DEATH CERTIFICATION RANDY FROST M D CHIEF MEDICAL

DEATH CERTIFICATION RANDY FROST, M. D. CHIEF MEDICAL EXAMINER BEXAR COUNTY MEDICAL EXAMINER’S OFFICE

BEXAR COUNTY FORENSIC SCIENCES CENTER

THIS TALK IS…… A GENERAL DISCUSSION OF DEATH CERTIFICATION…. l FROM THE PERSPECTIVE OF A MEDICAL EXAMINER, NOT THE VITAL RECORDS UNIT OR AN EPIDEMIOLOGIST l WILL PRIMARILY TALK ABOUT CAUSE AND MANNER OF DEATH STATEMENTS IN NATURAL DEATHS, SINCE MOST PROBLEMS ARISE THERE l PLEASE ASK QUESTIONS (BUT NOT ABOUT TER!) l

AUDIENCE l PRIMARILY GEARED TOWARD THOSE WHO COMPLETE CAUSE OF DEATH STATEMENTS (J. P. ’s OR PHYSICIANS) l THOSE WHO REVIEW DEATH CERTIFICATES WILL ALSO HOPEFULLY GET SOMETHING USEFUL OUT OF IT l OTHER THAN A SHORT NAP

THE GOOD NEWS l NO GORY PHOTOS IN THIS TALK!

THE BAD NEWS l NO GORY PHOTOS IN THIS TALK! l HOPEFULLY NOT TOO DRY A TOPIC

M. E. ROLE l AS A MEDICAL EXAMINER, I AM LIKE ANY OTHER PHYSICIAN IN TEXAS l I HAVE TO CERTIFY CAUSE AND MANNER OF DEATH AS BEST I CAN l BUT I DON’T MAKE THE RULES AND DID NOT COME UP WITH THE SYSTEM l I DON’T ENFORCE DEATH CERTIFICATION REQUIREMENTS

WHY CERTIFY DEATH? l WE ALL GET PAPERS COMING AND GOING: BIRTH l DEATH l l LARGELY FOR STATISTICAL PURPOSES l ALSO USED FOR A VARIETY OF OTHER LEGAL REASONS

WHO USES D. C. ’s? l l l FAMILIES FUNERAL DIRECTORS INSURANCE COMPANIES LEGAL SYSTEM (THOUGH D. C. USUALLY NOT THEIR PRIMARY INTEREST) l INCLUDES POLICE, D. A. ’S, J. P. ’S l ESTATES AND TRUSTS EPIDEMIOLOGISTS AND STATISTICIANS

WHAT IS DEATH CERTIFICATION? l l l l DEMOGRAPHICS DOCUMENTATION THAT DEATH OCCURRED WHERE AND WHEN DEATH OCCURRED CERTIFIER CAUSE OF DEATH MANNER OF DEATH OTHER STUFF

THE CURRENT D. C. l GREAT FOR DOCUMENTING THAT DEATH OCCURRED AT A PARTICULAR TIME AND PLACE l USEFULNESS AS A TOOL FOR COLLECTING CAUSE AND MANNER OF DEATH DATA ENTIRELY DEPENDENT ON HOW WELL BLOCK 33. IS FILLED OUT

PROBLEMS WITH THE D. C. l FOR SOME REASON, THE TIERED “DUE TO” LINES ARE VERY CONFUSING FOR PHYSICIANS l REQUIRES US TO ENTER SOME TIMES AND DATES THAT WE MAY NOT KNOW! l EXTRANEOUS INFORMATION (37 -38) l CONFUSING BLOCKS (35. )

WHO CONTROLS DEATH CERTIFICATION? l TEXAS DEPARTMENT OF STATE HEALTH SERVICES, VITAL STATISTICS UNIT l M. E. HAS NO CONTROL OVER THE DEATH CERTIFICATE WHATSOEVER l HOWEVER, YOUR FRIENDLY NEIGHBORHOOD M. E. WILL BE HAPPY TO ADVISE YOU ON CAUSE AND MANNER OF DEATH

