How to correctly complete the New Medical Certificate of Cause of Death (MCCD)

Transcription

1 How to correctly complete the New Medical Certificate of Cause of Death (MCCD) Best Western Park Hotel, Falkirk Thursday, 11 May 2017 Dr Fiona Downs Medical Reviewer Death Certification Review Service (DCRS)

2 DCRS WHO? The team WHAT? Process HOW? Hints and Tips

3 WHO?? The team of Medical Reviewers 10 part time medically qualified senior clinicians. 5 General Practitioners +/- other roles. 5 Consultants Supported by six MR Assistants

4 ADVICE Call us telephone calls in seeking advice 1000 so far in Mostly from doctors asking about writing MCCDs Other calls from registrars, funeral directors and family members

5 WHAT IS THE DCRS? National system of review Proportionate, independent scrutiny of deaths (except those reported to the Procurator Fiscal) Aims Improve the quality and accuracy of MCCDs Provide better public health information Strengthen clinical governance of deaths

6 The process after the MCCD issued Form 11 Medical Certificate of Cause of Death Level 1 DCRS Form 14 Registrar Level 2 No review Permission to hold funeral

7 The process after the MCCD issued 100% 8.2% Level 1 DCRS Registrar 2.5% 71.3% Level 2 No review PF 18%

8 How many in ? Deaths in Scotland 57,573 Number reviewed 5,020

9 The Review Supportive and educational Outcome National Figures No changes needed 54% amendment 38% Reissue of MCCD 5% Ask to report to PF 3%

10 The Review Supportive and educational Outcome National Figures No changes needed 54% amendment 38% Reissue of MCCD 5% Ask to report to PF 3% Amendment needed and CD not available Hazards boxes missed or wrong Missing signature Mandatory move to level 2 (Notes / 3 days)

11 The Review Level 1 Review the MCCD Check GMC and CHI Speak to certifying doctor or another member of the team 1 working day to complete Level 2 Level 1 review tasks Review medical records Emergency Care Summary ECS Key Information Summary ekis All or part hospital / GP records 3 working days to complete

12 e MCCDs Currently GPs, Hospices, some Community Hospitals Sequential roll out in secondary care Advantages Legibility! Accuracy auto-population Time CDs immediately available Family Review often completed before reach Registrar s office

13 HOW? TIPS FOR CDS (CERTIFYING DOCTORS) General Spelling!! Legibility - Write clearly and use black ink Business contact telephone number no personal mobile numbers Junior staff should discuss content of the MCCD with senior staff No part of the form is optional

14 HOW? TIPS FOR CDS (CERTIFYING DOCTORS) Specific Time of death Logical Morbid Sequence Durations Abbreviations Hazards Doctor who attended The X box PF referrals

15 TIME OF DEATH The time of death is the time that to the best of your knowledge and belief you think the patient died Ask the nurses or check their notes.

16 MORBID SEQUENCE SHOULD MAKE MEDICAL SENSE CONDITION DIRECTLY CAUSING DEATH DUE TO 1c LEADING TO 1a DUE TO UNDERLYING CONDITION 4 sections of 2 lines of 69 characters UNDERLYING CONDITION CONDITION CONTRIBUTING TO DEATH BUT NOT PART OF THE ABOVE SEQUENCE 3 sections of 1 line of 69 characters

17 MORBID SEQUENCE SHOULD MAKE MEDICAL SENSE CONDITION DIRECTLY CAUSING DEATH Most recent CAUSED BY 1c LEADING TO 1a CAUSED BY UNDERLYING CONDITION UNDERLYING CONDITION Oldest CONDITION CONTRIBUTING TO DEATH BUT NOT PART OF THE ABOVE SEQUENCE

18 LOGICAL MORBID SEQUENCE Should: Convey to another doctor what caused the death of the patient Be understandable to a bereaved relative Exclude diagnostic information Probable or Likely can be used

