PO, nurses must give 8/500 dose if 30/500 not specifi ed Co-dydramol 10mg dihydrocodeine and 500mg paracetamol; two tablets/6h PO Co-proxamol contained dextropropoxyphene and has been withdrawn owing to its potential toxicity and poor analgesic properties. Some patients may still be t aking this, but it is not prescribed to new patients. Strong opioids morphine is used for s evere pain. Use regular fast-acting opioids for acute pain with regular laxatives and PRN o r regular antiemetics. See \200\230weak opioids \200\231 for cautions, side eff ects and t oxicity. Use only one method of administration (ie PO, SC, IM, or IV) to avoid overdose: \200 Oral eg Sevredol or Oramorph 10mg/2 \200\2234h \200 SC/IM morphine 10mg/2 \200 \2234h or diamorphine 5mg/2 \200\2234h \200 IV titrate to pain; dilute 10mg morphine into 10ml H2O for injections (1mg/ml), give 2mg initially and wait 2min for response. Give 1mg/2min until pain settled o bserving RR and responsiveness. Long-acting opioids are used after major surgery or in chronic pain. Use standard opioids i nitially until morphine requirements known (b p93) then prescribe a regular long-acting dos e along with PRN fast-acting opioids to cover breakthrough pain (equivalent to 15% or one-s ixth of daily requirements). Laxatives will be needed. \200 Oral MST dose = half total daily oral morphine requirement (b p93) given every 12h, usually 10 \200\22330mg/12h, max 400mg/24h \200 Topical fentanyl patch lasts 72h, available in 12 \200\223100micrograms/h doses. Naloxone given orally anta gonizes the constipating eff ects of opioids, but is metabolized on fi rst pass through t he liver and does not interfere with analgesic eff ects. Compound preparations oxycodone/na loxone preparations (eg Targinact ) may be of benefi t for chronic pain relief in those wh o develop painful constipation despite regular laxatives. _OHFP.indb 87 _OHFP.indb 87 30/05/2014 16:17 30/05/2014 16:17 88 CHAPTER 2 Life on the wards Other analgesic options/adjuncts Nefopam a non-opioid analgesia that can be given with paracetamol, NSAIDs, and opioids; con traindications epilepsy and convulsions; side eff ects urinary retention, pink urine, dry m outh, light-headedness. \200 Nefopam 30 \200\22390mg/8h PO. Hyoscine butylbromide gives g ood analgesia in colicky abdo pain; contrain- dications paralytic ileus, prostatism, glauco ma, myasthenia gravis, por- phyria; side eff ects constipation, dry mouth, confusion, urine retention. \200 Buscopan (hyoscine butylbromide) 20mg/6h PO/IM/IV. Diazepam acts as a muscle relaxant, eg spasm with back pain contrain- dications respiratory compromise/failure , sleep apnoea side eff ects drowsiness, confusion, physical dependence (use for short-term only). \200 Diazepam 2mg/8h PO. Quinine used for nocturnal leg cramps; contraindications haemoglobinuria, optic neuritis, arrhythmias; side eff ects abdo pain, tinnitus, confusion . \200 Quinine 200mg/24h PO \200\224at night. Patient-controlled analgesia (PCA) a syring e driver that gives a bolus of IV opioid (usually morphine, but occasionally tramadol or fe ntanyl) when the patient activates a button. A background infusion rate, bolus dose and max imum bolus frequency can be adjusted to prevent overdose/ pain; changes to the PCA are usua lly undertaken by the pain team (see box). The patient must be alert, cooperative, have IV access and their pain under control before starting. Check hospital protocols. Epidurals are inserted by the anesthetist in theater usually prior to surgery. A local anes thetic infusion ( opioid) anesthetizes the spinal nerves, and usually produces a sensory l evel below which the patient has little or no feeling; if this level rises too high (higher than T4 (nipples)) there is risk of respiratory failure. The anesthetist or pain team (see box) usually look after epidurals and their dosing post-op. Complications include local ha ematoma, abscess (causes cord compression, b p357) or local infection; if there are concern s about an epidural speak to the anesthetist covering acute pain immediately. Syringe driver These are used mainly for palliative analgesia and symptom control (b p93). Pain team Most hospitals have pain teams, often sub-divided into acute and chronic services . These comprise of nurses and a pain specialist (usually an