Death Certificates... a Quandry

[Daiphon]

So, I'm gonna leave this to the collective groupthink of the SDN interwebs.

A patient comes in in full cardiopulmonary arrest. ACLS ineffective, and code called... exempting coroner's cases (after they clear it), what does everyone put in as the proximate cause?

Now, if the patient is known to the center, then 1) we can frequently infer history, and 2) turf the death certificate to the PMD or primary service.

But, in cases where the patient isn't known, given that "cardiopulmonary arrest" cannot be a proximate cause of death, what ought one put in that is sufficiently legitimate without opening a can of medicolegal worms?

e.g. I don't want to list "arrhythmia," as the post (if there is one) may show a PE or some other problem that would be incongruous, and thus open up liability.

Heretofore, hasn't been an issue, as hospital leadership has been primarily responsible for ED-based death certificates... but, new team is reversing this policy.

Just curious... and sorry for the long post.

Cheers!
-d


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[Apollyon]

What liability would there be, if, on PME, there is a PE? I don't think that any suit would have any chance, as long as you ACLSed the patient (and a big screw you to the people that might say something about ACLS - while you are thinking on your own, how about a milligram of epi?).

I recall a pt that came in when I was training at a new place (becoming accustomed). She had a cancer diagnosis, and didn't bleed when she was stuck. I said to the guy in charge that I bet she had a PE. No autopsy, so I don't know, but it was logical.

However, I don't know how an unknown patient can so easily be discounted from a coroner case. If family is there, they can say what past hx there was or wasn't. From that, you can infer. Lacking anything, then you are left with the most likely (and VERY likely) cause - arrhythmia. If the pt isn't getting a PME, what risk is there? If you did have such questions, then you could posit it to the coroner that the cause of death is unclear, and you can't be sure it's not suspicious.

I am thinking the idea as such: if the pt is going for autopsy, I am not entering a cause of death, only a time declared. If I, in the ED, have to put a presumed cause, then the pt is not getting an autopsy. So, this could be a quirk of death certificates in your state (I am familiar with NY, NC, SC, and HI), or I just don't see the question.

 

[southerndoc]

We don't complete death certificates in our health system. If the patient has a PMD, cardiologist, pulmonologist, etc., then they complete them. If not, then the ME's office completes it (even if the patient isn't cased).

 

[docB]

I will limit my rant as I could spew bile on this issue for a long time.

Here in Clark County, Nevada our coroner fought an won a legal battle with all of the EPs about signing death certificates. He has fixed it so we are now legally mandated to sign them.

We all put cardiopulmonary arrest cause unknown for all of them. The unknown part just started last year per some silly CDC program. So now all the funeral homes require the "unknown" to be added. We never have autopsy results so it's always unknown.

The reason we should not be signing these things has nothing to do with medicine. I'm happy to say someone is dead. My issue with a death certificate is the question of who it is that's dead. The reason doctors traditionally signed death certificates is that a person's family doctor would have known them for years and been able to identify them based on scars, lesions, etc. No EP has this knowledge of their patients. So the identification is made by our admitting clerks. And that's based on whatever documents are found on the person. I've seen people identified by junk mail with a name and address found on them. I'll say there's a dead body. The coroner needs to figure out who they are.

 

[Apollyon]

I will limit my rant as I could spew bile on this issue for a long time.

Here in Clark County, Nevada our coroner fought an won a legal battle with all of the EPs about signing death certificates. He has fixed it so we are now legally mandated to sign them.

We all put cardiopulmonary arrest cause unknown for all of them. The unknown part just started last year per some silly CDC program. So now all the funeral homes require the "unknown" to be added. We never have autopsy results so it's always unknown.

The reason we should not be signing these things has nothing to do with medicine. I'm happy to say someone is dead. My issue with a death certificate is the question of who it is that's dead. The reason doctors traditionally signed death certificates is that a person's family doctor would have known them for years and been able to identify them based on scars, lesions, etc. No EP has this knowledge of their patients. So the identification is made by our admitting clerks. And that's based on whatever documents are found on the person. I've seen people identified by junk mail with a name and address found on them. I'll say there's a dead body. The coroner needs to figure out who they are.

