El certificado médico de defunción en urgencias: aspectos éticos y legales / Medical death certificates in the emergency department: ethical and legal issues

En el complejo contexto de la atención a la muerte y al duelo, muchos médicos de urgencias deben realizar el certificado médico de defunción (CMD), el último acto médico con el paciente. El médico debe cumplimentar el CMD en aquellos casos que se descarte la muerte judicial. En las urgencias y emergencias médicas es habitual encontrar conflictos y dudas relacionadas con el CMD. Este artículo analiza los principales aspectos éticos y legales relacionados con el CMD en urgencias. Los principios éticos que hay que tener en cuenta ante un conflicto con el CDM son: lealtad con el enfermo, veracidad, no dañar y uso racional de los recursos. Para mejorar la gestión de la atención a la muerte en urgencias, se debe mejorar la formación de los profesionales sobre el CMD con el fin de que conozcan cuándo certificar, cómo hacerlo y sus requisitos legales. (AU)

The last medical act many emergency physicians must do in the context of caring for a dying patient and mourning relatives is to issue a medical death certificate (MDC). The physician is charged with filling in the MDC in cases that do not involve judicial certification. Ethical conflicts and doubts about the cause of death are common when MDCs are issued in emergencies. This paper analyzes the main ethical and legal issues related to MDCs in this setting. The ethical precepts to bear in mind when a conflict or doubt arises are loyalty to the patient, truthfulness, doing no harm, and using public resources wisely. Physician management of processes surrounding death in the emergency department can be improved by providing staff with better training so that they understand how and when to issue a MDC and what legal requirements are involved. (AU)

Subregistro de los suicidios en el Boletín Estadístico de Defunción Judicial en Málaga / Notification of suicides in the Statistical Bulletin of Judicial Death in Malaga (Spain)

El objetivo de este trabajo es confirmar, a partir de las Defunciones con Intervención Judicial (DIJ), si la causa de defunción fue un suicidio, según la información de la familia e identificar el porcentaje de los casos señalados como suicidio en el Boletín Estadístico de Defunción Judicial (BEDJ). Para ello se seleccionaron las DIJ de la base de datos del Parque Cementerio de Málaga en el año 2017. Se recabó información de las familias de las personas fallecidas a través del Gabinete Psicológico del Cementerio para confirmar o descartar el suicidio, y posteriormente se consultó el BEDJ para comprobar si los casos estaban identificados como suicidios. A través de los familiares se confirmaron 65 suicidios, de los que solo un 27% están identificados así en la sección correspondiente del BEDJ, documento que sirve de fuente de información para las estadísticas oficiales de suicidios. Se concluye que la familia puede ofrecer información complementaria que ayudaría a mejorar las estadísticas de suicidios

The objective of this study is to confirm from Deaths with Judicial Intervention (DIJ), whether cause of death was suicide, through family information and to establish the percentage of those identified as such in the Statistical Death Bulletin of Judicial Court (BEDJ). For this purpose, the DIJ were selected from the database of the Cementary Park of Málaga in 2017. Information was collected from the family of the deceased, through the Cementary's Psychological Cabinet to confirm or rule out suicide and the BEDJ was subsequently consulted to confirm whether these cases were identified as such. Relatives confirmed 65 suicides, of which only 27% are identified as such in the relevant section of the BEDJ, a document that serves as a source of information for official suicide statistics. From this study we concluded that the family can offer complementary information that would help improve suicide statistics

Aspectos médico-legales de la pandemia por COVID-19 / Medico-legal issues of COVID-19 pandemic

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La certificacion de la defuncion de casos de COVID-19 en España / Death certification in COVID-19 cases in Spain

La certificación de la defunción es un acto médico en el que el profesional debe poner el mismo esfuerzo y dedicación que en el resto de los informes elaborados en vida del paciente. Para su correcta cumplimentación el facultativo debe seguir las instrucciones básicas, poniendo especial cuidado en rellenar adecuadamente la secuencia de causas de muerte. En casos de pandemia, la cumplimentación del certificado de defunción corresponde a la medicina asistencial y para poder hacerlo, los organismos oficiales deben publicar instrucciones basadas en recomendaciones internacionales. Debe establecerse, cuanto antes, la posibilidad de comunicación telemática de las defunciones. Mientras eso no sea posible tienen que establecerse procedimientos que permitan en situación de pandemia, comunicar de forma inmediata la mortalidad a las autoridades sanitarias

Death certification requires the same effort and dedication as all reports by doctors during their patients' lifetimes. The physician must follow the basic instructions to complete a death certificate correctly, taking special care to fill in the sequence of causes of death. In the case of a pandemic, completion of the death certificate falls to the primary care physician and therefore the official bodies must publish instructions based on international recommendations. It should be established as soon as possible whether it is possible to report deaths telematically. While this is not possible, in a pandemic procedures should be put in place to enable the immediate reporting of deaths to the health authorities

