Medica Certification Cause Of Death - 2023 WILLIAM-NRB.pptx

certification of death

1. WILLIAM CHIMSANGA TRAINING IN MEDICAL CERTIFICATION OF CAUSE OF DEATH ( MCCoD )

2. Learning Objectives Be able to write a medical certificate of cause of death according to international standards Be able to understand the conventions and terminologies in medical certification of cause of death

3. Medical Certification of Cause of Death Outline Key Definitions Exercises

4. Use of Cause of Death Statistics ?

5. Key Definitions Cause of Death

6. Using your best clinical judgement, please identify the cause(s) of death in this case scenario A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms. He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions, the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot, and he makes a diagnosis of tetanus. The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding. The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control . The patient died of aspiration of gastric contents during a convulsion a day after admission.

7. Cause of Death ALL the DISEASES, MORBID conditions and or INJURIES which either resulted in or contributed to death & the CIRCUMSTANCES of the ACCIDENTS or VIOLENCE which produced any such injuries World Health Assembly (WHA)

8. CASE SCENARIO A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy (HIV/AIDS) for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms . He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions , the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot , and he makes a diagnosis of tetanus . The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding . The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control . The patient died of aspiration of gastric contents during a convulsion a day after admission.

9. Guidance on the Cause of Death Documentation Good diagnosis must include all words to describe What is the name of disease (morbid condition / injury / circumstance of accident or violence)? Where is the location of disease? Which type of disease? Must be final diagnosis or near final - not sign, symptom or m ode of dying - cardiorespiratory arrest and respiratory failure. 9

10. Key Definitions Immediate Cause of Death

11. Using your best clinical judgement, please identify the immediate cause(s) of death in this case scenario A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms. He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions, the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot, and he makes a diagnosis of tetanus. The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding. The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control . The patient died of aspiration of gastric contents during a convulsion a day after admission.

12. Immediate Cause of Death The final disease, injury, or complication directly causing the death. Also known as the terminal or final cause of death. The immediate cause does NOT mean the mode of death or terminal event e.g. cardiac arrest or respiratory failure (unless specified). The cause listed should be specific.

13. A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms. He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions, the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot, and he makes a diagnosis of tetanus. The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding. The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control . The patient died of aspiration of gastric contents during a convulsion a day after admission.

14. Key Definitions Underlying Cause of Death

15. Using your best clinical judgement, please identify the underlying cause of death in this case scenario A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms. He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions, the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot, and he makes a diagnosis of tetanus. The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding. The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control . The patient died of aspiration of gastric contents during a convulsion a day after admission

16. Underlying Cause of Death The DISEASE or CONDITION which initiated the TRAIN of events leading DIRECTLY to death OR The CIRCUMSTANCES of the ACCIDENT or VIOLENCE which produced the FATAL injury

17. Using your best clinical judgement, please identify the underlying cause of death in this case scenario A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms. He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions, the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot, and he makes a diagnosis of tetanus. The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding. The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control . The patient died of aspiration of gastric contents during a convulsion a day after admission

18. Key Definitions Intermediate Cause of Death

19. Using your best clinical judgement, please identify the intermediate cause(s) of death in this case scenario A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms. He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions, the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot, and he makes a diagnosis of tetanus. The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding. The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control . The patient died of aspiration of gastric contents during a convulsion a day after admission.

20. Intermediate Cause of Death Any cause between the underlying cause and the immediate cause of death. Also known as antecedent cause of death or complications of the underlying cause.

21. Key Definitions Contributory Cause of Death

22. Using your best clinical judgement, please identify the contributory cause(s) of death in this case scenario A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms. He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions, the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot, and he makes a diagnosis of tetanus. The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding. The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control . The patient died of aspiration of gastric contents during a convulsion a day after admission

23. Contributory Cause of Death Any cause of death that is neither the immediate, intermediate nor the underlying cause that somehow contributed indirectly to the death Any significant condition contributing to the death, but not related to the disease or condition directly causing the death