ONLINE D. C. ’S NOW REQUIRED IN TEXAS; ANY PHYSICIAN WHO MIGHT EVER NEED TO SIGN A D. C. MUST REGISTER l WEB-BASED, ACCESSIBLE ANYWHERE l TEXAS MEDICAL BOARD WILL FINE PHYSICIANS WHO SIGN A PAPER D. C. INSTEAD OF USING THE ONLINE SYSTEM l SO…. SOME DOCTORS REFUSE TO SIGN SINCE THEY ARE NOT REGISTERED IN THE ONLINE SYSTEM, BUT THIS WILL LIKELY ALSO RESULT IN BOARD ACTION l

WHAT IS THE MEDICAL EXAMINER? INVESTIGATIVE AGENCY MANDATED BY THE STATE, UNDER COUNTY AUTHORITY l CHARGED WITH INVESTIGATING (INQUESTS) DEATHS IN COUNTY OF JURISDICTION THAT ARE: l l l DUE TO INJURY OR INTOXICATION SUDDEN AND UNEXPECTED UNKNOWN CAUSE STAFFED BY FORENSIC PATHOLOGISTS NOT ASSOCIATED WITH LAW ENFORCEMENT OR PROSECUTORS

THE MEDICAL EXAMINER IS NOT…. AN AUTOPSY SERVICE l A STORAGE FACILITY l A MALPRACTICE INVESTIGATIVE SERVICE l A DEATH CERTIFICATE SERVICE. . IF IT IS NOT AN ME CASE, WE WON’T SIGN THE D. C. l THAT IS UP TO THE ATTENDING OR PRONOUNCING PHYSICIAN l THIS IS CONSIDERED A PROFESSIONAL RESPONSIBILITY l

NATURAL DEATHS l ANY PHYSICIAN HAVING KNOWLEDGE OF THE PATIENT MAY SIGN THE DEATH CERTIFICATE PCP l ATTENDING OR CONSULTANT l HOUSE STAFF l N. H. OR HOSPICE MEDICAL DIRECTOR l E. R. DOCTOR l FEDERAL (V. A. OR MILITARY) PHYSICIAN l

NATURAL DEATHS l DOCTORS TREATING A PATIENT ARE OFTEN RELUCTANT TO SIGN A D. C. FOR A VARIETY OF REASONS l l UNCERTAINTY (CERTAINTY NOT REQUIRED) LAWSUITS (BUT A DOC CAN’T BE SUED FOR TAKING HIS/HER BEST SHOT AT IT) DON’T FEEL “COMFORTABLE” DOING SO l IT’S A PROFESSIONAL RESPONSIBILITY. TOO BUSY (SEE ABOVE!)

RELUCTANT DOCTORS SHOULD REMEMBER…. DEATH CERTIFICATE IS ONLY A STATEMENT OF PROBABILITY AND PROFESSIONAL OPINION l CERTAINTY IS NEITHER EXPECTED NOR REQUIRED l YOU CANNOT BE SUED FOR PUTTING YOUR OPINION ON A DEATH CERTIFICATE IN GOOD FAITH l IT IS A “BEST GUESS” l

SUGGESTIONS FOR DOCS l DOCTOR, WAS THIS MOST LIKELY A NATURAL DEATH? l DO YOU HAVE A DIFFERENTIAL DIAGNOSIS? l IF SO, WHAT IS NUMBER ONE ON THE LIST? l THAT IS THE CAUSE OF DEATH

WHAT IS DEATH? l TEXAS HEALTH AND SAFETY CODE CHAPTER 671 l “IRREVERSIBLE CESSATION OF THE PERSON’S SPONTANEOUS RESPIRATORY AND CIRCULATORY FUNCTIONS” l l IN OTHER WORDS “CARDIOPULMONARY ARREST” OR “IRREVERSIBLE CESSATION OF ALL SPONTANEOUS BRAIN FUNCTIONS”

