Us Standard Certificate Of Death (Page 3 of 4) in pdf

Cause-of-death – Background, Examples, and Common Problems

Accurate cause of death information is important

•to the public health community in evaluating and improving the health of all citizens, and

•often to the family, now and in the future, and to the person settling the decedent’s estate.

The cause-of-death section consists of two parts. Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on

line a and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line. Part II is for reporting all other significant diseases,

conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I. The cause-of-death information should be YOUR best medical OPINION. A condition can be

listed as “probable” even if it has not been definitively diagnosed.

Examples of properly completed medical certifications

CAUSE OF DEATH (See instructions and examples)

Approximate interval:

Onset to death

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional

lines if necessary.

IMMEDIATE CAUSE (Final

Minutes

Rupture of myocardium

disease or condition --------->

__________________________________________________________________________________

resulting in death)

Due to (or as a consequence of):

6 days

Acute myocardial infarction

Sequentially list conditions,

_______________________________________________________________________________

if any, leading to the cause

Due to (or as a consequence of):

listed on line a. Enter the

5 years

Coronary artery thrombosis

UNDERLYING CAUSE

_______________________________________________________________________________

(disease or injury that

Due to (or as a consequence of):

initiated the events resulting

7 years

Atherosclerotic coronary artery disease

in death) LAST

__________________________________________________________________

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

33. WAS AN AUTOPSY PERFORMED?

■ Yes

Diabetes, Chronic obstructive pulmonary disease, smoking

34. WERE AUTOPSY FINDINGS AVAILABLE TO

COMPLETE THE CAUSE OF DEATH? ■ Yes

35.

DID TOBACCO USE CONTRIBUTE TO DEATH?

36. IF FEMALE:

37. MANNER OF DEATH

■ Not pregnant within past year

■

■ Natural

Yes

Probably

Pregnant at time of death

Homicide

Not pregnant, but pregnant within 42 days of death

Accident

Pending Investigation

Unknown

Suicide

Could not be determined

Not pregnant, but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

Approximate interval:

CAUSE OF DEATH (See instructions and examples)

Onset to death

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional

lines if necessary.

IMMEDIATE CAUSE (Final

2 Days

Aspiration pneumonia_______________________________________________________________

disease or condition --------->

resulting in death)

Due to (or as a consequence of):

7 weeks

Complications of coma

Sequentially list conditions,

___________________________________________________________________________________

if any, leading to the cause

Due to (or as a consequence of):

listed on line a. Enter the

7 weeks

Blunt force injuries

UNDERLYING CAUSE

________________________________________________________________________________________

(disease or injury that

Due to (or as a consequence of):

initiated the events resulting

Motor vehicle accident

in death) LAST

____________________________________________________________________________________

7 weeks

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

33. WAS AN AUTOPSY PERFORMED?

■ Yes

34. WERE AUTOPSY FINDINGS AVAILABLE TO

COMPLETE THE CAUSE OF DEATH? ■ Yes

35.

DID TOBACCO USE CONTRIBUTE TO DEATH?

36. IF FEMALE:

37. MANNER OF DEATH

Not pregnant within past year

Yes

Probably

Natural

Homicide

Pregnant at time of death

■ Accident

Pending Investigation

Not pregnant, but pregnant within 42 days of death

■ No

Unknown

Suicide

Could not be determined

Not pregnant, but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

38. DATE OF INJURY

39. TIME OF INJURY

40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)

41. INJURY AT WORK?

(Mo/Day/Yr) (Spell Month)

Approx. 2320

road side near state highway

Yes ■ No

August 15, 2003

42. LOCATION OF INJURY:

State: Missouri

City or Town: near Alexandria

Street & Number: mile marker 17 on state route 46a

Apartment No.:

Zip Code:

43. DESCRIBE HOW INJURY OCCURRED:

44. IF TRANSPORTATION INJURY, SPECIFY:

■ Driver/Operator

Decedent driver of van, ran off road into tree

Passenger

Pedestrian

Other (Specify)

Common problems in death certification

The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible. Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical

research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to

death, and place any other pertinent conditions in Part II. If after careful consideration the physician cannot determine a sequence that ends in death, then the medical examiner or coroner should be consulted about

conducting an investigation or providing assistance in completing the cause of death.

The infant decedent should have a clear and distinct etiological sequence for cause of death, if possible. “Prematurity” should not be entered without explaining the etiology of prematurity. Maternal conditions may have

initiated or affected the sequence that resulted in infant death, and such maternal causes should be reported in addition to the infant causes on the infant’s death certificate (e.g., Hyaline membrane disease due to

prematurity, 28 weeks due to placental abruption due to blunt trauma to mother’s abdomen).

When SIDS is suspected, a complete investigation should be conducted, typically by a medical examiner or coroner. If the infant is under 1 year of age, no cause of death is determined after scene investigation, clinical

history is reviewed, and a complete autopsy is performed, then the death can be reported as Sudden Infant Death Syndrome.

When processes such as the following are reported, additional information about the etiology should be reported:

Abscess

Carcinomatosis

Disseminated intra vascular

Hyponatremia

Pulmonary arrest

Abdominal hemorrhage

Cardiac arrest

coagulopathy

Hypotension

Pulmonary edema

Adhesions

Cardiac dysrhythmia

Dysrhythmia

Immunosuppression

Pulmonary embolism

Adult respiratory distress syndrome

Cardiomyopathy

End-stage liver disease

Increased intra cranial pressure

Pulmonary insufficiency

Acute myocardial infarction

Cardiopulmonary arrest

End-stage renal disease

Intra cranial hemorrhage

Renal failure

Altered mental status

Cellulitis

Epidural hematoma

Malnutrition

Respiratory arrest

Anemia

Cerebral edema

Exsanguination

Metabolic encephalopathy

Seizures

Anoxia

Cerebrovascular accident

Failure to thrive

Multi-organ failure

Sepsis

Anoxic encephalopathy

Cerebellar tonsillar herniation

Fracture

Multi-system organ failure

Septic shock

Arrhythmia

Chronic bedridden state

Gangrene

Myocardial infarction

Shock

Ascites

Cirrhosis

Gastrointestinal hemorrhage

Necrotizing soft-tissue infection

Starvation

Aspiration

Coagulopathy

Heart failure

Old age

Subdural hematoma

Atrial fibrillation

Compression fracture

Hemothorax

Open (or closed) head injury

Subarachnoid hemorrhage

Bacteremia

Congestive heart failure

Hepatic failure

Paralysis

Sudden death

Bedridden

Convulsions

Hepatitis

Pancytopenia

Thrombocytopenia

Biliary obstruction

Decubiti

Hepatorenal syndrome

Perforated gallbladder

Uncal herniation

Bowel obstruction

Dehydration

Hyperglycemia

Peritonitis

Urinary tract infection

Brain injury

Dementia (when not

Hyperkalemia

Pleural effusions

Ventricular fibrillation

Brain stem hern tion

otherw e specified)

Hypovolemic shock

Pneumonia

Ventricular tachyc rdia

Carcinogenesis

Diarrhea

Volume depletion

If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear

that a distinct etiology was not inadvertently or carelessly omitted.

The following conditions and types of death might seem to be specific or natural but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago).

Such cases should be reported to the medical examiner/coroner.

Asphyxia

Epidural hematoma

Hip fracture

Pulmonary emboli

Subdural hematoma

Bolus

Exsanguination

Hyperthermia

Seizure disorder

Surgery

Choking