Selasa, 14 Agustus 2012

Manner of Death


Assignment of a manner of death is also a required part of the death certification
process. Ostensibly, this is an attempt to classify the death as to the
circumstances by which death came about; unfortunately, this classification
is often problematic. There are five classical manner of death categories.21

•Homicide: Death caused by the intentional actions of another person.
•Suicide: Connotes a death due to one’s own intentional acts.
•Natural: Death due to natural disease processes only, with no contribution
from traumatic or external factors.
•Accident: Death due to unforeseen traumatic or external factors.
•Undetermined: The manner of death is not known or could not
be determined.
Some jurisdictions also add additional categories, such as unclassified,
therapeutic misadventure, etc., but these are not universal. The idea of a
manner of death classification is an American invention,31 and the manner
of death categories available for use in death certification are promulgated by
state vital records departments. Physicians, medical examiners, and coroners
are bound to and limited by these available choices.

The problem with manner of death classification is that the “pigeonholing”
of complex and disparate deaths into one of five (actually four) categories
is fraught with problems. One difficulty in reproducibly assigning an
appropriate manner of death category is the lack of agreement on definitions
for the classification terms. The brief definitions listed above are quite rudimentary
and broad, and are subject to considerable and substantive variationin various jurisdictions. For example, a homicide is generally considered to
be a death at the hands of another person, whereas suicide is death at one’s
own hands. Yet a death due to a motor vehicle crash is generally classified
as an accident, regardless of whether one or both of the drivers were at fault
or caused the crash. If a hunter fires at a target he believes to be a deer, but
inadvertently kills another hunter, many MEs will classify this death as a
homicide, since the rifle was purposely fired at a target, which was struck and killed. Others would consider it to be an accidental death since the
hunter did not intend to kill a human being. Some jurisdictions require that
intent to cause one’s own death be a factor in classifying a death as suicide.
Others require only that the act leading to death be intentional, regardless
of whether or not death was anticipated. For example, if a person is playing
Russian roulette with a partially loaded revolver and dies of a gunshot
wound of the head, many MEs would classify this as a suicide, without consideration
of whether or not the player actually intended to die, or just was
engaging in thoughtless, extremely risky behavior. Others would agree that
the death represents a suicide, but largely because of the high inherent risk of
the activity. Deaths due to acute intoxication by ethanol or other drugs are
usually classified as accidents unless suicidal intent is evident. But deaths due
to the chronic effects of the same drugs (cirrhosis, endocarditis, etc.) are typically
classified as natural deaths. These are but a few of the inconsistencies
and disagreements that may plague a manner of death determination. 

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 appropriately
certified as a “gunshot wound of the back,” or “urosepsis complicating
quadriplegia 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 statistical
information on primary causes of death, and that the lapse of time
between injury and death is of no importance in this documentation. 

Senin, 13 Agustus 2012

Death Certification


A major common denominator in any modern death investigation system is
the documentation of death and the determination of its cause and manner,
also referred to as death certification. In early times, records of birth and
death were kept inconsistently, if at all, but in 1538, clergy in England were A major common denominator in any modern death investigation system is
the documentation of death and the determination of its cause and manner,
also referred to as death certification. In early times, records of birth and
death were kept inconsistently, if at all, but in 1538, clergy in England were death investigation systems
 function of governments instead of the church. This change was given further
 impetus during infectious epidemics of the nineteenth century, when it came
to be appreciated that it would be worthwhile to keep track of the numbers
of deaths occurring as an infectious contagion progressed.18 Subsequently,
governments around the world began to require registration and certification
of births and deaths. Modern death certification is a function of state
governments, and all jurisdictions in the United States have a common
requirement that the death of a person be officially documented, with attestation
of the cause and manner of death by a physician, medical examiner,
coroner, or other official. The document serving this purpose is referred to as
a death certificate, and requirements regarding its use and filing are set forth
by a state department of health, vital records, or equivalent.28 State deathcertificates tend to be fairly similar, as most are based on the U.S. Standard
Certificate of Death, which is in turn based on World Health Organization
recommendations. A typical state death certificate is shown in Table 4.2.
Many states are also moving toward a standardized digital death registration
process that promises to make gathering of demographic and epidemiologic
data much simpler and more effective. 

Modern American Death Investigation Systems


As will be seen subsequently, the systems of death investigation in the United
States are widely varied. However, they generally share a number of mission
components in common. To paraphrase DiMaio and DiMaio,21 the various
components of a death investigation system are as follows:

1. Determine the cause of death, and how the death came about
2. Identify the decedent
3. Determine the time of death and injury
4. Collect evidence from the body that may be useful in the police
investigation
5. Document injuries that are present, or their absence
6. Deduce how injuries occurred
7. Document any natural disease present
8. Document or exclude any causative or contributory factors in the death
9. Provide testimony in court as needed
In spite of the widespread distribution and long history of the office of
the coroner, as medical science and the understanding of death have become
more complex, shortcomings of the system have became apparent. Most
obvious is the fact that most coroner jurisdictions do not require a coroner
to be a physician. Obviously, a nonphysician is in a poor position to render
a medical opinion on the cause of death, a determination that is manifestly
the practice of medicine. The likelihood of omissions or misinterpretations is
increased in such jurisdictions where the responsibility for this duty is vested
in someone other than a trained physician. Second, coroners are elected
officials in the United States. The necessity of maintaining public electoral
support has long been considered a potential impediment to the development
and maintenance of absolute impartiality in death investigation by coroners.
Death investigators must often make very hard and controversial decisions
that are difficult for families, local political forces, and others to accept. In
theory, at least, an appointed official, as opposed to an elected one, can make
such decisions without the fear of alienating a voting block necessary for his
or her continued employment in the position.