CAUSE OF DEATH THAT DISEASE, CONDITION, INJURY OR THING BUT FOR WHICH DEATH WOULD NOT HAVE OCCURRED l DON’T CONFUSE WITH MECHANISM OF DEATH l l l HYPOXIA RENAL FAILURE ELECTROLYE PROBLEMS ASPIRATION…. THESE ARE NOT CAUSES

REMOTE INJURY THE TIME SINCE INJURY IS OF NO CONSEQUENCE IN DETERMINING IF TRAUMA CAUSED OR CONTRIBUTED TO DEATH l DEATH MAY OCCUR MANY YEARS AFTER AN INJURY, BUT THE INJURY IS STILL THE CAUSE OF DEATH, NOT THE COMPLICATIONS THAT HAVE DEVELOPED l APPLIES TO GSW’S, TRAFFIC ACCIDENTS, OVERDOSES, OR ANYTHING ELSE. l

MECHANISMS OF DEATH l THE PHYSIOLOGIC ALTERATIONS IN THE BODY THAT ACCOMPANY THE PROCESS OF DYING LACK OF OXYGEN (ASPHYXIA) l PNEUMONIA DUE TO OTHER CONDITIONS l LACK OF BLOOD FLOW TO ORGANS l CHEMICAL DISTURBANCES OF THE BODY l

MECHANISMS OF DEATH l THESE PHYSIOLOGIC PROCESSES ARE USUALLY NOT THE CAUSE OF DEATH l GENERALLY THERE IS AN UNDERLYING CONDITION THAT RESULTS IN THE MECHANISMS OF DEATH l EX. GUNSHOT WOUND OF HEAD -> COMA -> BRONCHOPNEUMONIA

CREMATIONS l l l ALL CREMATION CASES GET REVIEWED BY THE M. E. GOOD THING, TOO WE PICK UP SEVERAL CASES EACH WEEK THE SHOULD HAVE BEEN REPORTED TO THE M. E. BUT NEVER WERE OUR STAFF SPEND A GREAT DEAL OF TIME ON THESE ISSUES 48 HR. WAITING PERIOD APPROVAL FOR ANY REPORTABLE CASE

RED FLAGS FOR OUR OFFICE l l l l l ANOXIC ENCEPHALOPATHY PULMONARY EMBOLISM HYPOXIA MALNUTRITION FAILURE TO THRIVE CARDIOPULMONARY ARREST ARRYTHMIA (NOS) WOUND (NOS)…SURGICAL VS. TRAUMA? SEPSIS

RED FLAGS ALL OF THE PREVIOUS ITEMS NEED SOMETHING ELSE IN THE “DUE TO” LINE l EX. SEPSIS DUE TO DECUBITUS ULCERS DUE TO ADVANCED PARKINSON’S DISEASE l OR: CARDIAC ARRHYTHMIA DUE TO CORONARY ARTERY DISEASE l OR: PULMONARY EMBOLUS DUE TO COMATOSE STATE DUE TO HEAD INJURY DUE TO ASSAULT l

MANNER OF DEATH l OUTDATED AND ARCHAIC SYSTEM l NO CONSISTENCY; SOME DEATHS DEFY CLASSIFICATION USING CURRENT SCHEME l NEEDS REVISION BUT WON’T HAPPEN IN MY LIFETIME, IF EVER l ONLY THE M. E. OR J. P. CAN CERTIFY HOMICIDE, ACCIDENT, SUICIDE OR UNDETERMINED DEATHS

