death investigation systems 45the birth and death of its citizenry in order to provide for transfer of estates,
administration of societal programs, payment of insurance settlements, etc.
The tracking of deaths from an epidemiologic viewpoint allows for better
public health surveillance in a society, be it related to epidemic diseases or
public safety issues. As all purveyors of television crime dramas are well
aware, adequate death investigation and certification is required for the
criminal prosecution of deaths due to the action or inaction of another
person or institution. And finally, knowledge of the cause and manner of
death is often of importance in allowing appropriate grieving and closure for
the family and loved ones of a decedent.
In most jurisdictions, deaths occurring solely by natural means may be
certified by attending physicians. However, deaths due to trauma, intoxica-
tion, or unknown means usually fall under the jurisdiction of the medical
examiner or coroner, and must be investigated and certified by that office.
In addition to the demographic documentation related to the decedent, such
offices must also attempt to determine the cause and manner of death.
4.5.1 Cause of Death
Cause of death is a concept applied somewhat more strictly and precisely by
the medical examiner than by other physicians or the lay public.^21 A number
of definitions of this term have been devised, but a simple one favored by the
author is “that disease, injury or event, but for which death would not have
occurred at the time it did.” In death certification, the first insult that begins
a cascading series of events leading to death is of primary interest. This is
referred to as the cause of death, or as the proximate cause of death. This is in
distinction to the subsequent resultant physiologic derangements caused by
this event. These derangements are often referred to as mechanisms of death
or the immediate causes of death.
For example, suppose an individual receives a gunshot wound that
injures the spinal cord and renders the victim quadriplegic. If, years later, he
or she succumbs to a urinary tract infection related to the paralytic bladder
caused by the spinal cord injury, the cause of death should be appropri-
ately certified as a “gunshot wound of the back,” or “urosepsis complicat-
ing quadri plegia due to gunshot wound of back.” Many physicians, however,
would inappropriately list the cause of death as “urinary tract infection”
(a mechanism of death) without referencing the true cause of the condition,
the gunshot wound. The reasons for this are readily apparent, as most clinical
physicians are concerned with diagnosing and treating acute conditions that
can be ameliorated by medical or surgical therapy. The medical examiner,
however, recognizes that the purpose of death certification is to provide sta-
tistical information on primary causes of death, and that the lapse of time
between injury and death is of no importance in this documentation.