What deaths should be referred to the Maricopa County Office of the Medical Examiner? Example of properly completed medical certification of death

ƒ Any external trauma, regardless of cause or intentionality, Example of properly completed medical certification of death such as an accident ƒ Any suspicion that death may have been violent (a suicide MEDICAL CERTFICATION SECTION CAUSE OF DEATH PART 1 or a homicide) IMMEDIATE CAUSE A. APPROXIMATE INTERVAL ƒ Any drug overdose or intoxication whether from a 5 OF DEATH CEREBROVASCULAR ACCIDENT IMMEDIATE prescribed, not prescribed, legal or illegal substance DUE TO OR AS A APPROXIMATE INTERVAL B. CORONARY ARTERY DISEASE ƒ Any death occurring during surgery or as a possible 6 CONSEQUENCE OF: YEARS consequence of anesthesia, at any time between DUE TO OR AS A C. APPROXIMATE INTERVAL 7 CONSEQUENCE OF: administration and the time when the patient was supposed to recover, even if the patient never recovers DUE TO OR AS A D. APPROXIMATE INTERVAL 8 CONSEQUENCE OF: Pocket Reference Guide for from the anesthesia ƒ Any disease or condition that could have been CAUSE OF DEATH PART II Cause of Death Certification OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING CAUSES GIVEN ABOVE TIME OF DEATH: occupationally related 0900 9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE in Arizona ƒ Any unattended death*** and/or unexplained death AM PM X MILITARY ƒ Any death thought to be a potential public health hazard DID TOBACCO USE IF FEMALE: WAS AN AUTOPSY WERE AUTOPSY FINDINGS ƒ Any death occurring in a prison regardless of who was the CONTRIBUTE TO MM PERFORMED? AVAILABLE TO COMPLETE THE deceased DEATH? iimm NOT PREGNANT WITHIN LAST YEAR KDKALDKFmmJAtKHGAKJHHI CAUSE OF DEATH? 10 DFJADJ X YES MM PREGNANT AT TIME OF DEATH MM HH YES DLKJFALFJALDKFJAKDJFKJFJFKJ ƒ Any death occurring to a prisoner, regardless of where the GIIDFAJNF NO NOT PREGNANT, BUT PREGNANT WITHIN 42 DAYS OF DEATH MM LKJDFADLdfammdjFADFLKM FJIF YES IKDJFKJBII PROBABLY NOT PREGNANT, BUT PREGNANT 43 DAYS TO 1 YEAR BEFORE DEATH I X NO DFMKIIJDFKJDFJ;ALKDJJAKJJL;FJ death occurs DKKIGIIIDF UNKNOWN X UNKNOWN IF PREGNANT WITHIN LAST YEAR IIIMIF NO ƒ All maternal deaths (reportable with possible ME involvement) MEDICAL EXAMINER USE ONLY - DID IT RESULT FROM AN INJURY OF ANY KIND? - LEAVE BLANK IF NOT AN INJURY M 11 If you suspect but are not sure that one of the above situations E has occurred, please consult the Office of the County Medical O N 12 Examiner L Y 13 To consult about a potential Medical Examiner case within CAUSE AND MANNER OF DEATH CERTIFICATION Maricopa County, contact 602-506-1138. 14 MANNER OF DEATH: X NATURAL ACCIDENT SUICIDE HOMICIDE PENDING INVESTIGATION COULD NOT BE DETERMINED It is the discretion of the Office of the Medical Examiner to decline or accept jurisdiction of any case referred to the Office. Any case MM Certifying Physician, Physician's Assistant or /Nurse Practitioner SIGNATURE & TITLE OF PERSON COMPLETING CAUSE OF DEATH DATE CERTIFIED: –To the best of my knowledge, death occurred due to the cause(s) and (MD, DO, CI, CNP) declined reverts back to the health care provider. manner stated. 15 ***Unattended Death - death when not under the current care of a MM Medical Examiner/Tribal Law Enforcement Authority - On the basis of examination, and/or investigation, in my opinion, death occurred at the time, physician within 18 months preceding death*** ______date, and place, and due to the cause(s) and manner stated. REFERENCES: 16 CERTIFIER'S ADDRESS: Office of Vital Registration For more information on how to complete the medical certification section of the death certificate, refer to our website at www.medicalcertifier.org. Medical Certification Unit 6 02-372-0535

