PATIENT ‘DEAD ON ARRIVAL’ – WHAT NEXT?
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
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.
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.
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.
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.
As an ophthalmologist, till now, never had to handle deaths.
ReplyDeleteBut this write up gives clear information about issuing DC.
Most informative in a lucid manner. As always . Sir your selfless service & eagerness to help at any & all times is humbling & awe inspiring.
ReplyDeleteBetter safe than sorry
ReplyDeleteVery informative sir most of us living in blissful ignorance would realise the importance of this issue and plan to impliment it before its too late
ReplyDeleteExcellent blog as usual. Very informative and very clear.
ReplyDeleteThanks
Dr Bhushan Sabnis
Orthopaedic surgeon
Very much needed information 🙏🏼🙏🏼
ReplyDeleteVery informative sir.
ReplyDeleteSo many deaths at home in Covid Pandemic. Very nicely explained what a doctor should do in cases brought dead to hospital. Thank you Dr Lalit Kapoor
ReplyDeleteExcellent article Sir
ReplyDeleteAbsolutely detailed and precise Dos & Don'ts given by you Sir! Thanks for highlighting the point that Doctors can fall prey to wily relatives & one needs to beware of this and focus on following the rule book, come what may. Looking forward to your next article🙏
ReplyDeleteInformative & useful to all practioners.
ReplyDeleteVery helpful Dr. Kapoor.
ReplyDeleteThanks for a very lucid article. Saving it for future reference and sharing in some groups.
ReplyDeleteTrue living in society were people expect you to give death certificate for near one is so difficult but we have to take a stand n refuse it were it's deemed necessary. Thank you Sir for bringing out this so important topic.
ReplyDeleteVery informative and clear
ReplyDeleteAs usual,he always help others.
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Very informative sir..We should be guided by science and not emotions .
ReplyDeleteVery informative blog Sir.
ReplyDeleteThank you for taking the sincere effort to educate all of us.
Wonderful and extremely relevant and informative
ReplyDeleteWishing you all the Best Doctor
Radhakrishnan
Wonderful and extremely relevant and informative
ReplyDeleteWishing you all the Best Doctor
Radhakrishnan
Very informative sir
ReplyDeleteExplained in detail sir, difficult to handle such situation.shoul b aware about possibilities ,never came across such useful and specific write up. Want to read more and more write ups from sir.
ReplyDeleteExcellent teaching ,learning by experience from such a senior sir dr Kapoor.thanks sir for guiding g us
ReplyDeleteMuch needed information since such an incident can come as a bolt from the blue.
ReplyDeleteExcellent and very informative for all practitioners
ReplyDeleteExcellent information presented in a very lucid manner. Must read for all dictors
ReplyDeletevery informative sir.. so many times.. a young doctor specially finds it so difficult to refuse certifying death in the wake of social pressures. these stories should be eye openers
ReplyDeleteDr Tushar D Rege
Very informative, Sir. It is also for general public to note that if they have a sick or very old person in the family, they need to be in constant touch with the doctor about the status of his/ her health.
ReplyDeleteVery informative article
ReplyDeleteOne query: Is the certificate of death given on the death certificate with question marks on the cause of death columns or is it given on the hospital letterhead?
While working in a hospital I was informed that a dead person was brought to casualty.
ReplyDeleteI examined and told that postmortem have to be done.
Send a letter to police.
Police as usual was murmuring and told to avoid.
I insisted and shifted to mortuary.
In night local people came opened mortuary and took away the body.
I called police.
FIR registered and body brought back.
Om pm the cause of death was suffocation.
Son did this to get job in Railway.
He was arrested
Very meticulous and very helpful.only suggestion is we should spread the message that postmortem is many a times a necessity and has to be advised.if anyone has statistical data may be we are not utilising postmortem as much as we should as lot of inconvenience can be avoided by patients relatives as well as attending doctor
ReplyDeleteVery informative and.lucid. Thank you
ReplyDeleteVery Clear, Informative and practical writeup which will be useful to all who are faced with Death in their practice and issuing DC in unusual cases.
ReplyDeleteVery Clear, Informative and practical writeup which will be useful to all who are faced with Death in their practice and issuing DC in unusual cases.
ReplyDeleteVery informative
ReplyDeleteVery informative. Thanks,sir.
ReplyDeleteVery nice efforts sir keep guiding everyone with your vast experience and knowledge
ReplyDeleteVery informative excellent article
ReplyDeleteThnx u sir for a lucid informative and excellent teaching to all of us.u have always stood by us doctors and no words can express our gratitude.
ReplyDeleteExcellent message and need to get incorporsted in our medical curriculum. Ever so grateful to u .
Thanks for such a lucid information.
ReplyDeleteVery useful for our daily practice.
Hope you guide us with such knowledgeable blogs, case studies, articles in future also.
Dr Siddhesh Parhar
Thanks for such a lucid information.
ReplyDeleteVery useful for our daily practice.
Hope you guide us with such knowledgeable blogs, case studies, articles in future also.
Dr Siddhesh Parhar
Very informative
ReplyDeleteThanks a lot sir
ReplyDeleteVery informative
Thank you sir!
ReplyDeleteThank you very much Dr Kapoor for your good article with some examples of doctors issuing certificates and getting in to trouble. This will help doctors to be very careful in issuing a death certificate in their practice. These are not taught in text books.
ReplyDeleteDR ANIL SUCHAK
Most informative article which helps you to deal with such circumstances as and when it arises.thanks ,DR KAPOOR.
ReplyDeleteThis artcle guides you as to how you should deal with under such circumstances. Thank you very much ,dr .kapoor
ReplyDeleteExcellent as always; must read for every practising doctor; very practical exemplified by real situations.Real eye opener. Dr Lalit Kapoor is excellent Surgeon and extremely great Medicolegal advisor.We all are blessed to have him; he always try to solve everyone’s problem.He also trains us in such blogs to avoid problems.
ReplyDeleteAs part of the same community I was aware of the first case but you have always enlightened laymen like me with the simplicity of your language and domain expertise. Drs will definitely find this write up invaluable.
ReplyDeleteExcellent article Sir. All details explained in the article are very useful. Thanks.
ReplyDeleteDr Prajakta Deulkar
Most informative and lucid explanations.Each and every doctor in their practice likely to come across above situations,sir your guidance will definitely help us to avoid horrific situation 🙏
ReplyDeleteVery well explained sir....thank you sir.
ReplyDeleteExcellent article. An eye opener for all of us. Thanks Dr Kapoor Sir we are practicing in an era with stalwarts like yourself around. Thank you for clear guidelines for a doctor who is put in that situation.
ReplyDeleteDr Ashit Shah
Consultant Knee Surgeon
Very nice. Thanks.
ReplyDeleteYour pearls of wisdom are always very helpful in time’s of stress during medico legal entanglements!! Thank you dr lalit for always being so passionately helpful !!
ReplyDeleteWonderful post! Thanks for sharing!
ReplyDeleteVery informative,thank you for sharing
ReplyDeleteExcellent
ReplyDeleteVery informative
Thank you sir
Regards,
Dr Surekha waghmare
Very important information presented. Even if the patient has been under your treatment and then brought in dead if not seen by you for a while one should be careful of giving certificate. Better to loose the family coming to you in future than take a risk if in doubt.
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