anesthetist). The acute pain s ervice is sometimes run by the Outreach Team. In-patients with pain issues can be referred to the teams for assessment, though ensure all simple measures have been undertaken to addr ess the patient \200\231s pain fi rst, namely identify and treat cause of pain, and ensure the patient is receiving adequate simple analgesia (regular paracetamol, NSAIDs (if not con traindicated), and an opioid, if appropriate). OHFP.indb 88 OHFP.indb 88 30/05/2014 16:17 30/05/2014 16:17 89 PAIN Neuropathic and chronic pain Neuropathic pain is caused by damage to or chronic stimulation of nerve fi bres, eg radiculopathy (nerve root pain), peripheral neuropathy, and phantom l imb pain. The pain tends to be diffi cult to describe or pinpoint and is often aching, burn ing, throbbing, or shooting in nature. Chronic conditions can cause signifi cant pain, eg c hronic pancreatitis, arthritis, post-traumatic, DM, trigeminal neuralgia; there is frequent ly a psychogenic component. Standard analgesia is often ineff ective and the services of a chronic pain spe- cialist should be sought. Commoner chronic pain therapies include: Tricyclic antidepressants given at a low dose; contraindications recent MI, arrhythmias; si de eff ects dry mouth, constipation, sedation. This is the fi rst-line treatment for neurop athic pain according to NICE guidance.1 \200 Amitriptyline 10 \200\22375mg/24h PO. Pregab alin Contraindications hypersensitivity, pregnancy, lactation; side eff ects dizziness, tir edness, cerebellar signs. Can be used instead of ami- triptyline as fi rst-line treatment f or neuropathic pain. \200 Pregabalin 75 \200\223300mg/12h PO. Duloxetine Contraindication s uncontrolled hypertension, pregnancy, seizures; side eff ects nausea, dizziness, somnolen ce, dry mouth. First line for painful diabetic neuropathy. Avoid abrupt discontinuation. \200 Duloxetine 60 \200\223120mg/24h PO. If fi rst-line drugs are unsuccessful, combinatio n therapy with two or more agents can be considered. If this is unsuccessful then referral for a specialist opinion should be considered. The following are examples of more advanced therapies a pain specialist may prescribe. TENS Transcutaneous Electrical Nerve Stimulation is believed to aff ect the gate mechanism of pain fi bres in the spine and/or to stimulate the production of endorphins. Use at a high frequency for acute pain or slow frequency for chronic/neuropathic pain. Steroids and nerve blocks Injections of steroids combined with local anesthetic into joints or around nerves can reduce pain for long periods. This needs to be done by a specialist. Sympathectomy and nerve ablation The ablation of sensory and sympa- thetic nerves by surger y or injection; used as a last resort in some forms of chronic pain. Acupuncture Eff ective in some trials and with a greater evidence base than most complementary therapies. Counseling and cognitive \200\223behavioral therapy (CBT) to develop coping strategies are widely studied in chronic pain and may be considered by appropriately skilled specialists. Concern remains that it make things worse for some patients. Some terms in chronic pain Allodynia Hyperpathia A short episode of discomfort causes prolonged, severe pain Hyperalge sia Discomfort which would otherwise be mild is felt as severe pain Seemingly harmless stimuli such as light touch can provoke pain 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG173 _OHFP.indb 89 _OHFP.indb 89 30/05/2014 16:17 30/05/2014 16:17 90 CHAPTER 2 Life on the wards Thinking about death The best medicine in the world can only delay death; it is an inevitab le outcome for us all. Patients often die in hospital and as a junior doctor you will have a vital role in supporting the individual and their loved ones through this process. As wit h everything else in medicine, playing this role well requires knowledge, skills and compas sion. Getting things right can be enormously challenging, but equally rewarding. The follow ing pages act as a guide to help you in these regards. Fears It is natural for patients to have a fear of death and dying. It is common to most of us. It should also be noted that ma ny patients, especially the elderly, may be entirely at ease with the prospect of their own death. If your patient is afraid, it is important to