2. Death- has no legal Definition
Complete & Irreversible cessation of
Brain, heart & Lungs,
Apparent death / suspended animation
Minimum of 20 to 30 min continuous
examination after vital functions
ceased.
3. Death certification & after
If COD is natural issue MCCD
If death is due to of un-natural cause
inform police.
Suspected Un-natural deaths inform
police.
COD col in 4 / 4a shall be Unnatural
4. Death Certificate
Should be issued only by
competent authority
TEM, Rural areas
Municipality, Corporation Etc in
urban areas
5. Mortality statistics – Why?
Integral part of vital statistics.
Basic component of population growth.
Key indicator of health trend in the
population.
Help in assessing the public health
measures.
6. Mortality statistics – Why?
Essential for better health planning &
management.
To decide the priorities of health &
medical research programs.
Provide feed back for future policy &
implementation.
7. MCCD implementation
Phase 1: Major & teaching hospital.
Phase 2: District & sub divisional
hospitals & PHC’s.
Phase 3: Private practitioners.
9. Success - How?
Involvement of medical professionals.
Co-operation of medical professionals.
Knowledge of medical professionals.
10. Legal problems
Section 10(2): State govt. has
made provision to get a
certificate of cause of death
by medical person.
11. Legal problems
Section 10(3): medical person who has
attended the last illness, should issue a
certificate of cause of death, without
charging fee, in a prescribed form (form no.
4/4A), stating the cause of death to the best
of knowledge. Confidentiality of
information of cause of death has to be
maintained.
12. Form of medical certificate
(form 4/4A)
Cause of death
I
Immediate cause:
State the disease. Injury/complication
which cause the death not the mode of
dying.
Antecedent cause:
Morbid conditions, if any, giving rise
to above condition
II
Other significant conditions
contributing to death but not related to
disease or condition causing it
Interval between onset & death
(approx.)
(a)
Due to (or as a consequence)
(b)
Due to (or as a consequence)
(c)
13. Responsibility of physician
Complete the medical part of the certificate
regarding all diseases, morbid conditions or
injuries which has resulted in or
contributed to death.
Cause of death are classified according to
international classification of diseases
(ICD-10).
Acute conditions – certification is easy.
14. Responsibility of physician
If multiple causes, some are causally related to
each other in a sequence.
If sequence is found – physician should record
the disease/condition in an order leading to the
underlying cause.
Eg. Inguinal hernia obstruction
perforation
If sequence is not found – contributory conditions
to death are recorded separately
15. Responsibility of physician
Medico legal cases: cause of death based
on evidence noticed by him.
Cause of death is confidential not indicated
in the certificate.
The form of medical certificate is to be sent
to the local registrar of births & deaths.
16. Instructions
Name of the deceased:
Block letter.
Legible.
Full. No initials.
Give father/husband after name (s/o, d/o, w/o)
In c/o infants, new born & not named – use
b/o mother / father name.
No abbreviations, no shortcut
17. Instructions
Age:
>1yrs: age in years last birth day
(completed no. of yrs).
<1yr: age in months & days.
<24hrs: age in hrs.
18. Instructions
Method of certification:
Format Designed by WHO to facilitate the
underlying cause of death.
Consists of 2 parts
1.Related to the sequence of events
leading to death.
2.Significant condition contributed to
death
19. Instructions
Name of the disease should be legibly
written in full form.
Do not use abbreviation & short form of
disease.
Avoid indefinite & inadequate terms.
Do not mention only terminal mode of death
or symptoms.
20. Instructions
Properly completed certificate should
indicate the underlying cause of death in
the lowest line in part I & conditions as a
consequence of is indicated as ascending
order of sequence.
21. Instructions – Part I
Only one cause is entered in each line.
Underlying cause of death is entered in the lowest
line it is the condition that started the sequence of
events between normal health & the death.
(bronchopneumonia measles).
22. Instructions – Part I
Line (a) :
Immediate cause is reported in line (a).
Disease/injury/complication that preceded death.
It may be the sole entry. But there must be an entry.
Mode of dying (heart failure/resp. failure) should not
be entered. It serves no purpose.
Violent deaths – enter the result of external cause (
skull #).
23. Instructions – Part I
Line (b) : due to (as a consequence of)
Condition on line (a) is due to another
condition, record that in line (b).
It is antecedent to the immediate cause of
death.
Antecedent condition prepared the way for
the immediate cause of death.
24. Instructions – Part I
Line (c) :
Mention the condition antecedent to condition on line
(b).
If condition on line (b) is underlying condition then
nothing more is entered.
Eg. Pneumothorax severe pneumonia
measles.
25. Instructions – Part I
When many conditions are involved:
Write full sequence.
One condition per line.
Most recent condition at the top.
Earliest condition at the last.
Normally lowest line used in the part I
is taken for the statistics.
Eg. Perforation – intestinal obst. –
inguinal hernia.
