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How do you solve a problem
like death cert ineptitude?
Several
different ideas have been proposed to solve the
death-certification-error problem.
1 Ask coroners and medical
examiners to call doctors and alert them to their
mistakes. That's a time-consuming process, though,
so some prefer idea number two:
2 Design a CME workshop
on death certification. The first such course
in Canada was tested last year in Ontario and
appears to have been successful.
3 Circulate a handbook
with advice, as the BC Vital Statistics Agency
has done (it's available online at www.vs.gov.bc.ca/
stats/handbooks.html).
4 But Dr Dowling, our
Alberta medical examiner with the longshoreman's
turn of phrase, has another idea for you to try:
"On the back of the death certificate, there are
instructions. You should read them. That's a good
start."
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Alberta's chief medical examiner
Dr Graeme Dowling is fed up with all the error-riddled
and incomplete death certification forms he gets from
physicians all over the province. He's so fed up that
he's resorted to cursing and swearing. On February 29
he let them have it with his presentation "How Do I
Fill This *!@# Form Out Anyhow?" to the Alberta College
of Family Physicians. (You can insert the expletive
of your choice there, he says.)
"What does 'cause of death' really
mean? Most doctors don't know," fumes Dr Dowling.
The perception of doctors' mortal
incompetence in this area is widespread. Dr William
Lucas, associate deputy chief coroner of Ontario, says
about 5% of death certification forms filled out by
doctors are "wrong or appallingly bad." The last Canadian
study to audit death certificates, in 1998, found mistakes
in 33% of certificates. "But it depends on how particular
you are," he says. "If you want to be nitpicky, it might
be approaching 50%."
CAUSE
OF DEATH
The vast majority of errors appear in the 'cause of
death' section of the forms. Physicians are asked to
write down the immediate cause of death (for instance,
congestive heart failure), followed by the antecedent
cause (acute myocardial infarction), the underlying
cause (ischemic heart disease) and any contributing
conditions (diabetes, hypertension, smoking). But in
many cases — too many — physicians botch this
section.
Eighty-five percent of mistakes
are due to the failure to identify the underlying cause
correctly, according to a 2005 Statistics Canada study.
The document is looking for the underlying cause, like
pneumonia, not the mechanism, like asphyxia. "Probably
the worst one in terms of telling you nothing and being
not even a diagnosis is if it says cardiorespiratory
arrest, and that's the whole thing," says Dr Lucas.
"That's what happens when you croak."
Doctors' mistakes are sometimes
so egregious that recounting their worst errors has
become a favourite pastime of Canadian coroners and
medical examiners.
"I have actually seen 'Been Poorly
Lately' as the immediate cause of death," says Liana
Wright, a BC coroner. "We still get a good laugh around
here from that one."
'Old age' as the cause of death
also crops up now and again, causing a great deal of
consternation — and more than a little bemusement
— among coroners and provincial Vital Statistics
agencies, which are responsible for reviewing death
certification forms.
Ten percent of the mistakes in
the 'cause of death' section are due to an illogical
chronology, says Dr Lucas. Each cause of death —
immediate, antecedent, underlying — must be accompanied
by an "approximate interval between onset and death"
and an underlying cause should have arisen before an
immediate cause. But that's not done correctly in all
cases.
LEGAL
CONCERNS
Outrageous screw-ups aside, errors can indeed be a serious
matter. The document is, after all, a legal form. The
most serious errors are those in which physicians don't
realize they have an obligation, under a provincial
Coroners Act or Fatality Inquiries Act or
similar legislation, to notify a coroner or medical
examiner of an unnatural death (ie, foul play, suicide,
work-related death, etc). Physicians are only authorized
to certify natural deaths, which are defined for the
purposes of death certification forms as deaths that
are primarily due to a disease. Mistakes on the forms
can potentially lead to lost evidence in criminal cases,
say coroners.
PAPERWORK
TRAINING
Physicians have good intentions when it comes to death
certification, but they simply don't get any training
on how to do it right.
"In med school we didn't have a
course or even a lecture on how to fill out these forms
correctly," says Dr Lucas. "Then you get out there and
someone tells you to do it and you don't know how. People
start off with bad habits and keep doing it that way."
Some med schools are trying to change that now, though,
he says. "To be fair, a lot of doctors might have to
do this two or three or four times over the course of
a year so part of it is they don't get a lot of experience."
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