COVID-19 y estudios microbiológicos post mortem / COVID-19 and post-mortem microbiological studies

En este artículo se revisan los aspectos microbiológicos de la infección COVID-19 y se presentan las recomendaciones sobre los análisis que deben realizarse en casos forenses. En primer lugar se analizan las características taxonómicas del virus, su relación con la familia Coronaviridae y su estructura genética. Se presentan brevemente las características clínicas y patológicas de la infección COVID-19, así como las coinfecciones que pueden asociarse a este virus. En el diagnóstico de laboratorio se describen la PCR -técnica de elección en la fase aguda de la infección-, los estudios antigénicos y los estudios serológicos. Finalmente se detallan los principales objetivos para los estudios microbiológicos en fallecidos en relación con la pandemia COVID-19 y se describen los principales análisis microbiológicos post mortem a realizar en fallecidos en el ámbito forense. Los estudios microbiológicos deben estar dirigidos tanto a la detección del SARS-CoV-2 como a la de las coinfecciones, que también podrían contribuir a la causa de muerte

We review the microbiological aspects of COVID-19 infection and present the microbiological studies that should be performed in forensic cases. We describe the taxonomic characteristics of the virus, its relationship with the Coronaviridae family and its genetic structure. We briefly present the clinical and pathological characteristics of COVID-19 infection, as well as the co-infections that could be associated with this virus. In the laboratory, PCR is a first-choice technique in the acute phase of the infection, together with antigen and serological studies. Finally, we describe the main objectives of microbiological studies in the deceased in relation to the COVID-19 pandemic, as well as the main post-mortem microbiological analysis to be carried out in the medico-legal context. The microbiological analysis should aim to detect both SARS-CoV-2 and coinfections, which may also contribute to the cause of death

Afectación de la pandemia por Covid-19 en los servicios médico forenses de Madrid (España) / Impact of the Covid-19 pandemic on the forensic medical services in Madrid (Spain)

La Comunidad de Madrid ha sido la Comunidad más castigada por la pandemia por la Covid-19. La reciente puesta en funcionamiento del Instituto de Medicina Legal y Ciencias Forenses de la Comunidad de Madrid ha obligado a que con su precaria estructura gestionara esta situación, mediante el establecimiento de acuerdos e instrucciones que han impedido que éste se colapsara. Especialmente las medidas adoptadas por el Servicio de Patología han impedido este colapso y disponer de personal necesario para hacer frente a las contingencias que pudieran producirse. Se ha tenido que adoptar medidas especiales para el tratamiento de cadáveres en la Comunidad de Madrid, con la apertura de depósitos temporales, que hicieran frente al elevado número de fallecidos. Se ha realizado un estudio comparativo del número de fallecidos, según etiología médico-legal entre los años 2019 y 2020 en el periodo comprendido entre 9 de marzo y 20 de abril

The Community of Madrid has been the hardest hit by the COVID-19 pandemic.The recent launch of Madrid's Institute of Legal Medicine and Forensic Sciences, has forced its precarious structure to manage this situation, through the establishment of agreements and operational guidelines, which have prevented it from collapsing.These measures, also promoted by the different Services, but in particular, those adopted by the Pathology Service, have helped to avoid this situation.Special measures had to be adopted for the management of corpses in the Community of Madrid, with the opening of temporary morgues to deal with the high number of deaths.A comparative study of the number of deaths, according to forensic medical aetiology, was carried out between 2019 and 2020, in the period between March 9 to April 20

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum.

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners' confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the "right way." The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.

[On the quality of the external post-mortem examination in cases of fatal head trauma : A comparison of death certificate and forensic autopsy]. / Zur Qualität der ärztlichen Leichenschau bei todesursächlichem Schädel­Hirn­Trauma : Ein Vergleich von Todesbescheinigung und gerichtlicher Obduktion.

