A lady, Mrs Frances, died on the ward overnight – her bed was empty in the morning, and I kind of assumed, but the first confirmation I got was when I got bleeped mid-morning by the bereavement team to come down and fill out the death certificate. It’s odd to go down to the almost-pathologically-still bereavement offices from the bustle of the ward, and to examine a body, stethoscope held to silent chest and lights shining into fixed pupils before sitting down to fill in a confirmation of death.
A death certificate is a surprisingly involved thing. It lists the cause of death, and conditions leading to that cause – these are separated from conditions which contributed to the death but were not responsible. For example, a death certificate might read:
Cause of Death
1a. Acute myocardial infarction (heart attack)
1b. Ischaemic Heart Disease (furred-up blood vessels causing narrowings of the arteries)
1c. Familial Hypercholesterolaemia (a genetic condition causing excess levels of fat in the blood)
2a. Diabetes (didn’t actually cause the person to die, but contributed by damaging blood vessels)
However, these causes aren’t always obvious and even when you think they should be they often defy easy definition. Did someone’s kidney failure contribute to or cause their death? They certainly had some, and it won’t have done them any good, but is it responsible? Did their high blood pressure contribute, or was it well-enough controlled on their medication that it is irrelevant? In the case above, it could easily be argued that familial hypercholesterolaemia should be in section 2, or likewise that diabetes should be in section 1c. It’s a mire made more complicated by the stipulation that some causes of death aren’t allowed, such as heart failure or (peculiarly) old age.*
The other problem is how literal to be. Everybody (almost) dies for one of two reasons – their heart stops, or they stop breathing and then their heart stops. Cardiac arrest, though, is not a 1a cause of death. Respiratory arrest is, but I don’t know why that is permitted when cardiac arrest isn’t. You can’t have any cause of death with a failure in (heart failure, liver failure, etc) except sometimes, when you can – making things problematic when the reason someone was in hospital and unwell was because of liver failure. Tricky. Inevitably, what happens is that you go in, read the notes, then ring the pathologist and ask them what you should be writing down. You fill in the sections, plus a few other bits and pieces, do a cremation form, and in a months time pop in to collect your cheque.
Yup, that’s right. People die, and we, the doctors, are paid. Quite the inappropriate incentive to get ~£75 pounds per death, when such financial generosity should surely be reserved for getting people out of hospital alive. It all comes down to legalities and cremation – I am legally obliged to certify someone dead and fill out the death certificate. I am not legally obliged to fill out a cremation form. It just so happens that cremation is an efficient way of destroying evidence if something untoward contributed to a persons death – as such, every death has to be checked through by a doctor and any suspicious issues flagged up to be checked before a cremation can go ahead. All this has to be documented on a long, long form; it takes roughly an hour to complete – hence the cheque.**
Despite the money and the peace and the quiet, I hate going to bereavement. I know that civilisation begins with respect for the dead and all, but I don’t like the feel of a cold, rigid body or the silent strangeness of a chest unmoving. I know there is a cheque waiting for me from Mrs. Frances (and I do see it as being ‘from’ the patient, even though that is ridiculous), but I won’t go back there to pick it up until I have to, for another signing. Doctors have an uneasy relationship with death, fighting it, delaying it, occasionally allowing it in when there is nothing further we can do. Somehow, though, we avoid acknowledging it as much as possible even when we’re staring it in the face. We understand the processes of life, but aren’t qualified on anything beyond that.
I guess that’s why there are chaplains of various faiths on-call, 24 hours a day, helping religious and non-religious people alike.
*although sometimes in exceptional circumstances that is allowed.
**a cheque that, perversely, dramatically overpays F1s for their time.