MANNER OF DEATH l HOMICIDE l ACCIDENT l SUICIDE l NATURAL l UNDETERMINED

NATURAL l NOTHING BUT NATURAL DISEASE WAS INVOLVED IN THE DEATH CANCER l HEART DISEASE (IGNORE THE FAST FOOD!) l STROKES l COPD (IGNORE THE CIGARETTES!) l DIABETES (TWINKIES? ) l KIDNEY DISEASE l

NATURAL DISEASE l BUT BY CONVENTION, THE LONG TERM, CHRONIC COMPLICATIONS OF SUBSTANCE ABUSE ARE CONSIDERED NATURAL CIRRHOSIS DUE TO ALCHOL USE l LUNG DISEASE DUE TO SMOKING l CHRONIC COMPLICATIONS OF ILLICIT DRUG USE l

FETAL DEATH CERTIFICATE l MOST FETAL DEATHS ARE OF UNKNOWN ETIOLOGY, BUT THESE ARE PRESUMED TO BE “NATURAL”, AND OF NO M. E. INTEREST l NO MANNER OF DEATH IN FETAL DEATH l FACTORS CONTRIBUTING TO THE DEATH: LARGE NUMBER OF FIELDS TO FILL OUT

DRUG USE ON THE D. C. l IF ANYONE OTHER THAN THE M. E. OR J. P. PUTS DRUGS ON THE D. C. , IT MUST BE CLEAR THAT IT DOES NOT REPRESENT AN ACUTE INTOXICATION l DEATH DUE TO RESPIRATORY ARREST DUE TO ACUTE HEROIN USE=ACCIDENT l DEATH DUE TO ENDOCARDITIS DUE TO CHRONIC INTRAVENOUS HEROIN ABUSE=NATURAL

“MALPRACTICE” CASES l NOT GENERALLY UNDER M. E. OR J. P. JURISDICTION l SHOULD BE CERTIFIED AS NATURAL UNLESS THERE WAS INTENT TO HARM (HOMICIDE) OR SOME EXTERNAL INCIDENT THAT WOULD CATEGORIZE IT AS ACCIDENT

ACCIDENT l SOME OUTSIDE, BUT UNANTICIPATED, FORCE ACTS ON THE BODY TO PRODUCE AN INJURY l NEED NOT BE THE ONLY FACTOR IN THE DEATH l MAY EVEN BE COMPARATIVELY MINOR INJURY, BUT FATAL IN THE SETTING OF ADVANCED AGE OR OTHER INFIRMITY

ACCIDENT l SOME ARE EASY AUTO CRASH l FALL FROM ROOF l l OTHERS ARE NOT “MINOR” INJURIES IN ELDERLY l INJURIES THAT ONLY CONTRIBUTE TO DEATH l

EXAMPLES l “MULTIPLE INJURIES DUE TO MOTOR VEHICLE MISHAP” l “SUBDURAL HEMATOMA DUE TO BLUNT HEAD TRAUMA DUE TO FALL FROM LADDER” l “ANOXIC ENCEPHALOPATHY DUE TO RESPIRATORY ARREST DUE TO INADVERTENT FENTANYL OVERDOSE”

REMOTE INJURY l l l PATIENT INJURED IN MOTOR VEHICLE COLLISION RENDERED VEGETATIVE DUE TO TRAUMATIC BRAIN INJURY DIES MONTHS LATER OF SOME COMPLICATION COD: COMPLICATIONS OF REMOTE INJURIES DUE TO MVA MOD: ACCIDENT

INTRACRANIAL HEMORRHAGE l SUBDURAL = TRAUMA: ME CASE l SUBARACHNOID HEMORRHAGE: ? ? l INTRACEREBRAL HEMORRAGE (GANGLIONIC, PONTINE, INTERNAL CAPSULE) = STROKE: NOT ME CASE l WE HAVE FOUND THAT RECORDS ARE OFTEN INACCURATE RE: TYPE OF INTRACRANIAL BLEED. WE’LL WANT TO SEE THE CT SCAN REPORT.