establish exactly what they are afrai d of; this may be diff erent from your assumptions: \200 Loss of dignity and control \200 Symptoms, eg suff ocating/pain \200 Their relatives seeing them suff ering \200 T he unpleasant death of a relative years ago. Many of these can now be carefully managed or avoided. When death is not expected or deterioration sudden, then your role in talking to t he patient and allaying their fear cannot be overstated. This will be emotion- ally diffi c ult and you must never hesitate to seek support yourself. Breaking bad news (b p22) Other s ources of help Even with sudden deteriorations there are many other sources of help: \200 Macmillan nurses and the palliative care team (b p91) \200 The acute pain team (usually part of anesthetics) \200 The chaplaincy. Do not forget you \200\231re working with nursi ng staff who may know the patient much better than you, so discuss their care with them. So rting arrangements Needless to say, marching in and off ering a priest and solicitor will b e insensi- tive, but the hospital will be able to provide legal support or an appropriate r eligious offi cial if asked. Many patients \200\231 strongest wish is to die in comfort, of ten in their own home. Get the Macmillan and/or palliative care team involved early and thi s can frequently be arranged. Do not resuscitate orders This decision should be initiated a t consultant or registrar level, and requires ratifi cation by a consultant at the earliest opportunity. It should be clearly written in the notes, on a DNAR form, signed and dated. As the patient \200\231s condition changes, further review may be appropriate. It should be dis- cussed with the patients and/or their relatives. Always inform nursing staff . Reques ts for euthanasia Deliberately quickening a patient \200\231s death is illegal. Relieving s uff ering so that you allow someone to die naturally, and free from pain, is not. \200 Ex plain you will always aim to minimize suff ering \200 Explain to relatives that relieving pain may hasten an inevitable death, before giving opioids (relieving pain removes the adr energic stimulus which may appropriately lead to a natural death within a few minutes) \200 Ensure you could justify actions in court; if in doubt, ask a senior colleague. OHFP.indb 90 OHFP.indb 90 30/05/2014 16:17 30/05/2014 16:17 91 PALLIATIVE CARE Palliative care Palliative care is the non-curative treatment of a disease; originally focu sed on terminal cancer, but now covers other disorders. In practice, cancer patients are st ill able to access more services, including the excel- lent Macmillan nurses who should be involved as early as possible. The aim is to provide the best quality of life for as long a s possible \200\223 this may include admission to a hospice (often temporarily). Pain (b p 86) This is a common problem in palliative care; opioids are often used. It is important to use all modalities of treatment. Consider: \200 Treating the source (urinary retention, bowel spasm, bony mets) \200 Non-opioid analgesia (nerve blocks, TENS, neuropathic pain) \200 Alternative routes (intranasal, PR, transdermal, SC, IM, IV). Table 2.6 is a guide t o converting between opioids, it is not an exact science and changes need to be monitored f or over- or under-dosing. Table 2.6 Opioids and their relative potency Opioid Codeine Dihydrocodeine Tramadol Oral morphine Oxycodone Morphine Diamorphine Fentany l Typical dose Route 60mg/4h PO 30mg/4-6h PO 50mg/4h PO 10mg/1 \200\2234h PO PO 5mg/4-6h SC/I M/IV 5mg/1 \200\2234h SC Topical 24h max 240mg 240mg 600mg N/A 400mg N/A N/A Relative 0.1 0.1 0.2 1 2 2 3 2.5mg/1 \200\2234h 25micrograms/h 2400micrograms 100 \200\223150 Other symptoms Many of the treatments listed in Table 2.7 can be used in non-palliative pat ients. For further information on prescribing in palliative problems see BNF and OHCM9 b p5 32. Table 2.7 Symptom management in palliative care Symptom Treatments Breathlessness O2, open windows, fans, diamorphine, benzodiazepines, steroids, heliox (helium and oxygen for stridor) See b p310, also bisacodyl Saline nebs, an tihistamines, simple/codeine linctus, morphine Chlorhexidine, sucking ice or pineapple chun ks, consider Candida (thrush) infection, synthetic saliva Antacids, eg Maalox , Gaviscon , chlorpromazine, haloperidol