Case 18: Death Certification. Expert comment by Dr Fletcher & Professor Sheaff

Thanks to everyone who contributed to the discussions about this 68 year old lady who died suddenly after admission to hospital.

photo 5 

You can see the highlights of the discussion on Twitter in the storify.

This week’s question setter was Dr Kate Fletcher, ST4 Histopathology, Barts & The Royal London Hospitals and expert was Professor Michael Sheaff , Consultant Histopathologist, Barts & The Royal London Hospital

Information available at the start of the week:

A 68 year old female was admitted to hospital with a cold, pale and pulseless left arm and was diagnosed with an acutely ischaemic upper limb. She underwent left arterial embolectomy the same evening. The procedure was uneventful and circulation to the left arm was restored.

Day 2

In the early hours of the next day (approximately 8 hours later), the patient was found on the ward, slumped to the left side with new onset aphasia and left sided hemiparesis. Clinically, stroke was suspected and the patient was referred to the on-call stroke team.

A CT head was performed which showed no intracranial haemorrhage, space occupying lesion or acute territorial infarct. Thrombolysis was given. The patient was stable for the rest of the night with a GCS of 12/15 (E4, V2, M6).

Day 3

During the morning, the patient was hypertensive with BP 212/92, and a GTN infusion was commenced.  At around midday the patient was found to have collapsed.  CPR was commenced and 7 cycles were performed, however resuscitation was unsuccessful.

Past Medical History: Atrial fibrillation, hypertension, angina, peripheral vascular disease (previous popliteal artery occlusion), mitral stenosis, and COPD.  The patient was on Warfarin.  The INR on admission was 1.4.

Question 1: As the team FY1 would you be able to complete this lady’s Death Certificate? What would you write

The team felt uncertain as to a cause of death in this case therefore the case was referred to the coroner and an autopsy was performed.

The main autopsy findings were as follows:

The deceased was a Caucasian female with a BMI of 17. The main finding was severe atherosclerosis of the aorta with anaortic dissection originating at the aortic arch. This had led to a massive haemopericardium (blood in the pericardial space). The heart was enlarged and showed mild to moderate atherosclerosis of the coronary arteries but no significant stenosis or occlusion. The mitral valve showed severe calcification and stenosis. The left atrium was dilated and the atrial appendage contained thrombus.

The carotid bifurcations showed atherosclerosis and were narrowed by approximately 60% on the left and 50% on the right.  No changes were seen in the brain.

The lungs showed emphysematous changes. The gastrointestinal and genitourinary system were unremarkable.

Q2. Given the autopsy findings, what should be written on the death certificate in part 1 and in part 2?

Further questions discussed on Twitter:

Question 3. Why is accurate death certification important?

Question 4. When should a case be referred to the coroner?

Question 5: What are the new changes which will effect Death Certification and autopsy?

Expert Comment

Key points:

  1. Clinicopathological correlation to formulate a cause of death
  2. How to complete a death certificate
  3. When to refer to the coroner
  4. Impending changes to the death certification system.

Resources:

1. How to complete a Death Certificate:

http://www.gro.gov.uk/images/medcert_july_2010.pdf

http://www.uhs.nhs.uk/Media/suhtideal/Doctors/MedicalPersonnelInduction/CauseofDeathCertificate.pdf

2. Post Mortem Information:

http://www.nhs.uk/conditions/post-mortem/Pages/Introduction.aspx

3. When to refer to the coroner:

http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_certification_post-mortems_and_referral.asp

http://www.hta.gov.uk/licensingandinspections/sectorspecificinformation/postmortem/postmortemsector.cfm

4. Legislation:

http://www.legislation.gov.uk/ukpga/2004/30/contents

Dr Kate Fletcher, ST4 Histopathology and Professor Michael Sheaff, Consultant Histopathologist, Barts & The Royal London Hospitals, say:

This was an interesting scenario which brought out some important issues surround death certification, referral to the coroner and the future of this process.

For the above case the following clinicopathological correlation was given:

“Post mortem examination revealed an aortic dissection originating at the aortic arch with rupture into the pericardial space, resulting in massive haemopericardium.

The dissection was related to rupture of an atherosclerotic plaque at the aortic arch.  Cardiac tamponade and subsequent cardiac arrest would have resulted from the haemopericardium.  It is likely that thrombolysis and the hypertension noted prior to the patient’s collapse, would have contributed to propagation of the aortic dissection.

