PATIENT ‘DEAD ON ARRIVAL’ – WHAT NEXT?

By Dr. Lalit Kapoor©

An unresponsive patient is brought to your clinic, nursing home, or casualty and is on examination found to be dead viz. Dead on Arrival (DOA) In some countries it is also known as BID –Brought In Dead. The Immediate question that needs to be answered is whether or not you should perform CPR. It is sometimes a dilemma.

NOTE **SUSPENDED ANIMATION 

Suspended animation: It is also called ‘apparent death’ –a condition which may persist from a few seconds to several minutes after which patient may revive. It may occur in cases of drowning, cerebral concussion, electrocution, in the new born, heat stroke, over dosage by barbiturates, etc. It is this condition which accounts for those cases which are reported in the media sometimes as patient waking up in the crematorium!!

The decision to do CPR will depend on the history of the patient –both present and past, and the duration of the condition. For example, if it was a gasping patient who got a cardiac arrest in front of you, attempts at CPR would be in order. The ultimate decision will have to be taken by you considering all the factors.

The CPR must be done with the standard technique, and as per the protocol of the American Heart Association should be done for at least 20 minutes. A colleague could take over intermittently. If unsuccessful, death must be declared to the relatives. This should be done solemnly and with due empathy. There have instances of emotionally shocked relatives going berserk and resorting to physical violence, etc and hence it is advisable to factor this in while breaking the bad news.

Death is a diagnosis. It must be made and certified by a Physician.

Whereas a Death Certificate categorically states the cause of death, a certificate of death only states the diagnosis of death i.e you are stating that on examination you have found signs of irreversible death.

To give an example, a Police Inspector once came to my clinic and informed me that a dead body had been reported to be found in the adjoining building. Would I please give a certificate of death? This would enable him to decide whether he should take the ‘body’ to a hospital or the mortuary. As a doctor, this would be your public duty.

Pursuant to the declaration of death, the question that will pose itself is Death certificate or Post-mortem.

If the person was a patient under your treatment until recently and you are aware of his medical records and feel that an appropriate cause of death can be given, only then should you issue a death certificate.

If the patient was unknown to you or not under your care recently, then it is mandatory to order a post-mortem. Occasionally, there may be a family doctor under whose regular care the patient has been until recently and he or she is willing to give a DC. The name of the doctor should be duly noted in your records & relatives should be allowed to take the body

When faced with a patient who is Dead on Arrival (DOA), one course of action which should never be adopted (but unfortunately is considered by many doctors as a smart option), is to tell the relatives that the patient is very serious and then advise them to take the ‘patient’ to a higher or tertiary care center. In other words, to avoid the hassles of police procedure, etc, you are referring the’ patient ‘‘(actually dead body) to some other hospital. A number of doctors have had problems after following this step. A doctor who had done this was asked by the hospital to which the patient was referred to, as to what were the findings on first being seen and what emergency treatment was given since the ‘patient’ was supposedly serious. In some cases, persistent relatives could ask the same question to the doctor and demand why no emergency measures were taken such as administration of oxygen, etc. Hence it is advisable to stick to the truth, declare death and follow the correct procedure, even if cumbersome.

The only exception is when the panicky relatives do not accept the bad news of the death of their loved one and insist on being referred to another hospital for confirmation, a suitable reference note can be given with the fact of death being conveyed in the note. Some years back, I had a young 16 year-old boy   brought to my Nursing home, DOA upon jumping from the terrace of a 3 storey building. He was a follower of a mobile game called Blue Whale which ended with the player being brain-washed into committing suicide. The body lay on my examination table with the head twisted almost 60 degrees, an indication that the injury was incompatible with life. Yet the relatives started yelling “Doctor, you are not doing anything. Do something!!!!” When told the patient was dead, they refused to accept this and told me rudely they were taking the patient to another hospital. I conceded to their request and gave a reference note. Occasionally even a straight ECG line does not convince them of the fact and they want the doctor to do a miracle.

 

Please remember consent of relatives is not required to send the body for post-mortem. If you do not know the cause of death, obviously you cannot fill the death certificate.

You have to intimate the police station of your jurisdiction the fact that a person was brought dead to your clinic/nursing home and whose cause of death is not known to you. Hence they should take charge of the body and do the needful (which includes transporting the body to the post-mortem center). Preferably, a written note should be sent to the Police Inspector in charge.

Many doctors feel, especially if no CPR was given that since the patient was dead on arrival, there is no need to register the case and document or record the incident. In fact, a record should be created like any other case wherein the time the body was brought, the name, age, sex, occupation, address of the person should be recorded. The name, address, and contact number of the person or persons accompanying the patient should be documented. Present and past history of the patient as well as a general examination of the Body especially looking for any evidence of injuries or unusual features should be mentioned in the case paper. Of course, the examination need not be as detailed as a forensic expert would have done, but at least the gross findings should be recorded.

In case CPR was done, the timing and duration of the procedure should be recorded.

The reason for doing all of the above is that it is possible that any time in the future, should there be a police investigation or judicial proceedings, especially in a case of some criminal offense involved in the death of the person, it is possible that you could be asked to produce the records of your findings, etc since you were the person who declared the death of the patient and in a way, was the first responder.

You may be called to do so sometimes, after a number of years of the incident. You could also be called to testify in the form of a witness. Hence you should preserve the case paper in your medico-legal file indefinitely. Larger hospitals have a file labeled “DEAD ON ARRIVAL PATIENTS “where all such records are preserved in one location.