19 DURATIONS Required for all entries (Parts I and II) - except Old Age Ticks are unacceptable For a sudden death use duration of 1 day

20 ABBREVIATIONS COPD CVA NSTEMI AKI E.Coli CT PACS TNM Classification all unacceptable ST is allowed as are HIV and AIDS

21 HAZARDS Hazards must be entered or a reissue is required Use ticks Avoid Y, N and crosses Deceased may have hazards unrelated to cause of death

22 DOCTOR WHO ATTENDED Doctor who Attended should have Cared for the patient during the illness or condition that led to death Been familiar with the patient s medical history, investigations and treatment No legal requirement for you to complete a certificate if you did not care for the patient in life You certify to the best of your knowledge and belief You are personally accountable A3 is rarely appropriate in hospital

23 THE X BOX Only tick this if you are awaiting histology toxicology other results which may change the cause of death. Don t tick it because you re a helpful sort of person.

24 PF REFERRALS Conditions recorded anywhere on the certificate: Any death due in part to an Accident - however long ago Asbestosis / pleural plaques / mesothelioma Notifiable organism - Acute and serious risk to Public Health Drug deaths prescribed and illicit If case will be part of a Serious Event Review Death under a Mental Health Detention Order Suicide If a Complaint is likely You can discuss or report. If you discuss leave the PF box blank

25 HANDING THE CERTIFICATE OVER GMC Good Medical Practice End of Life Care paragraphs without unnecessary delay. If there is any information on the death certificate that those close to the patient may not know about, may not understand or may find distressing, you should explain it to them sensitively and answer their questions. Worth mentioning about the review process

26 Some cases...

27 Mary is a frail 83 year old lady with Alzheimer's Disease and vascular dementia diagnosed 4 years ago. She lives at home with her elderly husband but her oral intake has been poor. She was admitted with behavioural problems and a medication review revealed poor compliance. She restarted her medication and was due to be discharged but began to refuse food and fluids and bloods showed mild dehydration. An intravenous infusion was commenced and she then refused to get out of bed. She developed a respiratory infection but no sputum culture could be obtained. Intravenous antibiotics were prescribed but she failed to respond to these and frequently removed her drip. Her condition continued to decline and her relatives were seen and the terminal situation explained. Comfort care was agreed and she died with her daughter and husband present 5 days after her infection had been diagnosed.

28 Approximate interval between onset and death 1 disease or condition directly leading to death (a) DEMENTIA Years Months Days Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last (b) (c) (d) II Other significant conditions contributing to the death, but not related to the disease or condition causing it

29 1 disease or condition directly leading to death (a) HYPOSTATIC PNEUMONIA NO ORGANISM Approximate interval between onset and death Years Months Days Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last 4 (b) MIXED DEMENTIA (c) (d) II Other significant conditions contributing to the death, but not related to the disease or condition causing it 3

30 1 disease or condition directly leading to death (a) BRONCHOPNEUMONIA Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last (b) ADVANCING DEMENTIA CAUSING IMMOBILITY AND REDUCED ORAL INTAKE Approximate interval between onset and death Years Months Days 6 5 (c) MIXED ALZHEIMER'S AND VASCULAR DEMENTIA (d) 4 II Other significant conditions contributing to the death, but not related to the disease or condition causing it

31 David is a 70 year old man with a history of schizophrenia for 35 years under a Detention Order. Life-long smoker, Chronic Obstructive Pulmonary Disease 30 years, Ischaemic Heart Disease 25 years. He developed haemoptysis and 3 months ago was diagnosed with a squamous cell carcinoma of left upper lobe of lung. He was referred to oncology but due to co-morbidities was not fit for aggressive treatment. However he was given a single fraction of radiotherapy for haemoptysis. Two months ago he was found to have spinal and right humeral metastases. That night while turning in bed he heard a crack and was found to have a pathological fracture of his right humerus. Surgical intervention was not possible but his arm was immobilised. He became bed bound and experienced sudden breathlessness and chest pain when on the commode. He was returned to bed but died while staff were with him.

