Friday, 23 March 2007

Sign here, please

In our part of the world the Coroner is keen to avoid post mortem examinations where possible. There are good reasons for this: bereaved relatives don't like them (not least because they delay the funeral arrangements) and they cost the Coroner's department money. A post mortem can be avoided if the GP is happy to certify the cause of death, and the Coroner is usually delighted to waive the requirement that the GP should have seen the deceased in the two weeks prior to the death.

Today the Coroner's officer rang me about an elderly gentleman whom I had not seen for several months. Since then he had been admitted to hospital and discharged to a nursing home outside our practice area, and so was now registered with a different practice. This morning he had been taken to the Emergency Department of a local hospital, where he promptly suffered a cardiac and respiratory arrest and died. Did I feel able to issue a certificate?

I could see things both ways. The chap was getting on a bit, and hadn't been visited by any suspicious-looking GPs recently. He had more pathology than you could shake a stick at: ischaemic heart disease, heart failure, renal failure and an industrial lung disease, and had also had bowel cancer and a pulmonary embolism in the past for good measure. I had no doubt that he had died of natural causes, and there was a wide range of natural causes to choose from.

But therein lay the rub. Death certificates demand a single cause of death, though you can add as many subsidiary causes as you like in part two: "other conditions contributing to the death but not related to the main cause". I didn't have the foggiest idea which of his many diseases had killed him in the end, and by signing a certificate I should be saying that I did.

In the old days (just a few years ago) I would have plucked a condition at random and happily signed a certificate, thus saving the relatives some anguish and the Coroner some expense. But in these po-faced times, that approach is untenable. I can just imagine some self-confident supercilious QC smiling knowingly at the bench and saying "so now Dr Brown, you admit that you hadn't seen the patient for four months and that he had had a hospital admission since then. Do tell us exactly how you came to your conclusion about his cause of death."

In an age when doctors seem to be mistrusted by the authorities, we can't bend the system to help people out any more. It's more than my job's worth, squire.


Anonymous said...

The mention of an industrial lung disease anywhere in the history is normally enough to provoke an autopsy.
We are spending enormous amounts of time doing autopsies on 80yrs plus people with multiple pathologies and nobody is really interested which of the diseases we arbitrarily assign as the cause of death.
At the same time we have almost no hospital autopsies - people are signed up with diagnoses based on radiology and clinical assumptions which may or may not be correct - and an autopsy would have real value for the clinicians.
Its all great for my bank balance but destroying my motivation.

Dr Andrew Brown said...

To be fair, I don't think the Coroner's officer knew about the industrial lung disease until he rang me.

My father always told me that he would have to have an autopsy because he is in receipt of an MOD pension for a medical problem related to his National Service. I don't know whether that rule still applies, but he may well escape the pathologist's clutches as he now lives abroad and is likely to die there.

I'm surprised at what you say about hospital medicine. I thought that we poor GPs were the lousy diagnosticians while the clever chaps in the hospital know all that is to be knowed. :-)

Anonymous said...

I don't think MOD pensions count - but dying abroad is no escape if the body is brought back to this country for burial.

There are studies comparing clinical causes of death with the actual findings at autopsy. 30% turn up something unexpected which may change the 'cause of death'. In 10-20% the unexpected finding would have had a major effect on the patients treatment.

Your patient is a case in point. You hadn't seen them for ages so it provided you with almost no useful information. If you did autopsies on patients who died days after you'd seen them you'd be getting information which would support or question your clinical assumptions. Todays litigious and squeamish environment has killed this stone dead.

This is most worrying with new techniques such as PET scanning. I know plenty of cases where CT scanning has got things wrong - like anything else it is a technique with sensitivities and specificities - often only assessed at autopsy. Who knows how many cancer patients will be refused surgical treatment based on a PET scan demonstration of disseminated malignancy which may or may not be correct but will never be tested - because we know the patient has cancer and we know what to write on the death certificate.

Sorry about the rant - its a hobby horse of mine!

Dr Andrew Brown said...

No need to apologise. Your comments made me think - and I'm sure you're right.