Emollients, chlorphenamine, cetirizine, colestyramine (obstru ctive jaundice), ondansetron Nausea/vomiting See b p304, also levomepromazine and haloperid ol Constipation Cough Dry mouth Hiccups Itching _OHFP.indb 91 _OHFP.indb 91 30/05/2014 16:17 30/05/2014 16:17 92 CHAPTER 2 Life on the wards The dying patient it seems still to be the case that, in practice, the discussion of de ath as an inevitable and, in some cases, imminent aspect of life is regarded as morbid and thus avoided. Even with patients suff ering from terminal conditions, it is common for ther e to have been no discussion with patients, their consultants or GPs, relatives, and carers , about preparing for dying. 1 For those patients who have reached the fi nal stage of thei r illness and are not expected to survive, the decision may be taken by a senior doctor to withdraw active treatment and focus on keeping the patient comfortable. These decisions and discussions are highly emotive and should be handled with consideration and skill (b p90). Much emphasis has been placed on achieving better deaths for hospital patients, but out- c omes have been mixed (see box). Identifying the dying The patient will often (but not alway s) be bed- bound with minimal oral intake and reduced GCS. This simple defi nition has poor specifi city, with potential for recovery, whilst timescales can be diffi cult to predict. Since considerable uncertainty will always persist, eff ective and honest communication is vital, along with regular review of treatment decisions by the senior responsible clinicia n. Communication Wherever possible, discussions should happen with the patient and their re latives well in advance; all views should be docu- mented and used to draw up a care plan. Even where an illness progresses rapidly, the withdrawal of active treatment needs to be ca refully considered and every eff ort made to discuss with the relatives; withdrawal of care by junior staff during out-of-hours periods should be avoided. Stopping medications Admini stering drugs may cause unnecessary distress, particularly those aimed at prophylaxis of lo ng-term conditions. Review all medications with a senior and stop those deemed to be unnec- essary. The decision to stop antibiotics can be a particularly diffi cult one, but again, this is made easier by documented prior conversations. but again, this is made easier by do cumented prior conversations. Stairway to Heaven or Conveyor Belt to Death? The Liverpool Care Pathway for the Dying Pati ent (LCP) was originally developed in the 1990s by the Royal Liverpool University Hospital and the Marie Curie Hospice in Liverpool and aimed to introduce some of the best principles of hospice care into the care of dying patients in other settings, particularly hospitals. Wide dissemination and uptake was not always accompanied by necessary training, in some in stances leading the pathway to become little more than a series of protocols for death, w ith complex paperwork delegated to junior doctors or nursing staff , or left incomplete. Wo rse was to come, when in some areas the percentage of dying patients placed on the LCP was deemed to be a measure of quality of care, and fi nancial incentives attached. Widespread p ublic concern about the Death Pathway and associated media pressure led the Department of Health to commission an independent review of the LCP,1 which identifi ed multiple instanc es of poor practice and concluded that the LCP should be phased out and replaced with more patient-centered end-of-life care plans. More guidance is sure to follow, but protocols, pa th- ways and tick boxes will have no place. 1 More Care, less pathway: a review of the Liv erpool Care Pathway Independent Review of the Liverpool Care Pathway, July, 2013. Availabl e free at (cid:27)www.gov.uk/government/publica- tions/review-of-liverpool-care-pathway-for -dying-patients OHFP.indb 92 OHFP.indb 92 30/05/2014 16:17 30/05/2014 16:17 93 THE DYING PATIENT Resuscitation Attempts at cardiopulmonary resuscitation in patients with end stage disease are inappropriate. Although the decision rests with the senior responsible clinician, patie nts and their relatives should be involved in the discussion and informed of decisions wher e possible prior to signing a \200\230DNAR \200\231 form (b