medical 1. pre--course survey certificate of cause of
TRANSCRIPT
MEDICAL
CERTIFICATE OF
CAUSE OF DEATH
(MCCD)
3. To receive the final survey
please email
1. Pre--course survey
2. E-learning module
MCCD E-LEARNING CONTENT
2
1. INTRODUCTION
• Historical background
• MCCD purposes
• Coroner role
2. English MCCD form
• Filling the form
• Order of events
• Underlying cause of
death
3. MCCD QUALITY
• Background
• Major errors
• Minor errors
• Miscellaneous
4. Cases in literature • Case 1
• Case 2
• Case 3
HISTORICAL BACKGROUND
• Article 20 of the Articles of Eyre from 1194 made provision for the election by every
county of individuals as "Custos Placitorum Coronas" (Keepers of the pleas of the
Crown), now called coroners.
• In 1538, when the English government first required that the clergy kept a weekly
register of christenings, marriages, and burials that occurred in its parishes.
• The General Register Office was founded following the Births and Deaths Registration
Act 1836, responsible of the recording of births, marriages, and deaths –by cause-
• From 1845 the cause of death had to be certified by a doctor before registration.
• The Coroners Amendment Act of 1926 clarified the duties and jurisdiction of coroners:
To investigate all sudden, unexpected deaths and all deaths in prison by holding an
inquest.
• In 1948, the Sixth Decennial Revision Conference for the International Classification of
Diseases agreed that the single cause of death to be used as the basis of routine
mortality statistics should be the underlying cause, representing the "disease or injury
which initiated the train of morbid events leading directly to death" or "the
circumstances of the accident or violence which produced the fatal injury".
• In 1975, the ninth Revision Conference produced the first International form of Medical
Certificate of Cause of Death (MCCD).
3
MCCD: CAUSE OF DEATH, NOT VERIFICATION
In the UK only a doctor can certify a cause of death.
The doctor was to be one that had attended the decedent in the
precedent 14 days before death (Births and Deaths Registration
Act 1953).
Current Covid-19 pandemic allows 28 days before coroner involvement
4
MCCD: PURPOSES
Primary use
The deceased's relatives/friends/carers, supporting the bereavement.
The registrar of births, deaths and marriages.
Secondary use
Provide accurate statistical information through the Office for National Statistics (ONS).
International comparative studies.
5
THE CORONER 1
The registrar has a statutory duty to report a death to the coroner if it is one in respect of which:
• The deceased has not been attended during his last illness by a registered medical practitioner that can certify the cause of death.
• The death could be the consequence of recent surgery/anaesthesia.
• The death to have been due to industrial disease or industrial poisoning.
• Tuberculosis.
• Occurred during detention in police or prison custody, or shortly after release or under the Mental Health Act.
• There are doubts on the cause of death
• The death has been unnatural/violent/due to neglect.
6
THE CORONER 2
210,900 deaths (40%) were reported to coroners
in 2019, the lowest level since 1998.
In 2019 the number of deaths reported to
coroners as a proportion of registered deaths
varied widely across coroner areas, from 23% in
North Yorkshire (Western) to 98% in Manchester
City.
There were 82,100 post-mortem examinations
ordered by coroners in 2019, a 4% decline
compared to 2018.
7
8
THE CERTIFICATE 1
9
The top section:
-Be certain the patient has been seen alive recently.
-Numbered options
In general practice most likely 3.
Discussion with the coroner is not a referral to coroner
(needing to complete also boxes at the back)
-Lettered options
Most likely a or b
THE CERTIFICATE 2
10
The bottom section:
The list of employment related diseases need to be
considered
-Be certain printed name is added
-GMC number as well as qualifications.
THE CERTIFICATE 3
WHO INTERNATIONALLY AGREED MEDICAL DATA
11
CONSIDERATIONS FILLING THE MCCD
A doctor's duty of confidentiality does not stop with the death
of the patient.
