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Confirmation of death & death certification Test Cases Undergraduate Medical Education

Confirmation of death & death certification Test Cases Undergraduate Medical Education. Mrs Joan Williams. 76 year old woman Admitted 2 days ago She died on your ward 28 hours after admission. A heavy smoker since adolescence

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Confirmation of death & death certification Test Cases Undergraduate Medical Education

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  1. Confirmation of death & death certification Test Cases Undergraduate Medical Education

  2. Mrs Joan Williams. 76 year old woman Admitted 2 days ago She died on your ward 28 hours after admission. A heavy smoker since adolescence Long history of breathlessness on exercise, increasing so that she could walk only a few yards. Clinical records indicate a history of productive cough each year for several years, with several hospital admissions When she came to hospital for this last time, she was very unwell, pyrexial, and coughing up green sputum. X-ray showed consolidation in the right lower lobe, but the lungs were otherwise hyper-inflated Answer: Ia Bronchopneumonia Ib Chronic obstructive pulmonary disease II Leave blank Training Case 1

  3. Mr Michael Jones. 72 year old man Consultant Mr. J.D. Walker Admitted 11th May 2008 (3 days ago) Died on your ward 36 hours after admission. Last seen alive by you 13th May 2008 Died 14th May 2008 Death confirmed by you. Death took place on Ward 2. A heavy smoker since adolescence, with a long history of intermittent claudication. Posterior myocardial infarct 2 years ago. Came to hospital this time with central crushing chest pain. Initial blood tests showed a raised troponin T and the ECG showed acute changes of an inverted T wave in most leads. Answer: Ia Acute myocardial infarction Ib Coronary artery thrombus Ic Coronary artery atheroma II leave blank Training Case 2

  4. Mr Robert Perkins. 56 year old man Admitted 3 days ago Died on your ward 32 hours after admission. A heavy drinker since adolescence, with a long history of alcohol abuse documented in the clinical records. Two previous admissions for fractures related to falls when drunk. Investigated for previous episodes of haematemesis, and had sclerotherapy carried out on the oesophagus three years ago. When he came to hospital this time, he was vomiting large amounts of fresh blood. Initially, he responded to resuscitation but then he had a second major haematemesis and this time, he could not be resuscitated. Answer: Ia Massive haematemesis Ib Oesophageal varices Ic Alcoholic cirrhosis of the liver II leave blank Training Case 3

  5. Mrs. Edna Simpson. 86 year old lady Admitted with a fractured neck of femur following a fall at her house. She had a hip replacement the following day. Very slow to mobilise despite the physiotherapist’s best efforts. Seven days later she began to complain of a pain in her left leg which was confined mainly to the calf muscle. The F2 doctor examined her leg and started her on low molecular weight heparin. The following morning she suddenly developed severe central chest pain and breathlessness. Treated with frusemide and oxygen but died 2 hours later. Her past medical history included ischaemic heart disease and hypertension for which she was on lisinopril and simvastatin before admission. She had a body mass index of 32. She had a mastectomy 8 years previously for carcinoma of the breast. Answer: Ia Pulmonary embolus Ib Deep vein thrombosis left leg Ic Fracture of left femur due to a fall II Ischaemic heart disease NB: The Coroner should be informed as the fracture was originally due to the accident but you can provide a Death Certificate. Training Case 4

  6. Answer: You cannot complete the certificate as you do not know what she died of (chest infection? MI? head injury?). The accident may also have been contributory to her death. The case needs to be referred to the Coroner. Training Case 5 Mrs. Rebecca Cohen. • 72 year old lady • Retired Teacher • History of breathlessness on exertion for several months. While driving her car back home in the early evening she drove head on into a wall. No other person was involved. • On admission she was found to have an elevated Troponin level but her ECG was normal. There were 6 undisplaced rib fracures on the left side. There was also bruising to the left hip and some minor cuts and abrasions on her face and arms. • Admitted to your ward and treated with IV fluids, analgesics and antibiotics. Despite this treatment she becomes confused, developed a chest infection and died 30 hours after admission. You have been asked to complete a Medical Certificate of the Cause of Death.