24. Using your best clinical judgement, please identify the underlying cause of death in this case scenario A 49-year-old male with a history of hypertension on treatment since five years ago, extrapulmonary TB treated two years ago, and has been on antiretroviral therapy (HIV/AIDS) for a year, was brought to the outpatient department with a three day’s history of uncontrolled painful muscle spasms. He had been taken to the village’s traditional healer the previous day, where he was diagnosed of being bewitched by his neighbour for his bumper harvest that year. With continued convulsions, the family decided to take him to Ntchisi District hospital. On examination the attending medical officer notes an infected wound of the right foot, and he makes a diagnosis of tetanus. The patient’s wife reported that while working in the fields two weeks previously, he had stepped on a nail and sustained a cut on his right foot which he treated by applying soil to stop the bleeding. The patient was admitted to the high dependency unit on intravenous antibiotics and muscle spams control. The patient died of aspiration of gastric contents during a convulsion a day after admission

25. How the medical Certificate will look I a: aspiration of gastric content Minutes b: tetanus 5 days c: pierced by a nail whilst working in the fields 2 Weeks d: II: Hypertension 5years : ExtraPulmonary TB 2 Years : HIV/AIDS 1 Years

26. Medical Certification of Cause of Death

27. Key Definitions Manner of Death

28. Manner of death Manner of death Describes the nature of processes that led to death Natural Unnatural (accident, suicide, homicide), Undetermined. Natural manner of deaths Results from an illness and its complications or an internal malfunction of the body not directly caused by external forces, other than infectious disease. 28

29. Manner of death Unnatural manner : Deaths resulting from external causes poisoning, homicide, suicide, medical errors, alcohol intoxications, drug overdoses or accidental in manner, depending on whether Intent must be described Intentional or unintentional Who caused the external injury Self inflicted or by an external factor 29

30. Manner of death Unnatural deaths In many countries, a coroner or other medical-legal officer is involved to certify if a death is due to or suspected of being due to violence (i.e., if the manner of death is an accident, suicide or homicide) 30

31. Manner of death Undetermined manner of death : Situations where there is no much evidence to determine the manner of death. Usually after investigation careful review and/or post-mortem examination. 31

32. Please indicate the manner of death in the following scenarios A 23-year-old man dies one hour after going into traumatic shock after sustaining multiple fractures when he was hit by a truck while walking across the road. The accident happened five hours ago.

33. Please indicate the manner of death in the following scenarios A 49-year-old male, a known asthmatic patient on inhaler and HIV patient on HAART for 8 years, was brought to the emergency department with an infected wound of the right foot and uncontrolled muscle spasms. The attending doctor made a diagnosis of tetanus and admitted the patient the hospital’s high dependency unit. The patient’s wife reported that whilst working in the fields two weeks prior, he sustained a laceration on his big toe after stepping on a nail. The patient died of aspiration of gastric contents during a convulsion a day after admission

34. Please indicate the manner of death in the following scenarios A 97 year old lady known hypertensive and diabetic for 33 and 27 years respectively is found dead in her bed in the morning.

35. Key Definition Medical Certification of Cause of Death

36. Medical Certificate of Cause of Death Medical Certification of Cause of Death (MCCoD) is the process of determining the cause of death and certifying the same. This must be done by an authorized medically trained clinician who fully understands the clinical sequence of disease or injury that led to death. MCCoD provides a cause of death statement: cause-of-death statement consists of the wording written in the format used on a death certificate to indicate the cause(s) of death and other significant conditions that contributed to death.

37. How is Medical Certification of Cause of Death Done? Medical certification of cause of death is done by filling a medical certificate of cause of death During MCCoD, the certifier provides a clear sequence of events leading to death.

38. How is Medical Certification of Cause of Death Done? Regardless of whether the law requires it; it is the professional responsibility of the attending doctor to complete the death certificate . Completion of the death certificate should be part of the patient’s end-of-life care provided by the doctor. A medical team should be put together in each health facility to do medical certification of cause of death – the team should have doctors, nurses/midwives and other paramedics It is important for the team to discuss and agree on the sequence of events that led to death before filling the medical certificate.

39. How is Medical Certification of Cause of Death Done? In the case of accidents or violent deaths, additional input may come from a coroner or other legal official. For deaths that occur where there is no doctor, verbal autopsy should be done to provide information on the cause of death. The person who completes and signs the medical certificate of cause of death is referred to as the certifier Who completes cause of death certificate in Malawi?

40. Key Definition Causal Relationship

41. Causal relationship A causal relationship exists if a disease or condition can be caused by another disease or condition. Pathological sense Chronological sense This is founded on medical assessment, epidemiological and public health considerations. 41

42. Key Definition Sequence

43. Sequencing A sequence is the chain or series of medical events in which each step is a complication of, or caused by the previous step. Reported line by line with a causal relationship between each element. 43

44. Instructions on filling the MCCoD form

45. Key Guiding Principles in Completing the MCCoD Form All entries should be typed or written legibly in black ink , without the use of abbreviations, alterations, or erasures. As much detail as possible should be recorded so that it can be used to assign complete and specific codes from the ICD. If the cause of death is due to injury or poisoning, the external cause of the injury should be reported as the underlying cause and should be specified by manner; unintentional, intentional self-harm, assault or undetermined (after investigation) intent.