Thrombus was noted in the left atrial appendage and is likely source of emboli leading to occlusion of the left brachial artery and ischaemic stroke.  Macroscopic changes were not seen within the brain at autopsy but this could be explained by the short time interval between the onset of stroke and death (acute changes, such as vasogenic oedema take hours to days to develop, and it takes weeks to months for infarcted tissue to undergo liquifactive necrosis). In addition, a small embolus could also be missed during dissection of the unfixed brain.

So the cause of death was given as:

1a.  Haemopericardium

1b.  Aortic dissection

1c.  Atherosclerosis

2.  Mitral stenosis and left atrial thrombus.

The MCCD and referral to the coroner

The Medical Certificate of Cause of Death (MCCD) should be completed by a medical practitioner who has looked after the patient in their last illness, who has seen the body after death and who is reasonably confident as to the cause of death. It is worth remembering that the cause of death is a clinical opinion and is a judgement made with the information available at the time.

In the above scenario, the doctors were uncertain of the cause of death and so referral to the coroner was made.

It is the coroner’s duty to investigate and rule out deaths due to unnatural causes or foul play. Therefore certain cases must be referred; these include deaths where the cause is unknown, where the death may be due to accident or injury, suicide, violence, neglect , those related to surgery or anaesthesia, or death which occurs in police custody.

In practice, it is a good idea to discuss the case with a coroner’s officer if you are uncertain as to whether you should certify the death.

When a death is referred to the coroner, he or she may decide whether to open an inquest and whether to request a post mortem examination. Remember, that as the coroner has a legal duty to investigate certain deaths, a coronial autopsy does not require consent from relatives or next of kin and in turn they may not refuse the autopsy.

A hospital post mortem is a different situation. In this case, the death certificate is completed as normal by the clinician but the clinician makes the request to the pathologist for a post mortem examination to be performed in order to answer a clinical question. Consent must then be obtained from the relatives. A detailed consent form is completed stating whether there are any limitations to the autopsy, for example, to look at one part of the body only, and asks whether tissue may be retained for research and teaching purposes. The retention of tissue is closely regulated by the Human Tissue Act 2004. The vast majority of autopsies performed by pathologists are coronial. These days, with improved access to clinical and radiological diagnostic tools, hospital autopsies are rarely sought.

How to complete the MCCD

The cause of death section of the MCCD consists of 2 parts. Part 1 is for documenting the chain of events that led directly to death, with the final disease, injury or complication in line (a), and the underlying cause on the lowest line. Part 2 is for reporting all other significant diseases, conditions or injuries which contributed to, but did not lead directly to, the underlying cause of death given in part 1.

Mortality statistics are derived from death certificates and ultimately this affects national decisions regarding how health service and public health programmes are prioritised. Therefore, ensuring the documented cause of death is as accurate as possible is important for the big picture. The relatives of the deceased will also benefit from being provided with an accurate explanation as to how their relative died and will receive information about their medical family history, which may be of direct relevance to them.

Reforms of the death certification process

The process of death certification in England and Wales is about to change. New legislation was introduced in 2009 under the Coroner’s and Justice Act. It will finally be implemented in October 2014 and sees the creation of the post of a ‘Medical Examiner’, a senior doctor who will scrutinise all MCCDs that are not referred to the coroner for investigation. Importantly, for the first time, relatives or representatives for the deceased will be asked, in every case, whether they understand the proposed cause of death and whether they have any cause for concern. The reforms will also unify procedures for all deaths whether the body is to undergo burial or cremation. The recent Francis report into deaths at Mid-Staffordshire hospital have given renewed impetus to this reform. It is hoped that relatives will provide a rich source of information about failings in the health service.

The future

Public objection to the autopsy has led to a search for minimally invasive alternatives, the so-called ‘virtual autopsy’. Studies have compared causes of death identified by radiology and autopsy and looked for discrepancies. In spite of the detail available through CT imaging and MRI, the studies showed that imaging frequently missed common causes of sudden death such as ischaemic heart disease and pulmonary embolism. Although post mortem imaging may play a role in the future, it looks as though the traditional autopsy is here to stay for some time, not least due to the financial restrictions of the coronial system.

 

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