  7. Mr Gordon Weasley. 48 year old man Mr. Weasley had been suffering from occasional headaches for about 5 weeks. They seemed to be related to stressful situations. They were mainly on the left side of his head. He saw his GP 12 days ago who told him that they were migraines. His GP also took his blood pressure and said that it was a bit high, took some blood tests and made him another appointment after 2 weeks. More recent headaches have been associated with pain down the neck. Then 3 days ago he suddenly developed a blinding headache which became rapidly worse and worse until he collapsed and lost consciousness. He was rushed by ambulance to A&E. A CT scan showed a massive subarachnoid haemorrhage. He had remained drowsy with a Glasgow Coma Score of 9-11 since admission. The neurosurgeons reviewed the scan and decided that there was no acute surgical management possible. He was treated with an infusion of nimodipine and full supportive measures. This morning he suddenly deteriorated and an urgent CT scan showed that he there had been a further bleed. He never regained consciousness and died a few hours later. Answer: Ia Subarachnoid haemorrhage Ib Systemic Hypertension Ic Leave blank II Leave blank Training Case 6

  8. Mr Mohammed Khan. 34 year old man Mr. Khan had a history of benign intracranial hypertension. He had been looked after by the neurologists for some years. He had a VP shunt inserted in his teens and it had been revised twice, the last time just over 4 years ago. 3 days ago he started to develop a headache and took some paracetamol. The next day it was becoming more troublesome so he went to see his GP who noticed that the site of the shunt was a little tender so gave him some amoxicillin and arranged for him to be admitted. He was admitted to your ward 36 hours ago. Blood cultures were taken. A CT scan showed that he did not have raised intracranial pressure so a lumbar puncture was performed. The CSF was turbid. The antibiotics were changed. Culture of the CSF grew pneumococcus. He began to become drowsy and his conscious level rapidly deteriorated. He had several grand mal seizures. A further CT scan showed no new changes. Shortly after he returned from the CT scanner he suddenly went into asystole from which he could not be resuscitated. Answers: Ia Bacterial meningitis Ib Benign intracranial hypertension with shunt Ic leave blank II leave blank *NOTE you would discuss this with the Coroner as the death may in part be a consequence of therapy Training Case 7

  9. Mr. Frank Anderson. 64 year old man Mr. Anderson had been becoming slowly more disabled by his Multiple Sclerosis for the past 12 years. About 12 months ago he had reached the stage where he could only move around in a motorised wheelchair. For the last 3 months, however, he had been confined to his bed and his wife was having to do almost everything for him. 4 days ago he started to develop a productive cough and became pyrexial. After 2 days his wife could not cope any longer and so he was admitted 2 days ago to your ward. A chest xray showed widespread patchy shadowing. His antibiotics were changed but he continued to deteriorate and he died this morning. Answer: Ia Bronchopneumonia Ib Multiple Sclerosis Ic leave blank II Leave blank Training Case 8

  10. Training Case 9 • Mrs. Anne Bennington. • 51 year old lady • Mrs. Benington had spent 3 weeks visiting her daughter in Australia. On the final part of the journey, the transatlantic trip from Los Angeles to Manchester, she started to notice that her left leg was a bit more swollen than the right leg. By the time she landed in Manchester her left calf was tender when squeezed. She and her husband took a taxi home, deposited their luggage, then her husband drove her to the A&E department. On examination her left calf was red, warm, tender and swollen. She was admitted. An ultrasound examination confirmed a DVT in the left leg. She was started on low molecular weight heparin. • Her past medical history included a removal of a lump in her left breast 1 year earlier which had proved to be a malignancy. She was still being followed up and had a clinic appointment in 3 weeks time to review this problem. She used to smoke about 10 cigarettes/day but had stopped 2 years earlier. • 2 days after she was admitted while visiting the toilet she suddenly developed acute central chest pain and breathlessness. She collapsed in the corridor. The cardiac arrest team was called but resuscitation was not successful. Answer Ia Pulmonary Embolus Ib Deep vein thrombosis left leg Ic leave blank II leave blank