BACKGROUND: In Germany it is required by law that basically every type of physician needs to be capable of executing a correct external post-mortem examination of a corpse. In recent years, numerous investigations on external post-mortem examinations repeatedly reported systematic mistakes and erroneous procedures in various clinical and medicolegal case groups. Accordingly, the completion of death certificates is frequently performed incorrectly. As one of the typical unnatural death cases, decedents dying from fatal head trauma (FHT) represent a special autopsy case group, which is expected to be correctly recognized during the primary external post-mortem examination because the external injuries are mostly obvious. OBJECTIVE: The present study aimed at investigating the quality of the external post-mortem examination in medicolegal FHT cases by means of comparison of death certificates and autopsy reports from a 10-year period. MATERIAL AND METHODS: In a retrospective study design all autopsy cases from the Institute of Legal Medicine of the University Hospital Münster in the years 2006-2015 (n = 3611) were analyzed as to the presence of FHT. A total of 328 cases with FHT and the concomitant presence of a death certificate filled out before the autopsy were identified. Subsequently, the cause of death according to the death certificate was compared with the cause of death according to the autopsy. The degree of agreement was classified into six different categories from I to VI. While category I represented a complete lack of agreement, category VI was assigned to cases with full agreement. RESULTS: In 58.5% of the cases (category VI) FHT was identified correctly during the external post-mortem examination. In 1.5% of the cases, a completely different cause of death was determined during the external post-mortem examination (category I). In 19.2% of the cases, no cause of death or the statement "unclear" was given as the cause of death in the death certificate (categories II and III). Cross-analyses and intuitive heatmap visualization were generated to identify case constellations with an increased risk for discrepancies. These analyses revealed that among all discrepant cases (categories I-V), falls were found significantly more often than in the nondiscrepant cases (p < 0.01), especially falls of women older than 57 years (median age of women) or falls considered as accidents by the examiner. In addition, traffic-associated FHT of men older than 44.5 years (median age of men) was identified more frequently in the external post-mortem examination. CONCLUSION: Despite the fact that FHT should be a cause of death that is comparably easy to identify during external post-mortem examination, more than one third of the cases were not sufficiently recognized. Therefore, special attention must still be paid to certain case constellations during the external post-mortem examination. Typical examples of such cases are burned bodies, cases of advanced putrefaction and falls.

Improving birth and death data for African decision making

The scarcity of current, complete, and accurate primary data on causes of death in most of sub-Saharan Africa restricts the ability of countries to measure progress against many of the Sustainable Development Goal targets, measure the impact of programmatic interventions, prioritise and plan to address their health needs, and achieve the goals of the Africa On Aug 10, 2018, the Agenda 2063.1 first African Civil Registration and Vital Statistics (CRVS) Day was celebrated, underscoring the importance of working towards compulsory, uni versal CRVS systems across the However, progress towards continent.2 establishing these systems has been slow; even with substantial inputs and political will, universal CRVS will probably take decades to be functional in all countries.

Aspectos médico-legales derivados de la pandemia de la COVID-19 / Medico-legal issues regarding from the COVID-19 pandemic

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Completeness of death registration in the Civil Registration System, India (2005 to 2015).

Background & objectives: In many developing countries including India, the civil registration data are incomplete, inadequate and not timely, therefore, compromising the usefulness of these data. The completeness of registration of death (CoRD) in the Indian Civil Registration System (CRS) was assessed from 2005 to 2015 at State level to understand its current status and trends over time and also to identify gaps in data to improve CRS data quality. Methods: CoRD for each year for each State was calculated from the CRS reports for 2005-2015. Data were analyzed nationally by geographic region and individual State. The availability of CoRD by age group and sex was also reported. Results: About 40 per cent increase in CoRD was documented for India between 2005 and 2015, with CoRD of 76.6 per cent in 2015. CoRD was >90 per cent in the western and southern regions and the eastern, central and northeastern regions had CoRD lower than the Indian average in 2015. Among the 29 States, 16 (55.2%) State had CoRD >80 per cent and five (17.2%) <50 per cent and 10 States recorded 100 per cent CoRD. Despite the highest per cent increase during 2005-2015 (108.5%), CoRD in Uttar Pradesh was 44.2 per cent in 2015. Varying levels of progress in 2015 were seen between the State with similar CoRD estimates in 2015. Nagaland (-63.3%), Manipur (-33.1%) and Tripura (-30.3%) were the only States that documented a decrease in CoRD during 2005-2015. The age non-availability for India ranged from 37.0 per cent in 2009 to 37.9 per cent in 2015, an average of 41.5 per cent over the seven years and was an average of 35.6 and 36.6 per cent for males and females, respectively. Age was available for all registered deaths only in five (17.2%) of the 29 States in 2009 and four (13.8%) in 2015. Sex non-availability for the recorded deaths was much lower as compared with that for age. Interpretation & conclusions: Despite the significant progress made in CoRD in India, critical differences between the States within the CRS remain, with poor availability of reporting by age and sex. Concentrated efforts to assess the strengths and weaknesses at the State level of the CRS processes, quality of data and plausibility of information generated are needed in India.

Setting the Record Straight: Supreme Court Curtails TMB for Over-Sanctioning Physician.

Eight years ago, when he experienced a rare patient death, McAllen family physician Ruben Aleman, MD, signed the death certificate the way Texas physicians had been doing it for years, and the only way he knew how: using pen and paper. That resulted in the Texas Medical Board (TMB) not only coming after him, but accusing him of "unprofessional or dishonorable conduct that is likely to deceive or defraud the public" - words found in the state Medical Practice Act. The Texas Supreme Court recently decided that was an overreach for a physician who simply hadn't signed up on the state's electronic death registration system, which at the time was relatively new.