Initial Proposal

DATE: March 22, 1999

PROJECT TITLE: Death Certificates: An Online Continuiing Medical Education Course (title subject to change)

UT AUSTIN ISD TEAM: Lynda Abbott, Kristin Scott, Laurie Williams

OTHER TEAM MEMBERS: Mark Gregg (Public Health Professional EducationProgram); Kate Hendricks, MD (Infectious Disease Epidemiology & Surveillance Division and CME Chair, TDH); Rose Brownridge, MD (Bureau of Vital Statistics); Steve Elkins (Bureau of Vital Statistics)

GOAL: Improving the accuracy of death certificates

TARGETED AUDIENCE: The targeted audience for this unit of instruction is primarily physicians in Texas. There is a possible secondary audience made of of others who may be responsible for filling out death certificates (ie. funeral directors or Justices of the Peace).

PROPOSED IMPLIMENTATION PLAN: The project is to be designed as an website meeting the goal in two ways: (1) As an online CME course; (2) As a "just in time" learning resource;

CONCEPT MAP (See Appendix Item 1): The concept map depicts the flow of information that is to be delivered in this unit of instruction. It includes introductory information, a procedural strand and a strand specific the sections of the death certificate that pertain to physicians (Part I and Part II).

OBJECTIVES (See Appendix Item 2): Objectives are broken into the following categories: (1) Significance; (2) Procedural; (3) Medical Opinion; (4) Identification of Common Errors.

OUTLINE (See Appendix Item 3): The outline represents the organization of information that is to be covered within the instructional unit.

SAMPLE TEST ITEMS (See Appendix Item 4): Three samples of possible test items are given.

Approved: ................................................................................................Date:.......................................................

Revisions Needed:.................................................................................................................................................

APPENDIX

ITEM 1: CONCEPT MAP

 

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ITEM 2-OBJECTIVES:

1.

Explain to whom and why the cause of death is significant.

1.1

2.

Explain the criteria for deciding when the Medical Examiner or Coroner should be notified of the death.

2.1

3.

Explain how the decision is to be made about who should fill out the form in the case of a death by natural causes.

2.12

4.

Explain how the decision is to be made about deaths that are remanded to the Medical Examiner or Coroner.

2.13

5.

Know which form and in what circumstances a Fetal Death Certificate should be completed.

2.21

6.

Understand the procedures for filling out the Fetal Death Certificate.

2.21.1

7.

Know the circumstances in which a standard Death Certificate form can be used.

2.22

8.

Know how to identify the place of death (particularly in the case of patients who die en route to the hospital in an ambulance or bodies found -- when unknown is the appropriate entry for place of death).

2.3

9.

Know when and how to amend the death certificate.

2.4

10.

Know how and when, and who should pronounce the time of death and enter this time on the Death Certificate.

3.1

11.

Know how and when, and who should certify the cause of death.

3.2

12.

Know how to specify a medically significant sequence of events as the cause of death

3.2

13.

Differentiate between the immediate cause of death and underlying causes of death (in a manner appropriate to the needs of vital statistics data-collectors and decision-makers about resource allocations).

3.2.a

14.

Know when a cause of death can (or should) be filled out as a simple, Part 1 one-line cause of death.

3.2.b

15.

Know when and how to record the cause of death with an appropriate sequence of "due to" lines in Part 1.

3.2.c

16.

Know what to do when more lines are needed to fill in Part 1 of the cause of death portion of the Death Certificate.

3.2.d

17.

Know how to decide when a cause related to the death belongs as part of Part 1 or Part 2 of the cause of death portion of the Death Certificate form.

3.2.3

18.

Differentiate between the "mode of dying" (or "mechanistic terminal events") and a more relevant cause of death (and explain why the difference is important to accurate collection of vital statistics data).

3.2.f

19.

Know which designations of cause of death are non-specific "system failure" descriptions and understand how to add specific details in order to pinpoint a medically significant cause of death.

3.2.g

20.

Know how to specify the time sequence for the causes leading to the most significant cause of death.

3.2.h

21.

Be able to identify the most common errors in completing the death certificate and explain how to avoid these errors.