46. Key Guiding Principles in Completing the MCCoD Form Be as specific as possible, for example: If accident: specify circumstances, place of occurrence and intent (car accident, a fall) If alcohol or drugs: Specify use e.g., long term or single, addiction If complication of surgery: Specify disease: disease that caused surgery If dementia: Specify cause: Alzheimer, infarction, old age, other

47. Key Guiding Principles in Completing the MCCoD Form Be as specific as possible , for example: If hepatitis: Specify course, etiology: acute or chronic, alcoholic… If viral: specify Type (A, B, C, ...) If infarction: Specify site: heart, brain, ... Specify cause: arteriosclerotic, thrombotic, embolic. If infection: Specify: primary or secondary, bacterial or viral, causative organism If leukemia: Specify: acute, subacute, chronic lymphatic, myeloid, monocytic

48. Key Guiding Principles in Completing the MCCoD Form The mode of dying is the final common pathways to death that describes how a death occurred, rather than why it occurred, therefore should not be reported as the immediate cause of death. The mode of death include cardiac arrest, respiratory arrest, cardiopulmonary arrest, asystole, ventricular fibrillation, electromechanical dissociation etc.

49. Key Guiding Principles in Completing the MCCoD Form If the cause of death is unknown , even after investigation, it is correct to record it as ‘unknown’. Do not forge a diagnosis of cause of death if you are not sure. Provide a clear sequence of events leading to death Only conditions that are part of the disease sequence should be entered in Frame A of part 1 and part 2. Underlying cause of death is reported alone on the lowest used line on the cause of death certificate. In many instances where only one line has been filled, the immediate cause of death is also the underlying cause of death.

50. Key Guiding Principles in Completing the MCCoD Form Time interval from onset to death should be entered Which may be instantaneous, seconds, minutes, hours, days, weeks, months, years. If the decedent is a pregnant woman , the section of the form, “for women, was the woman pregnant”, should be filled. If both mother and baby die at birth; two separate medical certificates of cause of death should be completed: one for the mother and the other for the baby Ensure the baby’s birth notified for birth registration In case of fetal death, maternal condition that caused the fetal death is the underlying condition.

51. Key Guiding Principles in Completing the MCCoD Form Nonspecific anatomic processes should not be captured as underlying cause of death. These are complications or sequel of underlying causes of death and may be a macroscopic or microscopic alteration that may have functional consequences and more than one possible cause. A typical example is cirrhosis, which can be the result of more than one disease. Nonspecific physiologic derangement should not be captured as underlying cause of death. These are nonspecific functional disturbances that are complications of an underlying cause of death and that may have more than one cause. Typical examples include hemorrhage; hypovolemic shock; cerebrovascular accident. It is appropriate to include important nonspecific processes and derangements in cause-of-death statements as an immediate or intermediary cause of death, but the underlying cause of death also needs to be reported.

52. Key Guiding Principles for completing MCCoD form A nonspecific process or derangement may be included in the cause-of-death statement if it meets the following criteria: It is a recognized, potentially fatal complication of the underlying cause of death. It comprises part of the sequence of conditions that led to death. It is not a symptom or sign. An etiologically specific, underlying cause of death is also reported, when possible.

53. Examples of nonspecific processes and derangements that do not stand on their own as an underlying cause of death. If such conditions are reported on the death certificate, a specific underlying cause of death should also be reported, when possible. 53

54. The International Form of Medical Certificate of Cause of Death

55. Why WHO developed the International Form of Medical Certificate of Cause of Death? WHO developed the international form of medical certificate of cause of death to: Ensure standardization of cause of death reporting within and across countries Facilitate comparison of data over time Countries can adapt the international form of medical certificate of cause of death to their contexts by adding , not deleting , information on the certificate – particularly in the administrative section of the form. The International Statistical Classification of Diseases and Related Health Problems (ICD), now in its eleventh revision (ICD-11), is an additional tool that should be used with the medical certification of cause of death to ensure standardization and comparability of data within and across countries

56. The International Medical Certificate of Cause of Death 56

57. Administrative Information / Demographics 57 C ountry should decide the demographic information they want to collect Additional information might include place of residence, the national identification number (NIN), age of deceased, occupation, education level, religion etc – information that is used for disaggregating data for reporting.