p90). Investigations These may be unnecessary. This includes routine blood tests, where the outcome will not infl uence c linical management, but will also extend to the taking of nursing observations in the fi na l stages of illness. Food and \202 uid A loss of appetite in the terminal stages of disea se is common and at this stage nutrition should not be forced. The intake of oral fl uids s hould be supported as long as tolerated, even if this incurs a risk of aspiration. Beyond t his stage, artifi cial hydration (IV or SC) should be used only where it increases comfort, although regular mouth care may continue. Bear in mind that studies have shown no clear be nefi t to length or quality of life in a palliative setting.1 Analgesia Not all dying patients are in pain, and overuse of syringe drivers is inappropria te. However, where present, it is vital to control pain whilst avoiding oversedation (b p91 ). Always exclude a treatable causes eg urinary retention, constipation. If the patient is currently in pain give an immediate diamorphine bolus (2.5 \200\2235mg SC max 1hrly if not currently on diamorphine or give 1/6th of 24h dose 1hrly if already on diamorphine). Where pain is regular and predictable, discuss starting a syringe driver with a SC diamorphine in fusion giving a total 24h dose equivalent to current cumu- lative opioid requirements (use Table 2.6 to convert between opioids). Agitation This may be a sign of pain. Try PRN doses initially; add a syringe driver (with a dditional PRN dose) if regular doses are required: \200 PRN levomepromazine 12.5 \200\223 25mg SC 6 \200\22312hrly or: \200 PRN midazolam 2.5 \200\2235mg/4h SC max 4hrly \200 Sy ringe driver levomepromazine 50 \200\223150mg/24h and/or midazolam 10 \200\22320mg/24h SC ( higher doses up to 60mg/24h may be required). Nausea + vomiting Continue existing antiemeti cs in a syringe driver if they are controlling the symptoms; if there is no nausea then pre scribe PRN cyclizine and add a syringe driver if it is needed regularly. If further antieme tics are required use a 5HT3 antagonist (eg ondansetron). \200 PRN cyclizine 50mg/8h SC \200 Syringe driver levomepromazine 5 \200\22312.5mg/24h SC. Secretions The patient \200 \231s breathing may become rattly due to the build-up of secretions with a poor cough/swall ow refl ex. Sitting the patient up slightly may help; medication improves the symptoms if s tarted promptly. Start with a PRN dose and add a syringe driver if regular doses are requir ed: \200 PRN glycopyrronium 200 \200\223400micrograms SC 6hrly or hyoscine butylbromide 20mg SC 6hrly Syringe driver glycopyrronium 1.2 \200\2232mg/24h SC or hyoscine butylbromide 90 \200\223120mg/24h SC. Further care Review the patient regularly. Ask the patient and/or rela- tives if there are any new symptoms and adjust medications accordingly. If you are unable to control symptoms ask for palliative care review. 1 Good, P. et al. Cochrane Database of Systemic Reviews, 2008 available at (cid:27)onlineli brary.wiley. com/doi/10.1002/14651858.CD006273.pub2/full _OHFP.indb 93 _OHFP.indb 93 30/05/2014 16:17 30/05/2014 16:17 94 CHAPTER 2 Life on the wards Death Declaring death You will often be asked to declare that a patient has died. This is not an urgent request, but the patient cannot be transferred to the mortuary until it is done. There may be other members of staff who can do this if you are busy and unable to attend in a timely fashion. If you are uncom- fortable doing this alone, or are doing it for the fi rst time, ask anoth er member of staff to accompany you. The Academy of Medical Royal Colleges have guidance on the diagnosis and confi rmation of d eath from which the following advice is adapted,1 but your hospital may have specifi c guid elines which you should follow. 1. Con \201 rming cardiorespiratory arrest You should observe the patient for a minimum of \201 ve minutes to confi rm irreversible cardiorespiratory arrest has occurred: \200 L isten for heart sounds in two places, for one minute in each place (total two minutes), then Palpate over a central artery (carotid/femoral) for one minute, then \200 Listen for brea th sounds in two places, for one minute in each place (total two minutes). It is common to hear transmitted gastrointestinal sounds when auscultating the chest, which should be ignored. However, in a very recently deceased patient it is also not uncommon fo r a lone complex to appear on the ECG, or for them to take a last (agonal) breath: This o r any other spontaneous return of cardiac or respiratory activity during your period of obs ervation should prompt a further fi ve minute observation from the next point of cardioresp iratory arrest, unless the patient is for active resuscitation. 