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Medical certification of the cause of death

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Medical certification of the cause of death

  1. 1. Registration of birth and death act 1969 Medical certification of the cause of Death Dr. Sanjeev Kumar Prasad Medical officer . CMO office Dhanbad
  2. 2. Medical certification of cause of death• Introduction: Historical back ground: The RBD act 1969 Legal frame work• Death report/death certificate/MCCD• Why MCCD• Status of MCCD• How to fill up MCCD• Issues related to MCCD• Challenges and initiatives.
  3. 3. Introduction Fact of life: Man is mortal and Death is inevitableDeath certificate is a permanent record of the fact of death.
  4. 4. Historical Background• Started middle of the nineteenth century.• Introduction of sanitary reforms for control of pestilence and disease and not so much for studying population trends.• A central legislation on the subject was considered absolutely necessary to bring about improvement in the system.
  5. 5. Historical Background ( contd)• The RBD act was first introduced in Rajya Sabha in 1964, lapsed on the dissolution of the Parliament.• The Bill was first passed by the Rajya Sabha on February 27, 1968.• The Lok Sabha passed the Bill on May 27, 1969 with certain amendments.• Approved by Rajya Sabha in 1969.• Received the assent of the President on May 31, 1969.• Notified in the Gazette of India Extraordinary, Part II Section I on June 2, 1969.
  6. 6. Registration of birth and death act 1969• As per provisions of the Registration of Births and Deaths Act, 1969 registration of every birth and death is compulsory. The persons who are responsible, are to report the events of births and deaths to their nearest Registration Units within 21 days of occurrence of such events failing which late fees for delayed registration are charged.
  7. 7. This Act provides for• Uniform law across the country on the registration of births and deaths• Compulsory reporting and registration of all births and deaths• Implementation of the Act is the responsibility of the State Governments• Rules framed by the state governments are based on a model set of rules provided by the Central Government (Registrar General, India).
  8. 8. Benefits of death registration • Family • Society and the nation• practical issues like hospital reimbursement, • key indicators of the health trends in the population• Life insurance • assessing the effectiveness of claims, obtaining a probate or public health programs, succession certificate, settling property claims, • providing a feed-back for future policy and implementation,• releasing gratuity and • better health planning and provident fund claims management,• deleting the deceased name • deciding priorities of health and for the Ration Card, and medical research programmes. Voter’s List or employer’s register
  9. 9. This Act actually states ..• A Birth or Death has to be reported for registration, within 21 days of occurrence. Free copy of the certificate can be obtained at the time.• Birth and Death registration is to be done at the place of occurrence.• Any death , after the expiry of twenty one days, but within thirty days of occurrence, shall be registered on payment of a late-fees. after thirty days of occurrence, but within one year shall be registered only with the written permission of the Officer prescribed in this behalf and on payment of late-fee.• not been reported within one year of its occurrance, shall be registered only on orders of the First Class Judicial Magistrate and on payment of a late-fees.
  10. 10. Status of Death Registration in India• As per Unicef only 54 % of the deaths are reported• In 2001- this figure went down to 46 %• Reporting varies from state to state – e.g Assam( 13.7%) ,Karnataka-100% Goa and Punjab 90%• Female deaths are under reported• Child and infant deaths are less reported.(dev. countries like india)• Child mortality were studied in ICDS centers in Lucknow only 1/3 were reported > 70 death occurred at home. 94.5% of the reported case did not have certified cause of death
  11. 11. Cause of death reporting and Medical certification of Death In civil registration system – Death is subdivided due to – accident ,violence, disease• ¾ of the deaths occur at home and half of them do not have certified cause .• MCCD- only 4% of the 9.5 million reported deaths have it• All these are in Urban places. This does not reflect the true picture.
