Ascertaining                             Cause of Death              in a

 Complicated Case

In actual practice, death certification may be relatively straightforward in certain cases and complicated in others. If a person has died because of a single condition such as malaria or tuberculosis or stroke, then the underlying cause of death is pretty straightforward -- it is malaria or tuberculosis or stroke respectively. Very often, individuals will have multiple disease conditions.

  • The cause of death depends on the biologically plausible sequence of events

  • Three case scenarios differing in the terminal sequence of events are as follows

 Example 1: Case scenario

An adult who is a smoker has ischemic heart disease, myocardial     infarction, diabetes, hypertension, stroke, COPD and pneumonia.

When this person dies, what is the single underlying cause that his death will be attributed to ?

Multiple terminal sequence of events leading to death 

​If he deteriorated because of the stroke and subsequently developed pneumonia and then died. The terminal sequence of events would appear as in Case 1 If on the other hand, it was COPD which worsened his terminal condition following the development of penumonia which triggered an acute exacerbation of COPD and then he died,  it would appear as in Case 2  If it was Myocardial infarction which caused his death then the terminal sequence of events would appear as in Case 3
               Case 1                          Case 2              Case 3
                Death

            Pneumonia

               Stroke		                            Death

                 Acute exacerbation

                      Pneumonia

                           COPD		                Death
 
     Myocardial Infarction

If the terminal sequence of events leading to death was:

Case 1 Case 2 Case 3
Death

Pneumonia

Stroke		 Death

Acute exacerbation

Pneumonia

COPD
 		 Death
 
Myocardial Infarction
Here,
 Stroke is the Underlying Cause of death		 Here,
 COPD is the Underlying Cause of death		 Here,
 MI is the Underlying Cause of death

If the terminal sequence of events leading to death was:

Case 1 Case 2 Case 3
Death

Pneumonia

Stroke		 Death

Acute exacerbation

Pneumonia

COPD		 Death
 
Myocardial Infarction
Here in Case 1,
all other conditions not in the disease pathway (such as hypertension, diabetes, IHD, MI, and COPD) should be listed as Contributory causes 		 Here in Case 2,
all other conditions not in the disease pathway (such as hypertension, diabetes, IHD, MI, and Stroke) should be listed as Contributory causes		 Here in Case 3,
all other conditions not in the disease pathway (such as hypertension, diabetes, Stroke and COPD) should be listed as Contributory causes

To be able to fill in a death certificate accurately, it is also very important to have good knowledge of standard terminologies that are commonly used during death certification.

Your next exercise is on standard terminologies in death certificate

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