Septicemia – gangrene foot –
diabetes
26. Instructions – Part II
Other conditions/diseases unfavorably influenced
the course/ modified/ contributed to the fatal
outcome.
Not related to the disease causing death.
Eg. Pneumothorax – pneumonia – measles –
severe anemia.
27. Instructions
Interval between onset & death:
Exact period when it is known.
When unknown – approximate
period (several yrs).
Provides useful check on the
sequence of events.
28. Instructions
Accidents:
Suicide / homicide should be ruled
out.
Indicate briefly the type of accident.
In c/o MLC inform police.MCCD
should be obtained from police.
29. Instructions
Female deaths:
15-49yrs – information on
pregnancy & delivery is needed
even though pregnancy has nothing
to do with death.
30. Instructions
Ensuring the completeness of the
information:
Mention the causal chain of events.
Enough details – do not write case sheets.
Record the diagnosis as precisely as
possible.
Use information of autopsy or biopsy
31. Instructions
Incomplete description:
Symptom (dypsnea) arising from different cause.
Sepsis – many casual condition.
Acute, sub acute, chronic conditions (appendicitis).
Mention of a disease which is localized (abscess)
with out indicating site.
32. Instructions
Infections:
Acute /sub acute/ chronic.
Name of the disease.
Name of the organism.
If localized – site.
Mode of transmission where relevant.
Eg. Chronic malaria, acute staph. Osteomylities
of tibia.
35. Instructions
Maternal deaths:
Nature of complication.
Timing – ante partum, intra partum or
post partum.
Abortion – spontaneous , induced , MTP.
Pulmonary embolism due to toxemia of
pregnancy.
43. Case history
On 03.01.1977 a 60 yr old female was admitted
with a ‘strangulated femoral hernia’ which had
started 4 days earlier.
C/o abd pain & fecal vomiting
Apparently, SI were perforated even before.
On 4th Jan – surgery for hernia with end- end
anastomosis.
On 5th Jan – developed s/o peritonitis & died an
14 Jan
44. Part I
a) Peritonitis, acute
b) Perforation of small
intestines.
c) Strangulated femoral
hernia.
12days
15days
Part II
Nil
45. Case history
On 14.01.1976 an old man slipped on same
level & fell down, resulting in fractures
On admission, #s of Lt ischium & ilium
were reduced.
Pt suffered from azotemia, general
atherosclerosis, arteriosclerotic heart disease &
pulmonary emphysema
Developed bronchopneumonia on 15th Feb
& died 6days later.
Autopsy revealed # hip & pelvis, cardiac
hypertrophy, chronic fibrous myocarditis &
coronary sclerosis
46. Part I
a) bronchopneumonia
b) Fracture of Left
Ischium & Ilium.
6days
7days
Part II
Arteiosclerotic heart with
coronary sclerosis
47. Case history
On 1st Feb, a 58yr old man presented at a clinic
C/o long duration of hemoptysis & loss of weight.
O/E anemic – admitted.
Diagnosis: advanced pulmonary TB reactivation
type with cavitation 8yrs duration.
Also had generalized arteriosclerosis – long
duration.
Also had mod. Varicose vein of lower limb.
On admission pt had massive & acute pulmonary
hemorrhage & died in the evening.
48. Part I
a) Pulmonary hemorrhage.
b) Advanced pulmonary TB.
10hrs
8yrs
Part II
Generalized Arteiosclerosis &
varicose vein of lower limb
49. Case history :
A 63yr old man had been treated for malignant
hypertension for some yrs & developed hypertensive
heart disease & chronic renal failure.
He developed acute appendicitis & appendix
ruptured.
Appendicectomy was carried out successfully.
But heart condition detoriated & died 2wks later
50. Part I
a) Congestive cardiac failure
b) Cardiac hypertrophy
c) Malignant hypertension
2wks
Some
yrs
Part II
Hypertensive renal failure
51. Case history
A 68yr old female was admitted to ICU with dyspnea
& mod retrosternal pain of 5hrs duration which didn’t
respond to nitroglycerin.
Past h/o obesity, NIDDM, hypertension, &episodes of
non exertional chest pain (angina pectoris) for 8yrs.
Over 1st 72 hrs – significant elevation of CPK-MB –
acute MI.
Type II second degree AV block – temporary pace
maker was placed.
52. Case history
Subsequently developed dyspnea with fluid
retention & cardiomegaly – improved with diuretics.
On 7th day during ambulation she suddenly
developed chest pain & increased dyspnea. An acute
pulmonary embolism (later confirmed by V/P scan)
was suspected & IV heparin was started.
One hr later, became unresponsiveness & died
53. Part I
a) Pulmonary embolism
b) Acute myocardial infarction
c) Chronic ischemic heart disease
1hr
7dys
8yrs
Part II
NIIDM, obesity, hypertension.