32 Approximate interval between onset and death 1 disease or condition directly leading to death (a) LUNG CANCER Years Months Days 3 Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last (b) (c) (d) II Other significant conditions contributing to the death, but not related to the disease or condition causing it

33 1 disease or condition directly leading to death (a) PROBABLE PULMONARY EMBOLUS Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last (b) IMMOBILITY AFTER A PATHOLOGICAL FRACTURE OF RIGHT HUMERUS (c) BONY METASTASES (d) SQUAMOUS CELL CARCINOMA OF LEFT UPPER LOBE OF LUNG II Other significant conditions contributing to the death, but not related to the disease or condition causing it CHRONIC OBSTRUCTIVE PULMONARY DISEASE 30 ISCHAEMIC HEART DISEASE 25 SCHIZOPHRENIA 30 Approximate interval between onset and death Years Months Days

34 Procurator Fiscal (tick if applicable) PF1 This death has been reported to the procurator fiscal 1 disease or condition directly leading to death (a) PROBABLE PULMONARY EMBOLISM Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last (b PATHOLOGICAL FRACTURE OF HUMERUS (c) SQUAMOUS CELL CARCINOMA OF LUNG (d) CIGARETTE SMOKING Approximate interval between onset and death Years Months Days II Other significant conditions contributing to the death, but not related to the disease or condition causing it

35 Procurator Fiscal (tick if applicable) PF1 This death has been reported to the procurator fiscal 1 disease or condition directly leading to death (a) PROBABLE PULMONARY EMBOLISM Approximate interval between onset and death Years Months Days 1 Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last (b) IMMOBILITY AFTER A PATHOLOGICAL FRACTURE OF R HUMERUS (c) BONY METASTASES (d) SQUAMOUS CELL CARCINOMA OF LEFT UPPER LOBE OF LUNG II Other significant conditions contributing to the death, but not related to the disease or condition causing it COPD 30 ISCHAEMIC HEART DISEASE SCHIZOPHRENIA 30

36 Helen is a 68 year old lady mobile and active but worsening memory in a care home. Became confused and delirious and was admitted to hospital 1 month ago. Diagnosed with an acute urinary tract infection from E coli. During the admission a formal diagnosis of vascular dementia was made. Five days ago, as she was getting up to the toilet without using her buzzer, she slipped on a wet surface and fell, fracturing her left neck of femur. She underwent surgery the next day but vomited post op and was thought to have aspirated. She developed a pneumonia and died within 24 hours.

37 1 disease or condition directly leading to death (a) ASPIRATION PNEUMONIA Approximate interval between onset and death Years Months Days 1 Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last (b) VOMITING AFTER SURGERY (c) FRACTURE OF LEFT NECK OF FEMUR FROM A FALL 4 5 (d) II Other significant conditions contributing to the death, but not related to the disease or condition causing it ESCHERICHIA COLI URINARY TRACT INFECTION 1 VASCULAR DEMENTIA 1

38 Procurator Fiscal (tick if applicable) PF1 This death has been reported to the procurator fiscal 1 disease or condition directly leading to death (a) ASPIRATION PNEUMONIA Approximate interval between onset and death Years Months Days 1 Antecedent causes - Morbid conditions, if any, giving rise to the above cause, staying the underlying condition last (b) VOMITING AFTER SURGERY (c) FRACTURE OF LEFT NECK OF FEMUR AFTER A FALL 4 5 (d) II Other significant conditions contributing to the death, but not related to the disease or condition causing it E COLI URINARY TRACT INFECTION 1 VASCULAR DEMENTIA 1

39 FURTHER READING Well worth a read: CMO guidance CMO(2014)27 - Guidance on completing MCCD PF Guidance Reporting Deaths to the Procurator Fiscal 2015 Both can be accessed through (a very useful website) or simply Google these titles. Remember to record in your learning log. QUESTIONS?