Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Tuesday, July 10, 2007
    Death and Mondays

    Our monthly staff meetings are always held on Mondays ("Monday Night Meeting" is a dreaded phrase among the doctors in The Firm, and on the rare occasions the meeting is canceled for the month it is known as "Miracle Monday"). In last night's meeting, as a special treat, we had one of our periodical lectures from Risk Management on How to Do Things Properly. This month it was How to Fill Out a Death Certificate. These talks, to be honest, are often useful and we usually come away from them knowing something we didn't know before. For instance, according to law the doctor has to complete the certificate within fifteen hours of the patient's death. This is a practice more honored in the breach than the observance: it's rare that the certificate is actually filled out within that time.

    Weekends are a perennial issue, as patients have an annoying habit of dying on Friday and Saturday nights. In Orthodox Judaism, for instance, the rule is that burial must take place within twenty-four hours after death. At one time or another every doctor in my group has received an urgent call from funeral homes on a Saturday or Sunday requesting that we sign off on a death so that the funeral can proceed on time. Getting access to the certificate is not the issue, as mortuaries serving the Orthodox community are very accommodating. Given their schedules, they have to be. They're happy to send messengers to the doctor at the hospital - or even at home - to get the thing signed. It's a different story when the doctor on call doesn't know the patient, doesn't feel comfortable certifying the cause of death, and we can't get hold of the primary care physician for clarification (most common scenario: the PMD is out of town on vacation). I've spent a few weekends in my time trying to pacify a distraught family by running to the office and ransacking charts, trying to figure out a cause of death that wouldn't involve me in fraud or perjury charges. Most of the time, fortunately, we are dealing with elderly patients with multiple medical problems who often reside in nursing homes, so that you don't have to be Sherlock Holmes to deduce the likely cause of death.

    This brings me to another tradition: the weekend phone call from the police. Oh yes, we get those: "Mr. Smith has been found dead at home. Will you sign the death certificate?" Usually the hapless on-call doc can give only one answer: "No." In this situation we usually have no information at all, meaning we don't know when the patient was last seen by their doctor, what the decedent's medical problems were or whether the death took place under suspicious circumstances. I usually lamely offer, "You can call Dr. X on Monday," but that's rarely a satisfactory answer unless it's 3 a.m. Monday morning.

    "But we'll have to call the coroner then!"

    So call him, dammit. That's his job.

    Assuming the primary care doctor is located, that the patient is considerate enough to die early on a weekday, and all the planets are aligned, we go on to the fun of actually completing the form. The mortuary usually faxes a "dummy" certificate for the doctor to fill out and fax back so that the formal certificate can be typed up and then brought to the office for the doctor to sign. (I have had funeral homes try to cut to the chase by having someone drop by with both the blank form and the actual certificate, asking me to sign the blank certificate and have them complete it later. I always refuse to do this. Never do this. One of the most valuable pieces of advice I ever got during my training came from a hardbitten attending who'd signed his share of these things: "Never sign a blank death certificate. It's like signing a blank check.")

    Stating the cause of death can be like determining how many angels can dance on the head of a pin. If you scroll to the bottom of this sample form here you will see that there are four lines for cause of death. You don't have to use all of them, but in some cases you might need to. This is to list both the immediate cause of death and whatever disease process might be linked to it. For instance:

    Cause of Death: Sepsis
    Caused By: Gangrene
    Caused By: Diabetes

    You get the idea.

    Most people get the hang of this after filling out one or two certificates, but coroners and mortuaries tend to be picky about what they will and will not accept as a cause of death. I myself, sad to say, have often defaulted to "cardiopulmonary arrest due to..." as my standard cause of death. After a few clashes with mortuary directors (and, if I recall correctly, one coroner's office), I lost my will to live. I mean, argue.

    This very issue was debated at our meeting last night, in which we were exhorted not to default to "cardiac arrest" as a standard cause of death. One MD reminded us of the vast amounts of money erroneously (he implied) devoted to cardiac disease research - money that is driven by death statistics, which are determined by... listings on death certificates. He said that when his elderly demented patients die, he lists respiratory arrest due to end-stage Alzheimer's and hasn't had it questioned so far.

    "But how exactly does that contribute to the cause of death?" countered another MD.

    One of my office mates fired back: "They forget to breathe." She brought down the house.




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