4.1

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ITEM 3-OUTLINE:
  1. SIGNIFICANCE -- What's so vitally important about Vital Statistics? What are the ethical issues?
  2. PROCEDURES
  1. NOTIFICATION
    1. Who should be notified about the death?
    1. Who should fill out the form (or who should fill out a portion of the form)?
  1. DEATH DUE TO NATURAL CAUSES
    1. Fetal Certificate
    1. Is the decedent a fetus? (Is this a death due to stillbirth?)
    2. Filling out the Fetal Death Certificate form (pertinent issues/general line-by-line procedures) -- except any medical portions
    1. Regular Death Certificate
    1. When should the Standard Death Certificate form be used?
    2. Filling out the Standard Death Certificate form (pertinent issues/ general line-by-line procedures) -- except the medical portions
  1. DEATH DUE TO CAUSES OTHER THAN NATURAL CAUSES
    1. Accident or Injury?
    2. Homicide or Suicide?
    3. "Found" Body?
    4. Child Under 6 Years of Age?
  1. SPECIFYING THE PLACE OF DEATH
  2. AMENDING THE DEATH CERTIFICATE
  1. MEDICAL OPINION / CAUSE OF DEATH
    2.
  1. PRONOUNCING THE DEATH
    1. What are the responsibilities of the pronouncing physician?
    2. What are some of the common errors or complicating circumstances that cause problems regarding the time or date of death?
  1. CERTIFYING THE DEATH
    1. Who is the primary "audience" for the cause of death? How does this affect how the cause of death is written?
    2. Completing Part I of the Cause of Death portion of the Death Certificate
    1. When is one line enough for the Cause of Death?
    2. When should multiple lines be used for Part I of the Cause of Death?
    3. What method should be used if more lines than those provided are needed for Part I of the Cause of Death?
    4. When is probable, presumed, or unknown the appropriate entry in Part I?
    5. What is the difference between the mode of death (or "mechanistic terminal events) and the cause of death needed for the certification?
    6. What method should be used to clarify a cause of death that may err because of a possibly vague organ system failure designation rather than a data-collection significant cause of death?
    1. Completing Part II of the Cause of Death portion of the Death Certificate
    1. What is the criteria for deciding whether to put a cause in Part I or Part II of the Death Certificate ?
    2. How related do the "related causes" need to be?
IV. COMMON ERRORS -- AND HOW TO AVOID THEM

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ITEM 4-EXAMPLES OF TEST ITEMS:

Example 1-

Instructions: Read the following case scenario. Based on the information presented, determine the following:

  1. immediate cause of death
  2. sequence of conditions leading to immediate cause of death
  3. other significant conditions contributing to but not resulting in the underlying cause

Write your answer in the appropriate space in the table below.

A 70-year-old man with a 10-year history of diabetes mellitus and hypertension and a 2-year history of angina presents to hospital with an acute myocardial infarction. Two weeks after discharge, he returns with recurrent pain and signs of congestive heart failure. His electrocardiogram shows ischemia. He is admitted to the coronary care unit, where he has a cardiac arrest and dies.

Cause of Death Statement

Part

Approximate interval between

onset and death

Part I

a)

b)

c)

d)

 

Part II

 

 

 

 

Example 2-

Instructions: Read the following case scenario. Based on the information presented, identify the errors in the completion of the "cause of death" section on the left.

Write the correct information in the section on the right.

A 69-year-old woman falls on an icy sidewalk and fractures her hip. She is admitted to hospital, where she undergoes surgery to repair the fracture. Her postoperative course is complicated by a deep venous thrombosis and a fatal pulmonary embolus 1 week after surgery.Incorrect completion of Cause of Death statement

Correct completion of Cause of Death statement

Part

Approximate interval between

onset and death

Part

Approximate interval between

onset and death

Part I

a) Pulmonary

embolism

b)

c)

1 hour

Part I

a)

b)

c)

 

Part II

Hip fracture

1 week

Part II

 

 

Example 3-

Instructions: Read the following case scenario. Based on the information presented, differentiate between the immediate cause of death and underlying causes of death. Write your answer in the space provided.

Immediate cause of death: ______________________________________________

Underlying cause(s) of death: ___________________________________________

____________________________________________________________________

Clostridium difficile colitis develops in an 88-year-old nursing-home resident. The woman has not received antibiotics recently. She is admitted to hospital for rehydration and antimicrobial therapy. She has a 25-year history of type II diabetes mellitus and a 10-year history of angina. On the day of her scheduled discharge from hospital, she suffers a thrombotic stroke in the territory of the left middle cerebral artery that is confirmed on a CT scan of the head. Her level of consciousness deteriorates, and she dies.

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Last Update 7/20/99