I daresay that such a definitive statement isn't true. Who told the story in the "Things I Learn From My Patients" thread about a patient coming in, again, to the ED, after having been struck by a train a second time? Although mangled, she was affirmatively identified by scars from previous suicide attempts. Here it is, from 7 years ago.

Some nearly 20 years ago, in the city in which I worked EMS, a frequent flyer, who was also a frequent pain to the police, was found dead, frozen in the river, on the riverbank. The scuttlebutt was that the police had killed him. He had no family, but a paramedic that worked nights exclusively was called, and made a positive identification at the morgue, having transported this fellow for what seemed to be infinite times.

I can think of at least one guy that I would be able to affirmatively ID if I was called to do so after he coded, just from being a frequent flyer.

 

[deleted109597]

Death certificates fall under the "Not my job" problem.
No PCP? The ME gets to fill it out.

Although the PCPs are sometimes comical. Sometimes the nurses ask me to call them because "they aren't comfortable" or whatever bull**** nursing reasons they always have for not doing something they don't want to. So I've got this guy on the phone, and he keeps asking me "well how did the patient die?"
My response, after the third time they asked that was "because obviously their primary care provider didn't know anything about their medical problems." I expect a nasty letter from that one eventually.

 

[Daiphon]

Death certificates fall under the "Not my job" problem.
No PCP? The ME gets to fill it out.

I agree that they oughtn't be my job... but my Coroner (not even an ME) in cook county says "not gonna do it."

So it falls to us if the case is passed on by the coroner; hospital can't release a body w/o the stupid form.

Although the PCPs are sometimes comical... he keeps asking me "well how did the patient die?"

My response, after the third time they asked that was "because obviously their primary care provider didn't know anything about their medical problems." I expect a nasty letter from that one eventually.

I just shot my beverage out my nose. d=)


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[Cerberus]

Interesting discussion. Mostly because I thought the pronouncing physician always did the death certificate (as we do at my hospital).

 

[Rendar5]

Interesting discussion. Mostly because I thought the pronouncing physician always did the death certificate (as we do at my hospital).

That's NY for yah Cerb. I always had to fill them out when I was in residency.

 

[Cerberus]

That's NY for yah Cerb. I always had to fill them out when I was in residency.

Yup. I do love getting hassled by admitting for the death certificate that has to be done right now so they can release the body (thankfully as a resident this only happened on floor months since attendings do it in the ED...unfortunately I'll be an attending in NY next year).

 

[VienneseWaltz]

Our instruction from the ME is to write ASCVD for COD when we don't know, which is always. What's awesome in my state is that we have to fill out a DC even when the patient is getting an autopsy. That makes sense, right? The very nasty people in the admitting office play hardball when we refuse and leave the body until someone signs it. One of them tried to make me sign one on a patient who expired an hour before my shift started because, well I was there now (the family had later decided on an autopsy, invalidating the first DC signed by my colleague). Eventually, I got hold of a supervisor with a brain who sent someone to get the body.

I could rant about the ME and all the stupid rules for hours.

 

[deleted65604]

I don't get it. What is the big deal about signing a death certificate? Cardiopulmonary arrest... Whose heart doesn't stop beating at death?

 

[deleted109597]

Really? ASCVD? In Bal'mor?

I would think "crack overdose" would work just as often. Or "high velocity lead poisoning."

 

[VienneseWaltz]

Jar, cardiopulmonary arrest is a mechanism of death, not a cause, and we can't use it as COD, precisely because it applies to basically everyone.

 

[docB]

I don't get it. What is the big deal about signing a death certificate? Cardiopulmonary arrest... Whose heart doesn't stop beating at death?

It's like I said, I'm fine diagnosing dead. I shouldn't be signing a document that puts a person's estate in probate and bestows insurance money on their beneficiaries without someone besides my admitting clerk saying who they are. As is it's based on rifling through their pockets or third hand info from the next door neighbor delivered by EMS.

 

[jdh71]

I understand why you guys don't want to sign them, but what makes you think a primary doc has any better idea about why a patient died acutely. Lots of things can kill a guy, especially a sick guy, and if the primary wasnt there for the death how the hell should he know what killed the patient?