Responsibilities of Health Care Providers emergency or urgent care). Eliminates the The cause of death information should be your BEST ƒ Outline the sequence of conditions that led to line A. When Certifying Death Records According to requirement for the examiner to sign when the nurse MEDICAL OPINION at the time of signing. A condition Depending on the complexity of the case, you will Arizona HB 2370 (A.R.S.§§ 11-593, 11-594,36- practitioner and attending physician are not available. can be listed as “probable” even if it has not been almost always use line B and you will often need definitively diagnosed. 301,and 36-325) ƒ Defines health care provider as a licensed doctor, additional lines (C-D or more). nurse midwife, nurse practitioner, physician assistant The National Center for Health Statistics (NCHS) ƒ Line B: Indicate how this patient came to have the ƒ Defines medical certification of death as the or health care provider qualified by another state or standards and logic rule the way underlying causes of condition in line A. If Proteus mirabilis sepsis is on opinion of the health care provider who signs the jurisdiction of the United States and who works in a death are sequenced and specified. The key is why the certificate of probable or presumed cause of death federal health care facility. (Private health care person died, not how. line A, indicate its cause on line B (e.g., infected

that complies with rules adopted by the State provider should be licensed in AZ with the exception sacral decubitus ulcer). Registrar of Vital Records and that is based on any of of those in VA or federal health care facility) ƒ Make your entry legible ƒ Line C and D: Continue backward in time. Specify, to the following that are reasonably available: ƒ Only ONE cause should be entered on each line the best of your knowledge, what led to the preceding Importance of an Accurate Cause of Death a) personal examination; ƒ Do Not Abbreviate line (e.g. Line C: complications of remote cerebral b) medical history; Accurate cause-of-death information is important for: infarction; Line D: atherosclerotic vascular disease). c) medical records; and ƒ Legal reasons, school, travel, insurance, pension and ƒ In Part I, document the complete chain of events that ƒ The last line should indicate the underlying cause d) other reasonable forms of evidence. social security payments, inheritance, adoptions, best explains why the patient died. The last item is that is NOT the result of another condition. ƒ Specifies that if a person under the current care of a genealogy, familial medical history, citizenship and the underlying cause that began this sequence. For Paraplegia, hypotension, and renal failure would not health care provider for an acute or chronic medical tribal membership; each cause, indicate the best estimate of the time be the underlying causes because you can specify condition dies of that condition, or of associated ƒ law enforcement, public health interventions, interval between the presumed onset and the time complications, the provider or designee shall the death occurred further why they developed. scientific studies, surveillance in emergency response complete and sign the medical certification of death ƒ Some appropriate underlying causes are chronic on a death certificate within 72 hours. situations; ƒ In Part II, document other conditions that contributed medical conditions. Without them, death would not ƒ accurate patient records and information for the to death but did not result in the underlying cause. Be ƒ Requires a hospital, nursing care institution or facility have occurred at the same time or in the same to designate a health care provider to complete and family, public health and scientific research reasons; specific and complete. For example, if a patient died manner (e.g., cerebrovascular disease, essential sign the medical certification of death within 72 hours ƒ funding medical programs, allocations for public of “sepsis,” include the medical conditions that hypertension, diabetes mellitus, dementia) if the person dies of natural causes. health programs, research projects and clinical trials; predisposed him or her to develop the infection

ƒ Exempts a health care provider who completes and ƒ establishing consistency and comparability across Examples signs a medical certification of death in good faith time and jurisdictions. Part I Line A, Immediate Cause of Death ƒ A patient with liver cirrhosis from chronic alcohol pursuant to statute from civil liability or professional ƒ Indicate what happened right before the patient died– disciplinary action. Cause of Death abuse dies of an upper gastrointestinal bleed. the condition that led to cardio/pulmonary / Line 1A: Upper gastrointestinal bleed, 1B: Ruptured ƒ Requires the medical examiner to complete and sign respiratory arrest. Remember! The key is why the Patients often have multiple conditions contributing to esophageal varices, 1C: Liver cirrhosis, 1D: Chronic the medical certification of death within 72 business death. Documenting the conditions on the death person died, not how. Examples: Proteus mirabilis hours after the examination, if current care has not alcohol abuse certificate requires basic training. Below, we outline the sepsis, congestive heart failure, liver failure, upper been provided by a health care provider (“Current steps required. You may access additional information gastro-intestinal hemorrhage, left lower lobe ƒ A patient with Parkinson’s disease is admitted for Care” means that a health care provider has at www.medicalcertifier.org or www.codhelp.org. A pneumonia aspiration pneumonia and dies in the ICU after the examined, treated (includes prescribing medication) free web-based CME course is also available at or provided care for a person for a chronic or acute family decides to withdraw ventilator support . condition within 18 months preceding that person’s http://gvahec.mrooms3.net/login/index.php Part I Lines B-D, Intermediate and Underlying following a prolonged period of respiratory failure. death. Current care does not include services This interactive course covers these steps and more. Cause of Death Line 1A: Aspiration pneumonia, 1B: Parkinson’s

provided in connection with a single event of Disease