Emergency physicians and death certificates

Letters

CJEM 2001;3(4):265-266

To the editor:
I was disturbed by the authors' response¹ to Dr. Jim Gall's letter² regarding their article.³ The authors acknowledge that they work in an institution "that routinely contacts the coroner for all ED pronouncements." They further admit that this practice was not changed despite efforts by the regional coroner's office to emphasize "the need for emergency physicians to complete the death certificate and to call the coroner's office only when the death met certain criteria." This request is described as "adding responsibility and more paperwork" and "must be weighed against competing service and academic demands."

Ontario, like most jurisdictions, has a statutory obligation to report certain deaths, such as those that are the result of trauma or medical misadventure. In the absence of the statutory criteria, it is every attending physician's obligation to complete the death certificate and attendant institution paperwork. Indeed, our duty to our patient is not ended until the death routines (e.g., notifying relatives, completing paperwork) have been performed. We are all busy, but deaths are infrequent and important events, and our obligations should not be taken lightly. In a teaching institution, in which future trainees are looking for role models and forming habits, the completion of our statutory and moral obligations should be completed faithfully and without reluctance or regret.

Howard Ovens, MD
Director
Schwartz/Reisman Emergency Centre
Mount Sinai Hospital
Toronto, Ont.

References

1. Cheung M, Morrison L, Verbeek PR. Prehospital vs. ED pronouncement of death [letter]. CJEM 2001;3(3):177-81.
2. Gall J. Prehospital vs. ED pronouncement of death [letter]. CJEM 2001;3(3):177.
3. 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. Ovens reminds us to strive to live up to the responsibilities of a complete physician against the adversity of the hectic climate in which we work. To do so would be in keeping with the best academic role model and performance benchmark. Our study and our observations are based on the reality of our institution and the demands of our department. In no way do we suggest the performance benchmark for legal documentation should be lowered. In clinical practice the legal responsibilities of complete documentation must always be weighed against the other time sensitive responsibilities of being a clinician. In comparison, there are no measurable performance standards for time spent with a grieving family and incident debriefing of paramedical and emergency staff. As academic clinicians we strive to balance our responsibilities and the making of choices under the pressures inherent in our specialty. This personal triage of where to spend our time is also an important opportunity to role model for trainees. We cannot be all things to all people and we make choices not with regret or reluctance but with a feeling that we have put the patient, their family, our staff and our trainees first.

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.