 

[Doctor Bob]

I understand why you guys don't want to sign them, but what makes you think a primary doc has any better idea about why a patient died acutely. Lots of things can kill a guy, especially a sick guy, and if the primary wasnt there for the death how the hell should he know what killed the patient?

The hope (which was somewhat disproven by an earlier post) is that the primary knows the patient well and can say what sorts of chronic issues they have been battling which likely (but not definitively) led to their death.

 

[Daiphon]

I don't get it. What is the big deal about signing a death certificate? Cardiopulmonary arrest... Whose heart doesn't stop beating at death?

The issue is that cardiopulmonary arrest, while the obvious final common pathway to death, can't be listed as the CoD.

I like ASCVD, though. Sufficient, broad, and in this country, highly probable.

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[deleted65604]

I've wrote cardiopulmonary arrest dozens of times. Nobody has ever given me grief. Who says it can't be the cause of death?

 

[Daiphon]

I've wrote cardiopulmonary arrest dozens of times. Nobody has ever given me grief. Who says it can't be the cause of death?

The CDC unfortunately.

http://www.cdc.gov/nchs/data/dvs/DEATH11-03final-acc.pdf

Page 2, item 32, part 1, bullet 4 --> can't use it.

Thus the problem.

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[deleted65604]

Screw the CDC. I can do whatever I want. What are the consequences of me writing cardiopulmonary arrest. The only relevant "rules" are those with real punishments.

 

[Daiphon]

Screw the CDC. I can do whatever I want. What are the consequences of me writing cardiopulmonary arrest. The only relevant "rules" are those with real punishments.

I don't disagree with either point; but the reality I'm in is that the administration has now made it our group's problem. Grr... So, if I'm stuck doing them, I'd prefer to do them right (e.g. I'm not gonna be bothered after the fact).

I personally don't think EPs ought to have to deal with these.

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[docB]

Screw the CDC. I can do whatever I want. What are the consequences of me writing cardiopulmonary arrest. The only relevant "rules" are those with real punishments.

The consequences for us if we do it wrong is that the funeral homes keep bringing them back again and agin for us to redo them. Fortunately they're just demanding the extra "unknown" in the cause box. They still let us use cardiopulmonary arrest.

 

[VienneseWaltz]

Any DC with "cardiac arrest" or similar listed in COD doesn't even make it out of the hospital and bounces back to the signing physician to redo (the entire certificate).

 

[VienneseWaltz]

Really? ASCVD? In Bal'mor?

I would think "crack overdose" would work just as often. Or "high velocity lead poisoning."

But if I think the COD is crack or her-on, I can make the ME take it!

 

[Arcan57]

In Texas you have to have some type of special certification to sign a death certificate, which I've studiously avoided obtaining or even learning how to obtain. I'm heartened to see that non-useful coroners/MEs are limited to the Houston area. I had a guy that was d/c'ed extremely recently from an OSH and collapsed on the way to the mail box with blood pouring from his right TM. The ME's clerk was pushing me to say the cause of death was MI so they didn't have to autopsy. Several nasty phone calls later they finally picked up the body.

 

[deleted109597]

Oh yeah, there's that too in Texas.
Not only do you have to sign death certificates electronically, but if you don't, you get fined.
They can't make me do something that will make me get a fine.

 

[deleted65604]

It must be an individual state thing. I've never come across anything remotely like the hoops you guys are being forced through. I can now see your frustration. The madness of meaningless bureaucracy!

 

[Cerberus]

It's kind of a hassle in NY, but not really that bad. The most annoying part is getting the fingerprint scan to actually work. Here the system will not let you submit the death certificate if you don't put an acceptable diagnosis (I've been told anyone with a hx of CAD/HTN/smoking can be put as "Coronary Artery Disease", which is what I usually use in the "how the F would I know? He was dead when he came here" cases).

 

[docB]

Nevada now has a new policy where a death certificate can be appealed by the family to the doctor who signed it. As previously mentioned in this thread here the ER docs are responsible for signing these. This is a big problem.

In my group alone we have three instances where families have appealed the death certificate and it's now on the EP to try to sort it out. In every case the families want the cause(s) of death change to help them in lawsuits or insurance claims.