2. Con \201 rming the absence of motor response After fi ve minutes of continued cardiores piratory arrest confi rm the absence of motor response in the patient: \200 Absence of th e pupillary response to light; the pupils will often be dilated and they should not change when exposed to a bright light source (eg pen torch) Absence of the corneal refl ex; passing rolled up cotton wool over the edge of the cornea should not elicit a blinking response Absence of any motor response to supra-orbital pressure; applying fi rm supra-orbital press ure should not elicit any motor response. 3. Documentation The time of death is recorded as the time at which these criteria are fulf i lled (Fig. 2.9). Remember to sign and print your name and bleep number. 1 Academy of Medical Royal Colleges A code of practice for the diagnosis and confi rmation of death , 2010. Available at (cid:27)www.aomrc.org.uk/publications/statements/doc_view/42 -a- code-of-practice-for-the-diagnosis-and-con \201 rmation-of-death.html OHFP.indb 94 OHFP.indb 94 30/05/2014 16:17 30/05/2014 16:17 95 DEATH 16/09/14 Asked to verify death. 03:30 No heart sounds for 2 minutes No carotid pulse for 1 minute No breath sounds for 2 minutes Pupils unreactive to light No corneal reflex No response to supra-orbital stimulation Death confirmed at 03.25 on 16/09/2014 Dr CJ Flint FLINT, F1 Bleep 3294 Fig. 2.9 Example of what to write in the notes when a patient dies. What happens to the patient after death When a patient dies the nurses prepare the body,1 i ncluding: closing the curtains, lying them fl at with one pillow, closing their eyes and cl osing the jaw (this may need to be propped closed with a rolled towel under the chin), wash ing the body, using pads to absorb any leakage from the urethra, vagina or rectum, and remo ving attachments (eg fl uids, pumps). Lines and tubes are not removed since these will be i nspected if a post- mortem examination is undertaken. The patient is completely covered wit h a sheet. Once they have been declared dead and the body has been prepared, they are taken to the mor tuary in a portable coffi n. Curtains and port- able partitions are used to try and screen this from other patients. Communication around death On occasion, it will be your duty to i nform others of the death of a loved one. This will produce strong emotions, even when the news is expected, and calls for skillful and sensitive communication (b p22). Ensure you ar e mentally ready to break this news (ask a nurse to accom- pany you wherever possible), kno w the identity of everyone in the room and that the environment is appropriate. Study the n otes beforehand so that you can answer questions relating to events leading up to the death \200\223 if you are still unsure of details, be honest and off er to check. Ask if they w ould like to see the body at that time, and be clear that there will be later opportunities too. The most important element is to give those receiving the news time \200\223 both si lence and emotion are completely acceptable and to be expected and should not be talked ove r or hurried. You will not be able to remove sorrow, but your empathy and profes- sionalism may just help to soften a painful memory that will be mentally revisited many times in the coming months and years. Always remember to inform the GP of the patient \200\231s death, especially if it was unexpected. This is both courteous and prevents any unfortunate phone calls from the GP enquiring about the patient \200\231s health. 