HIP FRACTURE l ELDERLY WOMAN WITH LONG HISTORY OF PARKINSON’S DISEASE, FALLS AND FRACTURES HIP DIES TWO WEEKS LATER AFTER STEADILY DECLINING POST-FRACTURE l THIS IS A M. E. CASE…FRACTURE IS CONTRIBUTORY TO DEATH l CAUSE OF DEATH: HIP FRACTURE COMPLICATING PARKINSON’S DISEASE l MANNER OF DEATH: ACCIDENT l

HIP FRACTURE IF SAME WOMAN RECOVERS FROM FRACTURE AND RETURNS TO HER BASELINE LEVEL OF FUNCTIONING, ONLY TO DIE 6 MONTHS LATER DUE TO ASPIRATION PNEUMONIA l THIS IS NOT A M. E. CASE l COD: PNEMONIA DUE TO PARKINSON’S DISEASE l MOD: NATURAL l FRACTURE SHOULD NOT APPEAR ON D. C. l

MINOR INJURIES IN ELDERLY l AT WHAT POINT DOES AN INJURY BEGIN TO CONTRIBUTE SIGNIFICANTLY TO DEATH? l HIP FRACTURE, BROKEN NECK, SUBDURAL HEMATOMA? NO PROBLEM: OBVIOUSLY CONTRIBUTE l BROKEN ARM, LACERATION OF HEAD, LARGE BRUISE? MORE DIFFICULT

SUICIDE l DEATH BY ONE’S OWN HANDS l INTENT TO DIE MAKES IT EASY SUICIDE NOTES OR THREATS l INTRAORAL SHOTGUN WOUND l l BUT OFTEN INTENT IS DIFFICULT TO PROVE DRUG OVERDOSE l “RUSSIAN ROULETTE” l AUTO CRASH l

INTENT l WE REQUIRE THAT THE ACT THAT PRECIPITATED DEATH BE INTENTIONAL l AND THAT THE ACT BE INHERENTLY DANGEROUS WITH HIGH RISK TO LIFE l BUT WE MAY NOT BE ABLE TO DEMONSTRATE AN INTENT TO DIE

EXAMPLES l “MIXED DRUG INTOXICATION DUE TO INTENTIONAL INGESTION OF PRESCRIPTION MEDICATIONS” l “CONTACT GUNSHOT WOUND OF HEAD” l “MULTIPLE INJURIES DUE TO INTENTIONAL JUMP FROM ROOF”

A WORD ABOUT DRUGS THESE ARE EXCEPTIONALLY DIFFICULT CASES l MORE AND MORE ARE FROM PRESCRIBED NARCOTICS l CAN NOT JUST LOOK AT A DRUG CONCENTRATION l CHRONIC USE CAN RESULT IN VERY HIGH LEVELS WITHOUT DEATH l INTERPRETATION REQUIRES AUTOPSY, MEDICAL RECORD REVIEW, KNOWLEDGE OF PRESCRIPTIONS l

ANOTHER WORD ABOUT DRUGS l MOST ILLICIT DRUG DEATHS ARE ACCIDENTAL (COCAINE, HEROIN) l HOMICIDE IS ALMOST NEVER A CONSIDERATION l PRESCRIPTION NARCOTIC DEATH EPIDEMIC l ACCIDENT VERUS SUICIDE VERY DIFFICULT

REMOTE DRUG OVERDOSE l l l PATIENT TAKES INTENTIONAL NARCOTIC OVERDOSE AND IS RESUSCITATED SEVERE ANOXIC ENCEPHALOPATHY (BRAIN INJURY) LIVES FOR MONTHS OR YEARS IN LONG TERM CARE FACILITY EVENTUALLY DIES FROM PNEUMONIA COD: COMPLICATIONS OF REMOTE DRUG OVERDOSE MOD: SUICIDE