The question is what criteria are we held to if we change the cause? Bear in mind none of these cases have autopsies. Can we be sued by the family if we don't change it? Can we be sued by the defendant in the family's lawsuit if we do change it?

So far none of us know what our real risk and obligations are with this.

 

[dchristismi]

Tough one, man. I don't know the answer, but I've managed to only sign 2 in my career.
Both were pretty obvious coronary disease/MI, but generally I can get the PCP to agree to do it, or the ME takes it. If I know that something contributed (witnessed VF arrest), by all means, I let the PCP in on it. But I practice in a smallish community, and I know most of the PCPs.

 

[SoCuteMD]

Nevada now has a new policy where a death certificate can be appealed by the family to the doctor who signed it. As previously mentioned in this thread here the ER docs are responsible for signing these. This is a big problem.

In my group alone we have three instances where families have appealed the death certificate and it's now on the EP to try to sort it out. In every case the families want the cause(s) of death change to help them in lawsuits or insurance claims.

The question is what criteria are we held to if we change the cause? Bear in mind none of these cases have autopsies. Can we be sued by the family if we don't change it? Can we be sued by the defendant in the family's lawsuit if we do change it?

So far none of us know what our real risk and obligations are with this.

Question for you. When patients are pronounced in your emergency department, is the family offered an autopsy?

 

[StevieStud]

how does this appeal process work ?

 

[Daiphon]

Question for you. When patients are pronounced in your emergency department, is the family offered an autopsy?

If the coroner passes on the case, then at least one of my shops (academic ED), then yes... and the path department pays for it as part of their resident education budget.

At my community shop, it's offered but exclusively arranged for & discussed by pathology... the ED doesn't get involved. I don't know if they charge for that.

Cheers!
-d

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[docB]

Question for you. When patients are pronounced in your emergency department, is the family offered an autopsy?

No.

how does this appeal process work ?

Apparently they send a letter to the Health Department requesting the change and whatever documentation they see fit and it then gets sent to the doc. There is no screening and I don't think there is any review by anyone either.

 

[StevieStud]

No.



Apparently they send a letter to the Health Department requesting the change and whatever documentation they see fit and it then gets sent to the doc. There is no screening and I don't think there is any review by anyone either.

Just sounds like an opportunity to whine and make you out to be the bad guy.

Nothing new there.

It is your fault that they can't get a refill on their narcotic vitamin of choice. And now it will be your fault that you won't correct grandpappy's COD from DM to GSW for the insurance double-down.

 

[VienneseWaltz]

Nevada now has a new policy where a death certificate can be appealed by the family to the doctor who signed it. As previously mentioned in this thread here the ER docs are responsible for signing these. This is a big problem.

In my group alone we have three instances where families have appealed the death certificate and it's now on the EP to try to sort it out. In every case the families want the cause(s) of death change to help them in lawsuits or insurance claims.

The question is what criteria are we held to if we change the cause? Bear in mind none of these cases have autopsies. Can we be sued by the family if we don't change it? Can we be sued by the defendant in the family's lawsuit if we do change it?

So far none of us know what our real risk and obligations are with this.

Are you allowed to sign a D.C. with manner of death as non-natural? In Maryland, the only manner of death we can sign for is natural--suspicion of anything else has to go to the M.E.--seems hard to imagine an insurance claim contested over a natural cause of death, or a lawsuit, for that matter, unless the family were trying to prove that a death was NOT natural (and therefore someone else's fault).

 

[docB]

Are you allowed to sign a D.C. with manner of death as non-natural? In Maryland, the only manner of death we can sign for is natural--suspicion of anything else has to go to the M.E.--seems hard to imagine an insurance claim contested over a natural cause of death, or a lawsuit, for that matter, unless the family were trying to prove that a death was NOT natural (and therefore someone else's fault).

Instances where foul play was a possibility will usually go to the coroner. In these cases families are coming back long after the body has been interred or cremated and asking for changes. Issues have emerged where the families want the the DC to list something as a contributor so that they can sue such as an accident or a fall.

 

[VienneseWaltz]

Instances where foul play was a possibility will usually go to the coroner. In these cases families are coming back long after the body has been interred or cremated and asking for changes. Issues have emerged where the families want the the DC to list something as a contributor so that they can sue such as an accident or a fall.

What a nightmare...