54. Case history
A 78yr old female - temp 102.60F
2yrs back – cerebrovascular accident – Lt
hemiparesis.
1yr- increasingly becoming dependent on others
for daily activities.
6mo – in –dwelling bladder catheter.
3days – loss of appetite & increasingly
withdrawn.
55. Case history
On admission, TLC- 19,700, pyuria, Gram –ve
organisms in urine.
IV Ampicillin & gentamycin were started.
On 3rd day, culture showed pseudomonas aeruginosa
resistent to ampicillin & gentamycin.
Antibiotic was changed to sensitive ticarcillin –
clavulanate.
Despite, fever persisted.
On 4th day became hypotensive & died.
56. Part I
a) Pseudomonas aeruginosa sepsis
b) Pseudomonas aeruginosa urinary
tract infection
c) Indwelling bladder catheter.
d) Left hemiparesis.
e) Old cerebrovascular accident
Days
Days
6mo
2yrs
2yrs
Part II
Nil
57. Case history
A 1,480gm male infant was born at 32 wk
gestation to a 20yr old primiparous women.
Developed RDS & required mechanical
ventilation for 7days.
Despite adequate calories – poor weight gain
& persistent diarrhea with steatorrhea.
Elevated sweat chloride concentration.
58. Case history
On 37th day – became lethargic & edematous.
E.Coli was cultured from CSF & total S.
protein was low & prolonged clotting studies.
Infant died at 45 days of age.
Gross autopsy confirmed the clinical
impression of cystic fibrosis.
59. Part I
a) Escherichia coli meningitis
b) Cystic fibrosis
7 Days
45 Days
Part II
Prematurity, malabsorption,
respiratory distress syndrome.
61. Part I
a) Primary bronchogenic
Ca of RT lung.
b) Emaciation
c) Metastasis of lymph
nodes & liver
Part II
a) Emaciation
b) Metastasis of lymph
nodes & liver
c) Primary bronchogenic
Ca of RT lung.
62. Part I
a) Diabetes
b) Gangrene foot
c) Ca pancreas & chronic
bronchitis
Part II
a) Gangrene foot
b) Diabetes
c) Ca pancreas
Chronic bronchitis
63. Part I
a) Retention of urine with
hypertrophy of prostate
with uremia
b) Cataract
c) Ischemic heart disease
Part II
a) Uremia
b) Retention of urine
c) Hypertrophy of
prostate
Ischemic heart disease,
cataract
64. Part I
a) Nephrectomy
b) Edema face, foot
c)
Part II
Embryoma of kidney
a) Edema face, foot
b) Embryoma of
kidney
65. Part I
a) Polycystic kidney
b) Renal failure &
hypertension
c) Ischemic heart disease
Part II
a) Renal failure
b) Hypertension
c) Polycystic kidney
Ischemic heart disease
66. Part I
a) Intestinal obstruction
b) Femoral hernia
c)
Part II
a) Femoral hernia with
obstruction
67. Importance of reporting
sequence accurately
A diabetic man who had been under insulin
control for many yrs developed ischemic heart
disease & died suddenly from myocardial
infarction.
Depending on the Dr. role in the fatal outcome
by one or the other conditions, the possible
certifications are:
68. Scenario - 1
If dr. considers that heart disease resulted from longstanding
diabetes then:
Statistical office would select diabetes as underlying cause
Part
I
a) Myocardial infarction
b) Chronic ischemic heart
disease
c) Diabetes mellitus
1hr
5yrs
12yrs
Part
II
Nil
69. Scenario - 2
If dr. considers that heart disease developed
independently of diabetes then
Statistical office would select heart disease as
underlying cause
Part
I
a) Myocardial infarction
b) Chronic ischemic heart
disease
1hr
5yrs
Part
II
Diabetes mellitus 12yrs
70. Scenario - 2
If the man instead died from some other complication of
diabetes (nephropathy), heart disease play only subsidiary part in
the death:
Statistical office would select diabetic nephropathy as
underlying cause
Part
I
a) Acute renal failure
b) Nephropathy
c) Diabetes mellitus
1wk
4yrs
12yrs
Part
II
Chronic ischemic heart
disease
5yrs
71. Summaries
MCCD form to be filled & signed by
attending Physician only.
General information regarding sex & age at
death is equally important.
Immediate cause of death to be given at (a)
of prescribed form.
Completed certificates should be sent to
local Registrar of the area
72. Summaries
In case of medico legal cases,required
certificate should be given to Police.
Immediate & antecedent cause of death
should be properly filled.
Underlying cause should be given in part 1
at ( c ).
In case of death of females, information on
pregnancy & delivery is needed.
73. Summaries
In cases of death due to accidents & violence,
both external cause & nature of the injury should
be stated.
Avoid registering two or more conditions in a
single line.
Write the name of the disease in full & legibly.
Do not use abbreviation.
Write correct age & sex of the deceased.