HOMICIDE l DEATH AT THE HANDS OF ANOTHER l AGAIN, INTENT TO KILL A PERSON NOT NECESSARILY REQUIRED, BUT AN INTENTIONAL ACT IS HUNTING “ACCIDENTS” ARE HOMICIDES l NOT THE SAME AS “MURDER” l

EXAMPLES l “GUNSHOT WOUND OF TRUNK” l “MULTIPLE GUNSHOT WOUNDS” l “BLUNT TRAUMA OF HEAD WITH ALCOHOL INTOXICATION” l “ASPHYXIA DUE TO STRANGULATION”

REMOTE GUNSHOT WOUND l GSW TO BACK DURING ASSAULT WITH SUBSEQUENT QUADRIPLEGIA l 20 YEARS LATER DEVELOPS FATAL UROSEPSIS DUE TO NEUROGENIC BLADDER l CAUSE OF DEATH: COMPLICATIONS OF GUNSHOT WOUND l MOD: HOMICIDE

UNDETERMINED l “WE DON’T KNOW WHAT HAPPENED” l 3 -5% OF M. E. CASES l A MEASURE OF HONESTY l BUT WHAT DO YOU DO WHEN YOU KNOW WHAT HAPPENED, BUT NONE OF THE CATEGORIES FIT?

HOMICIDE, ACCIDENT AND SUICIDE USUALLY NOT THE PROBLEM l PHYSICIANS WILL NOT NEED TO BE CONCERNED WITH OTHER THAN NATURAL DEATHS l J. P. ’s WILL LIKELY GET INPUT FROM A FORENSIC PATHOLOGIST FOR OTHER THAN NATURAL DEATHS l BUT LEARNING HOW TO RECOGNIZE INAPPROPRIATE D. C. ’s IS A GOOD THING

ACTUAL D. C. s l THESE WERE CULLED FROM CERTIFICATES COMING THROUGH OUR OFFICE WITH CREMATION REQUESTS OVER A BRIEF PERIOD l FAIRLY TYPICAL OF WHAT WE SEE DAILY l SOME HAVE SIGNIFICANT ISSUES

THIS IS NOT ONE OF THEM PERFECTLY ADEQUATE D. C. l EXCEPT THAT B. AND C. SHOULD BE ON THE SAME LINE l l HEPATITIS C DOESN’T CAUSE ALCOHOLIC HEPATITIS

OXYMORONIC IF YOU HAVE ALCOHOL USE, HOW CAN YOU HAVE NON-ALCOHOLIC STEATOHEPATITIS? ?

YEP, l WITHOUT A PANCREAS, YOU WON’T GET PANCREATIC CARCINOMA

GOOD D. C. BUT IT WOULD BE BETTER TO JUST SAY “PULMONARY ARTERY SARCOMA” l EVERYTHING ELSE IS PART OF THE MECHANISM OF DEATH, AND ADDS NOTHING TO THE DEATH CERTIFICATION l

GOOD D. C. EXCEPT A. AND B. ARE REVERSED l THE ANOXIC ENCEPHALOPATHY COMES FROM THE CARDIAC ARREST l IS THERE AN UNDERLYING CAUSE OF THE PNEUMONIA AND THE MALNUTRITION? l

HOW ABOUT…. “NON-SMALL CELL LUNG CARCINOMA” l WAY TOO MUCH INFORMATION CRAMMED ONTO THIS D. C. l CONFUSING AND ADDS NOTHING l EXTRA STUFF BELONGS IN THE MEDICAL RECORD, NOT ON THE D. C. l

Hmmmm…. SO RESPIRATORY FAILURE CAUSED THE COPD AND UTI? ? ? l BY THE WAY…SHOULD NEVER USE ABBREVIATIONS ON DEATH CERTIFICATES l AND NEVER PUT “UNKNOWN” ON A D. C. UNLESS YOU ARE A M. E. OR J. P. WITH A FULL INVESTIGATION TO WORK WITH l

