Certifying a Death: The happy-sad balance.

Now one thing that I am beginning to realise working in the Intensive Care Unit (ICU) is that the patients there are very very sick. They are indeed there for a reason – they need intensive treatment. Sometimes the lengths to which we go to ‘treat’ a patient will be capped. We call this a ‘ceiling of care’. This is a very complex, decision making process that is about balancing the advantages of pursuing an aggressive treatment course that may indeed cause distress and harm to the patient – versus – a kinder pathway that is about supporting the patient without such extreme methods but with an understanding that this will in all likelihood gently lead them to dying. There is no black and white in such a decision making process – it is done on an individual patient basis and involves discussions with the relatives at length to agree on a plan that is best for the patient. It is ALL about the patient.

With the above in mind, it is no surprise that I have found myself certifying a lot of deaths. As this is quite a delicate, sensitive area of medicine I thought I would share it with you. We will, after all, all have experienced a family death and so this process been completed. Once a person has died, a death certificate needs to be completed as soon as possible. This is a legal document that needs to be completed as soon as possible for without it, the family cannot have the body released for burial or cremation etc. The first thing that will happen is that the team looking after that patient will agree on the cause of death and the processes that led to it. There are very distinct parts to this certificate – referred to as PART 1 and PART 2

Part 1 of a death certificate is in three parts and is essentially the journey of the patient’s illness that led to their passing. It broken into:

1a.

1b.

1c.

So for example, if we had a patient who developed a community acquired pneumonia that led to them developing a respiratory failure and acute kidney injury, the certificate may read:

1a. Respiratory Failure

1b. Acute Kidney Injury

1c. Community Acquired Pneumonia

Part 1 of a death certificate is just 1 part and is simply all the co-morbidities that may have indirectly made it harder for that person to survive an illness. This could be anything from type two diabetes to chronic kidney disease to ischaemic heart disease.

Now, I know that this all sounds very clinical. It is. It is meant to be completed as quickly, professionally and respectfully as possible so the family can continue with their grieving process. Where it gets difficult (and I have experienced this three or four times now) is where a cause of death IS NOT clear. If you remember what I said – this means that no death certificate can be completed. As such, the family have to wait. What’s more distressing to them is that if no cause is determined, then I, as the junior doctor, have to call the local coroner to discuss the case. Sometimes this is just a chat and an agreed cause of death is reached with their help….or the decision cannot be reached and a post mortem is required.

Post mortems are distressing for any family and I feel so much for every one that has to endure it. They cannot move on, they cannot grieve fully and the distress is magnified. Afterall their loved one is dead – no word written on a line of a death certificate will bring them back. Personally, I hate having to tell families a post mortem is required – because it is was my family – I would fight them doing it. Professionally however I realise the importance to understand how a life is lost – especially if it is not clear. The lessons learned from it could prevent a future one being lost.

In medical school we learned something  called the Kubler-Ross Grief Model. It states that where we grieve we can go through a set cycle of emotions. These are:

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

My time on ITU has shown all those emotions in the faces and words of the families that I have seen. I wish I didn’t have to because it always reminds me that one day I will be in their shoes. That is the very cycle of life after-all.

Not wanting to end of a somber note I want to show you the upside of ITU. We get to see the relatives of ones who have died come back – and believe you me they do. They come back to say thank you (not to me obviously, as I am after all just a paper pusher!) to the doctors and importantly nurses that have looked after their loved ones. Seeing them always makes me smile as you can see that they have moved to a, well, let’s call it a better place, on their grieving cycle. That makes it worth it.

See you next week,

Dr Nick

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