  12. 12. Registration of birth and death act 1969 Functionaries RGI (central level) DRG Chief registrar ( state) Additional chief registrar District registrar (District) Additional District registrar Local registrar Rural urbanBDO, Office of local Panchayat, Health officer,Secretary of village Panchayat, Commissioner of municipality
  13. 13. Registration of birth and death act- legal framework in JharkhandNotification by Govt of Jharkhand
  14. 14. Registration of birth and death act [31st May 1969]• Chapter III section 8- Persons require to register in case of birth and deaths.• Chapter III section 10.- Duty of certain persons to notify births and deaths and to certify cause of death.• Chapter III section 11. Informant to sign the register. Every person who has orally given to the Registrar may information required under this Act shall write in the register maintained in this behalf, his name, description and place of abode.• Chapter III section 12 .Extracts of registration entries to be given to informant..The Registrar shall, as soon as the registration of a birth or death has been completed, give, free of charge, to the person who gives information under section 8 or section 9 an extract of the prescribed particulars under his hand from the register relating to such birth or death.,
  15. 15. Who can report death ?• It is the responsibility of the Medical Officer in charge of the hospital or Primary Health Centre, where the Delivery / death, has taken place, to report the Birth / Death, for registration.• It is the responsibility of the Head of the Household / Nearest relative, to report the Births / Deaths that takes places in households.
  16. 16. The persons responsible for doing Births and Deaths Registration are as follows: Area Birth and Death Registrars Village Panchayats Village Administrative Officers( panchayat sewak) Nagar Panchayats Health officer / Executive OfficersCorporation / Municipal Areas Executive Officers/health officer/Sanitary Inspectors of the Division Plantations / Estates Estate Manger / Plantation Manager
  17. 17. Chronology of events following death in hospital Death at hospital• Diagnose and declare death By the attending/treating doctor•• Natural Unnatural• Fill up the death reporting form and the MCCD form Fill up the death reporting form and the MCCD form incomplete. By the treating doctor Report is sent to the registering authority. Death Report is sent to the registering authority. (Death report form and the lower half of the MCCD form) ( MCCD form is incomplete) Death certificate issued Inform the police by the registering authority Inquest PME Cause of death is ascertained ( MCCD form is completed) Death certificate issued by the registering authority Body is allowed to be disposed off by the relatives
  18. 18. Death registration• Pronouncing physician ( will fill up the death reporting form)-A pronouncing physician is a physician who determines that the decedent is legally dead /doctor who diagnoses and declares the patient dead• Certifying Physician.( will fill up the MCCD form)-The attending physician is responsible for completing the cause-of-death section- the doctor who was treating the patient for the last 14 days/or who has full knowledge of the patient’s ailment.
  19. 19. Registration of birth and death act [31st May 1969]• Death report : is information that death has occurred ( given in Form 2) – can be given by persons apart from medical person.• MCCD – Medical certificate of cause of death by a Medical personnel only ( form 4)• Death certificate- is certificate issued by the registering authority.( form 6)
  20. 20. Formats - Death Registration Form 2 - is - Death Reporting Form Form 3- Is Still Birth Reporting Form Form 4 - is - MCCD form for the death occurred inHospitals Form 4 A - is MCCD form for death occurred in houses.(MCCD - Medical Certificate of Cause of Death) Form 6 - is - Death certificate
  21. 21. Filling up of form 4 Medical certification of the cause of Death• The cause-of-death section consists of two parts.• Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on line (a) and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line.• Part II is for reporting all other significant diseases, conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I.• Only one cause is to be entered on each line of Part I.
  22. 22. Filling up of form 4 Medical certification of the cause of Death• The immediate cause does not mean the mechanism of death or terminal event (for example, cardiac arrest or respiratory arrest). The mechanism of death (for example, cardiac or respiratory arrest) should not be reported as the immediate cause of death as it is a statement not specifically related to the disease process, and it merely attests to the fact of death. Therefore, the mechanism of death provides no additional information on the cause of death.
  23. 23. Completing Form F• There is difference between cause of death and mode of death• Words like cardio respiratory failure, respiratory failure , asthenia, old age should no be written in part 1 Of the MCCD – these are modes of death not the cause of death.• Such data carry no epidemiological value and are of no use.
  24. 24. Filling up of form 4Medical certification of the cause of Death Example 1
  25. 25. Examples of cause-of-death certification Case history no. 1• Shortly after dinner on the day prior to admission to the hospital, this 48-year-old male developed a cramping, epigastric pain, which radiated to his back, followed by nausea and vomiting. The pain was not relieved by positional changes or antacids. The pain persisted, and 24 hours after its onset, the patient sought medical attention. He had a 10-year history of excessive alcohol consumption and a 2-year history of frequent episodes of similar epigastric pain. The patient denied diarrhea, constipation, hematemesis, or melena. The patient was admitted to the hospital with a diagnosis of an acute exacerbation of chronic pancreatitis. Radiological findings included a duodenal ileus and pancreatic calcification. Serum amylase was 4,032 units per liter. The day after admission, the patient seemed to improve. However, that evening he became disoriented, restless, and hypotensive. Despite intravenous fluids and vasopressors, the patient remained hypotensive and died. Autopsy findings revealed many areas of fibrosis in the pancreas with the remaining areas showing multiple foci of acute inflammation and necrosis.