SPINAL CORD TRAUMA? !? !? ! JUST HOW IS THAT A “NATURAL” DEATH? l TURNS OUT THIS WAS FROM A GUNSHOT WOUND YEARS AGO, SO THIS IS A CLEARCUT AND OBVIOUS HOMICIDE, NOT A NATURAL DEATH! l

PRETTY GOOD D. C. A. AND B. SUPERFLUOUS l OTHERWISE, WORKS IN AN ELDERLY PERSON l IN A YOUNG PATIENT, THE COLON ISCHEMIA WOULD HAVE TO BE EXPLAINED FURTHER l

GREAT D. C.

WHY NOT JUST SAY “PANCREATIC CANCER”?

FAIR, BUT…. THE RENAL DISEASE WAS LIKELY DUE TO THE DIABETES AND HYPERTENSION l THESE CONDITIONS SHOULD BE IN PART I l

NOPE B. AND D. SHOULD BE IN PART II. l NOT RELATED TO THE HEART DISEASE THAT WAS THE CAUSE OF DEATH l

SEVERAL PROBLEMS WHAT DOES THE “SEPSIS” IN PART I HAVE TO DO WITH THE HEART DISEASE? l PART II IS REPETITIVE, AND NO CAUSE IS GIVEN FOR THE SEPSIS l M. E. WILL LIKELY QUESTION THIS l NSTEMI (DOES EVERYONE KNOW WHAT THIS MEANS? ) l DON’T ABBREVIATE l

GOOD D. C. l CORONARY ARTERY DISEASE LIKELY CAUSED PARTIALLY BY BOTH DIABETES AND HYPERTENSION l l I WOULD PUT BOTH OF THOSE CONDITIONS ON LINE C. PERFECTLY ACCEPTABLE TO PUT MORE THAN ONE CONDITION ON A LINE IF THAT’S WHAT YOU BELIEVE

BREAST CANCER DUE TO LIVER FAILURE? ? l PERHAPS THE OTHER WAY AROUND? l l DOUBT THAT LIVER FAILURE CAUSED THE CANCER D. C. HAS VERY CLEAR INSTRUCTIONS ON HOW TO ORGANIZE THESE STATEMENTS!

NO PROBLEMS AT ALL WITH THIS CERTIFICATE l DEMENTIA OFTEN DOES EVENTUALLY CAUSE DEATH DUE TO SUCH CONDITIONS A l l l INANITION ASPIRATION PNEUMONIA AGAIN, THIS IS FINE IN AN ELDERLY PERSON l NOT SO MUCH IN THE YOUNG; WOULD NEED AN UNDERLYING CONDITION

GREAT D. C……AND VERY NICE HANDWRITING! BUT A HANDWITTEN D. C. IS NO LONGER ACCREPTABLE TO DSHS l OTHERWISE, THE D. C. IS PROPERLY DONE, AND IS ALSO OK WITH THE M. E. l

ONLY PROBLEM IS… FORGET THE “CARDIORESPIRATORY FAILURE” l WHAT CAUSED THE SEPTIC SHOCK? l

THIS ISN’T A CAUSE OF DEATH STATEMENT IT’S MORE LIKE A MEDICAL RECORD l ALMOST NONE OF THIS BELONGS ON A D. C. l CAUSE OF DEATH SHOULD SIMPLY READ “PNEUMONIA” l l PROBABLY NEEDS A “DUE TO…” COULD ADD “HOSPITAL ACQUIRED” DOES EVERYONE KNOW WHAT S. O. B. MEANS?

IT’S REALLY NOT THAT HARD l INSTRUCTIONS ARE ON THE D. C. l DOCTORS TEND TO OVERTHINK THIS AND TRY TO TURN THE D. C. INTO PART OF THE MEDICAL RECORD DOCUMENTATION l JUST NEED TO CONCENTRATE ON THE MAJOR FACTORS THAT RESULTED IN DEATH

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