If the decedent, while alive asked the GP not to disclose a
condition (as HIV could cause for example shame), a level
of sensitivity is needed but it has to be balanced with the
need to provide accurate data on the form.
If the deceased has dementia as a cause of death, it has
potentially legal implications regarding the validity of a
will, and details of timescale can become quite important.
12
THE ORDER OR EVENTS
13
THE LAST LINE IN SECTION 1
14
The condition listed on the bottom line of Part I (i.e., the underlying cause of death) is
arguably the most important in that this is generally what will be coded as the cause of
death.
MCCD QUALITY. BACKGROUND-1
IN THE UK, up to 70% contain some flaw, with around 15% deemed very poor and
estimates suggesting up to 5% that cannot be registered.
GPs certify between 8% and 20% of deaths depending on the demography of their
lists (especially patients in residential care).
Old age, senility terms are allowed to be used for patients over the age of 80, but they
are not considered ideal.
"For cause of death statistics to become more useful for policy makers, it is
imperative not to certify the underlying cause of death as a garbage cause. The
quality of cause of death information can be improved if doctors use the
international guidelines when certifying the death".
15
"The most significant predictor of major errors was the deceased’s
age with the probability increasing by 62 % for every 20-year-
increase after the age of 40"
The number of disaster-related deaths is underreported. "One
reason is the lack of awareness by medical certifiers of what
constitutes a disaster-related death and how to document this
information on the death certificate"
"The CDC guidance states that disaster-related deaths include
indirectly related deaths from unsafe or unhealthy conditions;
in the context of the COVID-19 pandemic, this would include
loss of wages or housing, disruption to medical care from
temporary suspension of outpatient facilities, hospital or
emergency department avoidance, postponement of surgeries
or chemotherapy, and loss of health insurance, all of which
could result in premature deaths".
16
BACKGROUND-2
MAJOR ERROR: 1. MECHANISM OF DEATH WITHOUT AN
UNDERLYING CAUSE
Asphyxia Debility Respiratory arrest
Asthenia Exhaustion Shock
Brain failure Heart failure Syncope
Cachexia Hepatic failure Uraemia
Cardiac arrest Hepatorenal failure vagal inhibition
Cardiac failure Kidney failure Vasovagal attack
Coma Liver failure Ventricular failure
Renal failure
17
MODE OF DYING or cause of death
MAJOR ERROR: 2. NON-ACCEPTABLE CAUSE OF DEATH.
Garbage codes
They can be divided in
-Causes that cannot or should not be considered as underlying causes of death. we included in this category a number of causes that are described as the long-term sequelae of disease, such as G82, paraplegia and tetraplegia, or O94, sequelae of complication of pregnancy, childbirth, and the puerperium. In these cases, for public health purposes, it is more useful to assign these deaths to the underlying cause despite the long time lag between disease and death.
-Intermediate causes of death & Immediate causes of death that are the final steps in a disease pathway such as heart failure, septicemia, peritonitis, osteomyelitis, or pulmonary embolism. These are clearly defined clinical entities, but each has an underlying cause that would have precipitated the chain of events leading to death. Cardiac arrest (I46) and respiratory failure (J96), are other examples.
-Unspecified causes within a larger cause grouping (example B08 - Other viral infections characterized by skin and mucous membrane lesions, not elsewhere classified).
18
MAJOR ERROR: 3. AN IMPROPER SEQUENCE IN
IMMEDIATE, INTERMEDIATE & UNDERLYING
CAUSES OF DEATH
By adding the length of time the patient has had a condition a clearer path can be
explained
19
MAJOR ERROR: 4. MULTIPLE AND
INDEPENDENT CAUSES OF DEATH
"Certifiers should report a single event on each line, even
when the events occurred simultaneously"
20
MINOR ERRORS
-Abbreviation used [#, CVA, COPD].
-Absence of time interval.