58. Frame A: Part 1 and 2 58 Four lines provided for recording the sequence of events that led to death. Immediate cause- always recorded on line I(a). This may be the only condition recorded if there are no other conditions in the sequence Other conditions leading to I(a) are entered in sequence on lines (b), (c) and (d) with the underlying cause on lowest line Used to record other conditions that are not in part 1 but were present at the time of death and may have contributed to death . Interval between onset of the condition and death MUST be filled .Interval may be instantaneous, minutes, hours, days, weeks, months or years . If interval is not known write “unknown”

59. Frame B of the International Medical Certificate of Cause of Death T he second section, Frame B, helps to report detail that is relevant to coding and epidemiology analysis for deaths due to external causes, maternal deaths, perinatal deaths and deaths due to postprocedural conditions. 23 November 2021 59 Post-procedural conditions Deaths due to external causes Perinatal Deaths Maternal Deaths Death is either due to natural or unnatural cause

60. CASE SCENARIOS AND EXERCISES

61. NR 10 FORM COMPARE AND CONTRAST WITH INTERNATIONAL MEDICAL CERTIFICATE OF CAUSE OF DEATH

62. Common Errors in Medical Certification of Cause of Death

63. Common errors in medical certification The common errors in medical certification include: Improper address of disease. Missing date of birth. Wrong spelling. Use of ‘suspected’ or ‘possible’. Writing many conditions on the same line. Writing two unrelated disease condition one line. Writing mode of dying as the underlying CoD. Adding notes, that will crowd the certificate. Typing mistake. Unclear time interval, and time of death. Trivial information. Unclear sequence. Use of unacceptable abbreviations

64. Verbal Autopsy

65. Deaths outside facilities (~70%) Data lost for policy and program use Usable but insufficient and biased data for public health Facility Deaths (~30%) Where do people die?

66. How to Make use of the Missing Mortality Data 66 What is the solution? Ideal: Prioritized investment in strengthening CRVS and MCCoD. Can take years to achieve – leadership, technical, and financial resources Reality : Decision-makers will continue to need to make critical decisions about the allocation of limited resources on the basis of no or very poor data. Interim Solution - needed

67. What can be done in the interim? 67 The Interim Solution must be: Cost-effective (i.e. inexpensive and accurate) Rapid , and Applicable in rural, remote and underserved populations Verbal Autopsy

68. Verbal autopsy (VA) is a practical method for determining probable COD – where MCCoD not possible. It is used where MCCD and civil registration and vital statistics (CRVS) systems are weak Though not considered accurate at the individual level, VA provides useful population level COD information Different Instruments Verbal autopsy standard (who.int) What is Verbal Autopsy 68

69. Structured interview with caregivers of the deceased with computer assisted diagnosis of likely cause of death; Aggregated VA data provides missing population-level measures of causes of death outside of health facilities; Contributes to more complete cause-specific mortality fractions ; Enables government to plan using more data and a more representative data set. What is Verbal Autopsy

70. A VA interview questionnaire consisting of a series of structured questions on the key demographic characteristics of the deceased, as well at the signs and symptoms experienced by the deceased (and their duration) in the period before death; A validated automated coding algorithm for assigning the most probable cause to each individual death; A target cause list mapped to ICD-10 A means for compiling both summary and disaggregated cause-specific mortality fractions at the population level; Efficient business processes – including roles and responsibilities of all stakeholders, fully integrated into the operational architecture (including IT) of both the health system and the CRVS system. VA Components

71. InterVA http://www.interva-4.net/ InsilicoVA https://cran.r-project.org/web/packages/CrossVA/index.html SmartVA Tariff https://www.healthdata.org/verbal-autopsy/tool Each can be applied to the WHO 2016 VA data – yet to be customized for VA 2022 VA Analytical Tools

72. Data useable for health policy and program use Deaths outside facilities (~70%) Facility Deaths (~30%) All Deaths Verbal Autopsy

73. Limitations of verbal autopsy Imperfect method compared with physician medical certification of cause of death according to ICD standards. Generates data that are valid at the population level, but not at the individual level . Medically certified cause of death has legal status at the individual level; VA cause of death does not currently have similar legal status . Necessary and only practical option in populations where medical death certificates are not available. Primary purpose is to produce data essential for public health decision-making . Strict confidentiality and data security essential .

74. https://olc.worldbank.org/

75. Thank-you