Prehospital vs. ED pronouncement of death

Letters

CJEM 2001;3(3):177-178

To the editor:
I read with interest the article by Cheung and colleagues.¹ I believe a significant cost omission was made in the analysis of the costs involved in field pronouncement.

I work as coroner in Windsor, Ontario, a city and county that has been deemed by various reports of the Ministry of Health as underserviced to the tune of 50 general practitioners and 50 specialists. Often I am called to certify a death that has been pronounced in the field, either because the deceased has no physician or because the family physician cannot be reached (answering machine indicates to go to the ED or a walk-in clinic) or is unwilling to go to the scene in a timely fashion. In these instances funeral homes will not come to get the body without a death certificate being on the scene.

The cost of a coroner's investigation to the Ministry of the Solicitor General is $155 plus mileage. If the coroner is concerned about the circumstances of the death, an autopsy may be ordered. This necessitates transfer of the body to the nearest morgue (not by an ambulance doing field pronouncement but by a body removal service) ($89), then an autopsy (pathologist's fee: ~$400), not to mention the hidden institutional costs to the ministry for morgue attendants and facility fees.

Finally, there is the time involved in notifying the family of the autopsy results and answering their questions about their loved one's demise. Although this is covered in the $155 fee, it takes time and energy and, for most coroners who are busy family physicians, takes time away from their practices.

Studies into the cost benefits of field pronouncement that make statements such as: "Pronouncement in the field requires more paramedic time but less physician time" (p. 19) and "This study suggests an economic advantage for field vs. ED pronouncement" (p. 24) need to take the above facts into consideration before suggesting a significant saving to the system.

Jim Gall, MD
Coroner, Essex County, Ontario
Chair, Education Committee
Ontario Coroner's Association

Reference

1. Cheung M, Morrison L, Verbeek PR. Prehospital vs. emergency department pronouncement of death: a cost analysis. CJEM 2001;3(1):19-25.

[The authors respond:]

Dr. Gall has identified an important cost associated with field pronouncement that was not measured in this study. We chose a priori to exclude the cost attributed to the coroner's investigation, mileage, body removal and autopsy for specific reasons.

The patients in the ED pronouncement cohort were cared for in an institution that routinely contacts the coroner for all ED pronouncements. Thus, the cost of the coroner's investigation was the same for each group. Body removal by the coroner's office and autopsy are both at the discretion of the coroner and were similar for the two comparative groups. Body removal by a funeral home was presumed to be the same for both groups. The coroner's mileage to the out-of-hospital setting relative to the hospital was not taken into account because the impact of this difference was assumed to be negligible. Subsequent to the study period, the regional coroner's office emphasized the need for emergency physicians to complete the death certificate and to call the coroner's office only when the death met certain criteria. Presumably, this would reduce the cost of the coroner's investigation for each in-hospital ED pronouncement. However, requests for additional responsibility and more paperwork must be weighed against competing service and academic demands, and the routine practice of calling the coroner has not significantly changed.

Dr. Gall identifies an important factor that may limit the generalizability of our results to other regions as alluded to in the limitation section of the manuscript. We thank the Editor for the opportunity to respond and to Dr. Gall for his cogent comments and his interest in this subject.

Matthew Cheung, MD
University of Toronto
Laurie Morrison, MD
P. Richard Verbeek, MD
Prehospital Research Program
Department of Emergency Services
Sunnybrook & Women's College
Health Sciences Centre, and
Department of Medicine
University of Toronto, and
Toronto Emergency Medical Services
Toronto, Ont.