  26. 26. Examples of cause-of-death certification
  27. 27. Examples of cause-of-death certification Case history no. 2• A 68-year-old male was admitted to the hospital with progressive right lower quadrant pain of several weeks’ duration. The patient had lost approximately 40 pounds, with progressive weakness and malaise. On physical examination, the patient had an enlarged liver span that was four finger breadths below the right costal margin. Rectal examination was normal and stool was negative for occult blood. Routine laboratory studies were within normal limits . A chest x ray and barium enema were negative. His EKG showed a right bundle branch block. CT scan showed numerous masses within both lobes of the liver. A needle biopsy of the liver was diagnostic of moderately differentiated hepatocellular carcinoma, and the patient was started on chemotherapy. Three months after the diagnosis, the patient developed sharp diminution of liver function as well as a deep venous thrombosis of his left thigh, and he was admitted to the hospital. On his third day, the patient developed a pulmonary embolism and died 30 minutes later.
  28. 28. Examples of cause-of-death certification
  29. 29. Dos and don’t’s• Do not delay in filling up MCCD• Do not charge any fees for filling up MCCD• Do not with hold MCCD even if dues of the hospital are not cleared• Do not sign MCCD in advance without examining the deceased.• Fill up the MCCD carefully with and to the best of your knowledge and belief.• Unattended death needs to be informed to the police.
  30. 30. Please remember:• Certificate is not the list of all the diseases which individual was suffering from before death.• Full knowledge of events which lead to death.• Name of the diseases in capital letters ( along with ICD code)• Name of the qualification and reg. no of the doctor to be mentioned.• Date and time of the will be the same as mentioned in the death report ( except in unnatural deaths)• Lower half of the MCCD is to be dettached and handed over to the relatives.( complete MCCD form is not to be handed over to the relatives The MCCD form should be sent to registering authority officially .• The confidentiality of MCCD needs to be maintained( as per section 17 (1)( b) RBD 1969.
  31. 31. Please remember: Cause of death in the death certificate Section 17(1))• No disclosure shall be made of particulars regarding the cause of death as entered in the register.• For official purposes (i.e LIC, Accidents, etc.,) cause of death will be intimated in letter format only (not in certificate form) from department to department.• For medico-legal cases the cause of death will be recorded after chemical analysis report.
  32. 32. Important• Do not use abbreviations.• Use words probable if not sure of the cause of death.• While mentioning time- words such as approximately several hours days , years can be used.• If not sure of the cause of death it may be written as unknown – but that should be last resort and cannot be used routinely especially in medico legal cases where the doctor may be answerable to the court of law.
  33. 33. Errors in Certificates• Missing information in death reports-• Age, gender, marital status• Religion, occupation.• Information in MCCD-• Illegible handwriting.• Sequence of events• And the time of onset of disease to death.
  34. 34. Penalties• (1) Any person who-• (a) fails without reasonable cause to give any information• (b) gives or causes to be given, for the purpose of being inserted in any register of births and deaths , any information which he knows or believes to be false regarding any of the particulars required to be known and registered : or• (c) refuses to write his name, description and place of abode or to put his thumb mark in the register as required by section 11, shall be punishable with fine.• (2) Any Registrar or Sub-Registrar who neglects or refuses, without reasonable cause, to register any birth or deaths occurring in his jurisdiction ,shall be punishable with fine.• (3) Any medical practitioner who neglects or refuses to issue a certificate and any person who neglects or refuses to deliver such certificates shall be punishable with fine.
  35. 35. Key Issues & Challenges• Low priority accorded to registration and general apathy• Lack of inter-departmental co-ordination• Inadequate budget allocation by the States for Civil Registration work• Low levels of knowledge amongst registration functionaries about the processes and procedures of registration, reporting and management of data• Lack of regular monitoring and supervision of civil registration work in the states• Logistical hurdles• Weak demand of vital statistics among planners.
  36. 36. Addressing the issue: Sensitization program at all levels• Functionaries• General public• Doctors involved.
  37. 37. Thank you !“When death is certain let us sacrifice it for a good cause”