-Mechanism of death and underlying cause with incomplete information
21
MISREPORTED CONDITIONS
There is under-reporting of intellectual disability on the MCCD, and is
more accurately described as a disability. Thus, intellectual disability
should more appropriately be recorded in Part 2 of the MCCD, not
Part 1.
There is under-reporting of dementia and Parkinson's disease
There is over-reporting of cardiovascular disease and renal disease
22
TEST CASE 1 The patient was a 29-year-old Caucasian male with known multiple sclerosis for 3 years complicated by paraplegia and chronic
decubitus ulcers.
His other medical conditions include atopic dermatitis and asthma.
He was admitted to the intensive care unit with high-grade fevers, chills, and rigors, and leukocytosis. Vital signs included the following:
temperature, 102.5°F; pulse, 128 bpm; blood pressure, 85/55 mmHg; and oxygen saturation, 96% on room air.
He also had a chronic indwelling urinary catheter, which had been changed. Urine analysis revealed gross pyuria and bacteriuria. Urine
and blood cultures were obtained. He was started on levofloxacin (500 mg once daily intravenously) and was given 1.5 L of fluid
bolus, after which his blood pressure improved to 115/60 mmHg.
He was stable for the next 12 hours when his blood pressure dropped to 60/40 mmHg. Oxygen saturation dropped to 79% on room air,
and blood pressure started to decrease.
A Code Blue was called. No pulse or spontaneous breaths were detected. Cardiopulmonary resuscitation was initiated, and he was
intubated. No pulse or change in rhythm was noted after three DC shocks and three boluses of intravenous epinephrine.
Fifty minutes after initiating the second Code Blue, upon agreement with everyone involved, resuscitation attempts were discontinued,
and the patient was declared dead.
23
Correct completion of test case 1 would be as follows:
Part I,
line A = septic shock,
line B = urinary tract infection,
line C = neurogenic bladder,
line D = multiple sclerosis;
Part II = atopic dermatitis and asthma
TEST CASE 2 The patient was a 39-year-old African American woman with known sickle cell disease for the past 22 years. She has
been on chronic pain medications for intermittent episodes of sickle cell crises.
Her other medical problems include hypertension, mild renal insufficiency, and moderate mitral stenosis.
She was admitted to the internal medicine service with complaints of painful sickle cell crises involving the lower extremities, fever, nausea, and vomiting. She had mild leukocytosis. Vital signs included the following: temperature, 101°F; pulse, 114 bpm; blood pressure, 180/95 mmHg; and oxygen saturation, 92% on room air.
The next day, she started complaining of more leg pain with some tenderness in her right calf. On examination, the right calf looked bigger than the left, and the intern had promptly started the patient on IV heparin, and the patient was wheeled down to the radiology department for bilateral lower extremity Doppler to assess for deep venous thrombosis.
As the test was completed, patient complained of sudden onset of pleuritic chest pain with shortness of breath. Her oxygen saturation dropped to 82%. She became hypotensive, and a Code Blue was called.
Patient subsequently had agonal breathing without a palpable pulse. Portable monitoring unit showed sinus tachycardia at 140 bpm. Cardiopulmonary resuscitation was initiated,
After 30 more minutes, upon agreement with everyone involved, resuscitation attempts were discontinued, and the patient was declared dead.
24
Correct completion of the test case 2 would be as follows:
Part I,
line A = massive pulmonary embolism,
line B = lower extremity deep venous thrombosis,
line C = sickle cell disease,
Part II = hypertension, mild renal insufficiency and mitral stenosis.
TEST CASE 3
A 75-year old male, smoker with a 5-year medical history of emphysema, is admitted into a hospital for exacerbation of his lung disease caused by Haemophilus influenza pneumonia.
His only other medical problem is coronary artery disease of 10 years duration.
His clinical condition deteriorates but he decided against further extraordinary therapeutic measures, such as endotracheal intubation and mechanical ventilation.
A week after admission he is found on his bed with vital signs absent.
You are called to pronounce and certify his death.
25
