on pregnancy and delivery is needed in case of death of women in the childbearing age (15 to 49 years) even though the pregnancy may have had nothing to do with the death.

Status of implementation in AP:

Status of implementation in AP Rank 19 % of deaths recorded as per MCCD 16-9 Number reporting as per MCCD 618/3978

Status of implementation on AP:

Status of implementation on AP

The THM . . .:

The THM . . . Ensuring completeness of information

Slide 63:

TAKE HOME MESSAGES Form 4 should be filled by the Registrar in case of institutional death. H.O.D’s should keep a constant watch DAS/P’s should ensure the proper filling of the forms and duly countersigned by the specialist/CMO’s Filling of the Forms by Chowkidars /grave yard/cremation people should be banned. RMP’s of the concerned area should be assigned this job. All suspicious death should go autopsy procedure. The current practice of exemption by the executive magistrates should be discouraged. Training/Orientation of all health related persons. No death certificate to be issued by the Physicians/RMP’s MCCD scheme should be implemented under the guidance of Department of Forensic Medicine & Toxicology

Coming back:

Coming back CASE HISTORY On 03.01.1977, a 60 year old female was admitted with a “strangulated Femoral Hernia” which had started 4 days earlier. She came complaining of abdominal pain and fecal vomits. Apparently, the small intestines were perforated even before. On 4th January, she underwent a release of hernia and the recession of the intestines, with an end to end “ Anastomosis ”. On 5 th January, she started developing signs of “peritonitis”, and following that dies on 14.01.1977.

Slide 65:

Statement PART – I (a) Peritonitis, acute - (b) Perforation of small intestine – 12 days (c) Strangulated Femoral Hernia – 15 days PART-II …………………………………….

Slide 66:

Explanation: Clearly, acute peritonitis led directly to death and therefore appears on line (a). Perforation of small intestines gave rise to the immediate cause shown in line (a) and therefore , appears next in line (b). Strangulated Femoral Hernia was the cause of intestinal perforation and was the cause which initiated the chain of events leading to death and this is the underlying cause which is written on line (c).

Slide 67:

A man of 63 year had been treated for some years for malignant hypertension and developed hypertensive heart disease and chronic renal failure. While seriously ill with the heart condition, he developed acute appendicitis, and the appendix ruptured. Appendicectomy was carried out successfully but the heart condition deteriorated further and he died 2 weeks later.

Slide 68:

Statement PART – I (a) Congestive heart failure (b) Cardiac hypertrophy _ 2 weeks (c) Malignant hypertension _ Some years PART-II Appendicectomy for acute condition and rupture of appendix, hypertensive renal failure.

Slide 69:

On 14.01.1976 an old man slipped on same level and fell down, resulting in fractures . After being admitted for care, fractures of the left Ischium and Ilium were reduced The patient then suffered from Azotemia , general arteriosclerosis, arteriosclerotic heart disease and pulmonary emphysema . He developed “Bronchopneumonia” on 15th February and died 6 days later. Autopsy revealed also fractured hip and pelvis, cardiac hypertrophy , chronic fibrous myocarditis and coronary sclerosis.

Case study:

Case study Statement PART – I (a) Bronchopneumonia-6 days (b) Fracture of left Ischium and Ilium-7 days. (c) PART-II Arteriosclerotic heart with coronary sclerosis.

Slide 71:

Explanation: Bronchopneumonia is certainly the immediate cause of death. The fracture of left Ischium and Ilium Arteriosclerotic Heart Disease with coronary sclerosis were no doubt, significant conditions contributing to death and are therefore given in part II.

Slide 72:

Thank Q

Slide 73:

References Physicians Manual MCCD_ GoI , Office of Registrar General THE ANDHRA PRADESH REGISTRATION OF BIRTHS AND DEATHS RULES, 1999 = DoPH&FW , Vijayawada

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