Proponents of the coroner system respond that the nonmedical coroner
functions as an administrator and quasi-judicial agent, and can employ physicians
to perform examinations and make medical decisions under his or
her directions. However, since the coroner retains ultimate authority for the
investigation and determination of the circumstances and cause of death,
the possibility that such an individual will exercise that authority to veto or
influence the medical decision of an employed physician still remains. Some
coroner proponents also point to the greater political authority of an elected
death investigation systems 

The Coroner System


Though the cause of death was undoubtedly investigated in ancient times,
it was likely an ancillary duty of tribal elders, magistrates, priests, or other
authorities. The first instance of an official office charged with the investigation of death, as we know it today, was probably the English coroner.
Though officials with this responsibility are reported as far back as 871 A.D.,
in the time of Alfred the Great, the beginning of the coroner system in
England is generally taken to have been in 1194, with the publication of
the Articles of Eyre, the Eyre being a system of roving “circuit” justices in
England in the twelfth century. These itenerant judges traversed the land to
hear cases and dispense justice, but due to the long intervals between their
visits (an average of seven years), it was necessary to have local officials
perform careful investigations and keep records of offenses so that the cases
could effectively be brought before the justices when they finally did arrive.
Without proper records, many cases were never tried. This would not do, as
many of them involved production of revenues for the monarch, at that time
Richard the Lionhearted. Richard, a Norman king, was an absentee ruler
with a penchant for expensive foreign wars that placed a heavy strain on the
royal coffers. In addition to his travels and the need to equip large numbers
of troops, he also managed to become captured and imprisoned in Germany
during his return from the Holy Land in 1192. A huge ransom was required
to secure his release and return to England in 1194. These expenses created
an acute need for revenues, so no stone was left unturned in a desire to collect
all taxes and other dues to which the Crown was entitled under the law. There
were many such assessments, creatively applied in the name of law and order,
to enrich the king at the expense of his subjects.
It was customary at that time to seize the property of felons, and because
suicide was considered a crime against God, the property of those taking
their own lives was also forfeited to the Crown. Furthermore, villages were
penalized with a fine, or amercement, whenever a murder or other legal
infraction occurred in their jurisdictions, a punishment for allowing civil
disturbances to occur or for not properly following the complex system of
laws in the realm. Sometimes the victims of these murders were members of
the conquering Norman class who were unfortunate enough to find themselves
in the midst of local Saxons bent on revenge. To prevent having large
numbers of its Norman noblemen dispatched by the indigenous population,
the Crown levied a fine known as the lex murdrorum on the lord of any village
or territory in which a Norman was killed. And naturally this fine was passed
on to the populace in the form of a tax. Even the object actually causing a
death (referred to as a deodand) was subject to presentation to the Eyre, and
it could be confiscated in the name of the Crown because of its culpability in
the death or injury of a person. So if a person were injured or killed by a cart,
animal, or farm implement, this item would likely be appropriated by the
court, possibly depriving a farmer of the means of his livelihood. 

Early Death Investigation


The most primitive societies likely had a well-developed sense of the causative
relationship of trauma, old age, and illness to death, and early “investigations”occurred even in tribal societies to determine why a member of the family
group had died, though they were more likely to invoke superstition or
magical thinking instead of the “rational” methods employed by modern
societies.2–4 Early Mesopotamian civilizations, and those of ancient Egypt,
Greece, and India, had well-developed legal codes (the earliest being the Code
of Hammurabi, 2200 B.C.), and these laws often referenced medical issues,
such as duties of physicians, allowable fees, the viability of the fetus, and discussions
of injuries. These cultures also had well-developed medical systems,
but there is little or no reference in their extant writings to suggest that medical
practitioners were regularly involved in the investigation of death. Rather,
common sense and experience were applied by various officials, magistrates,
or priests in an attempt to explain why and how individuals died. Some of the
earliest death investigations probably involved deaths due to suicide, which
most societies have considered to be an unacceptable act for religious or
superstitious reasons.5 Taking one’s own life might result in denial of funeral
rites, reprisals against the decedent’s family, or other penalties, so a rudimentary
death investigation was necessary in such cases to determine if a death
was self-inflicted.

The earliest written documentation specifically related to formal death
investigation has been discovered in archaeological excavations in China.6
Here, bamboo strips unearthed and dated from the period of the Ch’in
Dynasty (221–207 B.C.) have been found inscribed with writings giving
instructions to civil servants charged with the examination of corpses who
died under suspicious circumstances.

Death investigation in ancient Athens was largely a private matter instead
of a concern of the state.7 As such, investigations by a governing body were
not consistent, and Greek physicians were apparently not involved in certification
or investigation of death, though there are reported instances of their
testimony in legal proceedings involving injury. 

Death Investigation Systems

Introduction

Throughout human history, the inevitability of death has inspired not only
a sense of fear, but also a paradoxical sense of fascination and curiosity. It is
no surprise then that the investigation of death has a long and varied history,
intimately involved with the rise and governance of human populations. The
sociologist Stefan Timmermans1 has noted that death is not an individual
event, but a social one, and every developed society has had an interest in the
phenomenon, be it from a legal or public health viewpoint in modern populations,
or as part of a mythic or superstitious worldview in earlier societies.
Beliefs about the phenomenon of death have also been inexorably linked to
religious systems throughout history.2–4