  11. Training Case 10 • Mr. Tim Smith. • 31 year old man • Mr. Smith was known to be HIV positive. He had contracted it at the age of 26. He had been treated fairly successfully until about 12 months ago at which point he started to develop increased complications and infections. He had lost a great deal of weight in the past few months and looked quite ill. • Over the past 6-8 months his GP has given him 3 courses of antibiotics for chest infections. One week ago he developed a dry cough, malaise and pyrexia. His GP gave him another course of antibiotics but after 4 days he was no better. He was therefore sent to A&E. • He was admitted to your ward 5 days ago. He looked pale and slightly jaundiced. He was pyrexial, breathless and hypoxic on room air. A chest xray showed diffuse bilateral shadowing. Sputum was sent to the lab requesting specifically to search for pneumocystis carinii. He was started on high dose cotrimoxazole. Despite this treatment he rapidly deteriorated becoming more breathless and hypoxic on high flow oxygen. A case conference with the ICU team took place and it was decided that ICU treatment was not indicated. He died this morning. The laboratory result confirmed the diagnosis of pneumocystis carinii pneumonia. Ia Pneumocystis carinii pneumonia Ib Human Immunodeficiency Virus infection Ic leave blank II leave blank

  12. UPSA A7: Confirmation of death & death certification Questions Undergraduate Medical Education

  13. E_U_A_I_N • Z T G E • F A N Q • U G C H • C T D O

  14. 1. Verifying the fact of death: Who can verify the fact of death? • Anyone involved in the medical care of the patient • Only the consultant or GP looking after the patient • Only registered medical practitioners • Only registered medical practitioner and appropriately trained nurses

  15. 2. Confirmation of death: • Fixed, dilated pupils • No ventilatory effort (10 seconds) • No pulse • No heart sounds (>1 min) What test would be INAPPROPRIATE when confirming cessationof cardio-respiratory function?

  16. 3. Confirmation of death: • Response to pain & retinal inspection • Retinal inspection & 3 lead ECG • 3 lead ECG and Arterial Blood Gas • Check responsiveness then look, listen and feel for breaths for 10 seconds If uncertainty remains, what 2 tests can be performed?

  17. 4. Recording the assessment • Whether relatives were present at time of death • What medication the patient was prescribed • If pacemaker or radio-active implants were insitu • The patient’s religion As well as recording that vital signs were absent, you should also note:

  18. 5. The medical certificate of the cause of death (MCCD) • The registrar of Births, deaths and marriages • The consultant in charge of the patient • The Chief Medical Officer • The Coroner’s office It is the statutory duty of the doctor who attended the deceased during their last illness to report the cause of death to:

  19. 6. Statement of cause of death • Part I records a patient’s reason for admission and Part II records any differential diagnoses • Part I records any acute illnesses and Part II records any chronic illnesses • Part I records presenting complaint for this admission and Part II records any previous causes for admission • Part I records the immediate causes of death & Part II records conditions that contributed to death The MCCD is divided into Parts I & II. Which statement is correct:

  20. 7. Fetuses, Infants and Stillbirths • Before 24 weeks of gestation a fetus is delivered with no signs of life • Before 24 weeks gestation a fetus is delivered with signs of life before it dies • After 24 weeks gestation a fetus is delivered with no signs of life • After 24 weeks of gestation an abortion is performed Death certificate is NOT required if:

  21. 8. HM Coroner • Died a violent or unnatural death • Died a sudden death (cause unknown) • Died a sudden death (cause known) • Died in prison (or in a place/circumstance that would required an inquest under any other Act) A death would NOT necessarily require reporting to the coroner if the deceased:

  22. 9. Cremation Cremation cannot take place until the death has been properly registered. Several forms must be completed (Forms A – F). In hospital which form is most likely to be completed by a pathologist? • Form 1 • Form 4 • Form 5 • Form 9

  23. 10. Cremation Which form contains 18 specific questions relating to violence, poison or neglect? • Form 4 • Form 10 • Form 1 • Form 9

  24. 11. Cremation Which form is the authority to cremate given by the medical referee? • Form 1 • Form 5 • Form 11 • Form 10

  25. That’s the end of the questions…

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