As mentioned emphatically earlier, a death certificate should never be given if the cause of death is unknown to you or just a possible cause. The consequences of not following this can be horrendous, once in a way, and totally disproportionate to the error. The following narrative will illustrate this.

DC GIVEN TO 'DEATH ON ARRIVAL PATIENT'- PHYSICIAN PAID HEAVY PRICE OF BEING SENT TO JAIL

A senior Internal Medicine specialist was called for a home visit from a family staying in a building adjoining his clinic. A 75-year-old man had reportedly collapsed while going to the washroom. The informant was the adopted daughter of the patient who said her father had complained of severe chest pain accompanied by profuse sweating after which he fell down and had to be lifted to his bed where he now lay motionless and unresponsive. On examination, the doctor detected all signs of irreversible death and informed the daughter of the fact. When asked whether he could give a death certificate, the doctor told her that this was not possible since her father was already dead and had never been his patient. The lady started weeping inconsolably and reminded him that a year ago she had brought her father to him to show his blood sugar reports and claimed to be an old patient of his.

She  further  pleaded with the doctor to give a DC as obviously her father had suffered a heart attack and being alone she will not be able to handle the trauma of a post-mortem. The Physician reviewed his decision and thought that considering the age of the patient and the history obtained, there was no harm in giving a DC stating Acute Myocardial infarction as the cause of death.  Accordingly, he gave a death certificate under his name and seal.

The deceased person was a Parsi gentleman. As we know, the manner of disposal of the mortal remains in the Parsi faith is to place the body in the Tower of Silence where the body is consumed by vultures and other birds of prey. The same ritual was carried out in the case of the above-deceased person. However, in recent times the population of vultures has diminished severely on account of a lot of them succumbing to diclofenac poisoning --- a drug that enters their bodies from feeding on cattle on whom this drug is used extensively.

On account of this, the bodies placed on the Tower of Silence remains intact for a longer period.

Coming back to the original story, 2 days after the Death certificate had been given by the physician, a Police complaint was made by a distant relative or friend alleging that this was not a natural death but was in fact, a case of murder. The Police acted quickly and retrieved the body which had obviously not deteriorated. . A post-mortem was conducted and the cause of death was declared as Homicide —Death due to smothering and suffocation.The adopted daughter, and –the driver of the deceased gentleman (with whom she was having an affair )  along with two other accomplices had smothered and suffocated  him by continuous pressure on his face  with pillows while the legs and hands were restrained.

The Police arrested the lady and her lover, the driver. But they also arrested the Internal Medicine Physician who had certified the death as a natural death on being a conspirator in the crime and on aiding and abetting in the murder. As I said earlier, he had to pay a price that was grossly disproportionate to his error. He spent time in prison for several weeks, having been denied bail a couple of times. It was a horrific experience for him. Fortunately, he was subsequently, after several anxious months acquitted of the crime.

FOOTNOTE: Had the patient been cremated, it would have been a different story, or rather there would have been no story !!

The message from this saga is loud and clear for all of us.

DC GIVEN TO OBLIGE FAMILY

A young newly passed doctor set up a new GP  practice in a low-middle-class locality. He was in what is called the ‘waiting period’ since he hardly had any patients. One day 2 young men rushed into his clinic in a panic and requested him for a home visit. They said their father had collapsed and was unresponsive. The doctor went along with them in a hurry. On reaching their home he found an old man lying still on a bed and on examination of all the parameters informed the relatives that the patient was dead.  As expected there was a lot of loud sobbing and commotion. The doctor too was flustered since he had no such previous experience. The same two men who had called him for the visit accompanied the doctor back to his clinic, insisted on paying his professional fees, and then requested him to issue a death certificate. And the request was added with the usual justifications of him being an old man who got sudden chest pain and collapsed and died. The doctor, eager to create contacts in the locality, thought it would help his practice if he obliged them. He took out his brand new DC book and issued a DC writing Ischemic heart disease leading to cardiorespiratory failure as the cause of death.

Later, while the funeral procession was making its way to the crematorium, a neighbor alerted the Police that this was not a natural death and he had heard lots of screaming and rowdy conversations just before the doctor was called. He told that there was definite foul play and the police ought to investigate.

Accordingly, the police rushed and halted the funeral procession and seized the body for post-mortem. PM revealed a tear in the right ventricle of the heart following a penetrating wound on the chest. A property dispute was the cause of one of the members of the family assaulting the disease with a long screwdriver. The penetrating wound on the chest wall –the wound of entry was only 1 cm long and had been cleverly covered with a small adhesive tape when the doctor came to see the patient. The freshly passed doctor missed this.

Murder charges were framed against the family members and the doctor too was named as one of the accused ---as a co-conspirator. Luckily for the doctor, the court took a lenient view considering the inexperience of the doctor. He got save from the criminal charges and from being de-registered by the Medical Council.

📌Never give a death certificate if you do not know the cause of death. The consequences of a carelessly given DC can be horrific.

📌Dealing with a patient who is dead on arrival must be done with all precautions detailed above.

©Dr. Lalit Kapoor 

ABOUT THE AUTHOR

Dr. Lalit Kapoor is a General Surgeon practicing in Mumbai. He is the founder of the Medico-Legal Cell, Association of Medical Consultants, and is a medico-legal expert assisting affected members with medico-legal problems for over four decades. He is also the author of the book Better Safe Than Sorry- Medico-Legal Do's & Don'ts.

💬Scroll down to add your comments in the comment box below or mail your comments and reactions to - drlalitprabha@gmail.com

💻Click on the follow button below my profile on the homepage to stay updated about new blogs