1 Henry C, Wilson J. Person al care at the end of life and after death, Nursing Times 8 May 2012, available free online at: (cid:27)www.nursingtimes.net/Journals/2012/05/08/h/i/z/120805-Innov- endo \202 ife.pd f _OHFP.indb 95 _OHFP.indb 95 30/05/2014 16:17 30/05/2014 16:17 96 CHAPTER 2 Life on the wards Medical Certi \201 cate of Cause of Death All deaths in the United Kingdom must be registe red with a local registrar s offi ce. In order for this to happen, a doctor may issue a me dical certifi - cate of cause of death (MCCD), confusingly often referred to as a death c ertifi cate . Alternatively, where the cause of death is not clear or there are any circums tances requiring clarifi cation, the coroner s offi ce must be informed (b p100). In Scotla nd, diff erent legislation applies and a slightly diff erent MCCD is used and the procurato r fi scal takes the coroner s role. Eligibility In hospital, it is ultimately the consultan t s responsibility to ensure the MCCD is properly completed but it can be delegated to a me mber of the team who attended the patient in the last 14d of life (28d in Northern Irelan d). This applies to those involved in the patient s care and who reli- ably know the histor y and course of in-patient stay. Where circumstances require involvement of the coroner s o ffi ce/procurator fi scal (b p100), do not complete the MCCD unless they instruct you to do so. Completing the MCCD Most of the entries are self-explanatory: \200 Name of deceased: full name of the deceased \200 Date of death as stated to me: eg fi fteenth day of Augus t 2014 \200 Age as stated to me: eg 92 years \200 Place of death: ward, hospital, and c ity where they died \200 Last seen alive by me: eg fourteenth day of August 2014 Then cir cle just one of these (most commonly option 3 ): 1. The certifi ed cause of death takes ac count of information obtained from post-mortem. 2. Information from post-mortem may be avai lable later. 3. Post-mortem not being held. 4. I have reported this death to the Coroner fo r further action. Then circle just one of these (most commonly option a ): a. Seen after d eath by me. b. Seen after death by another medical practitioner but not by me. c. Not seen after death by a medical practitioner. Cause of death This can be diffi cult: It is importa nt to take advice from the consultant the patient was under.1 It is important to think of t his as a sequence of events leading up to the death of the patient. The pathology listed in I(a) is whatever ultimately resulted in the patient dying (eg intra- ventricular hemorrhag e, myocardial infarction, meningococcal septi- caemia); avoid using modes of death (Table 2 .8) as this may lead to delays later in the process. The I(b) and I(c) entries should be th e pathology/ sequence of events which led up to I(a). Include pathology in II which likely contributed to death but might not have necessarily been part of the main sequence of event s leading up to the death. It is not compulsory to have entries in I(b), I(c) or II and the se can be left blank. Avoid abbreviations. Approximate interval between onset and death Thi s gives the sequence of events a time frame. An example I(a) Pulmonary embolism Fractured femur (b) (c) Osteoporosis II 6 hours 7 days 30 years 30 years Ischaemic heart disease 1 As part of the reforms to death certifi cation proposed for introduction in 2014, the new role of Medical Examiner (Medical Reviewer in Scotland) will provide an additional source o f advice (b p100). OHFP.indb 96 OHFP.indb 96 30/05/2014 16:17 30/05/2014 16:17 97 DEATH The death might have been due to or contributed to by the employment fol- lowed at some tim e by the deceased If you think the death was in any way related to their employment or an i ndustrial disease you should refer the case to the coroner/procurator fi scal for their con sideration. Signing the certi \201 cate requires your signature and medical qualifi cations, alongside which your local offi ce will usually ask you to print your name and often your GMC number . For Residence it is acceptable to enter the name of the hospital and the city. For deaths in hospital: you also need to enter the name of the patient s consultant at the time of de ath. Completing the sides Make sure you complete the stubs on either side of the main form, copy ing exactly your entries off the main form. Completing the back If you have spoken to the coroner s or procurator fi scal s offi ce, an d they have decided it is appropriate for you to com- plete the MCCD, they may ask you to c ircle one of the options and initial in box A on the reverse of the MCCD. Post-mortem There are two types of post-mortem (PM): Those man- dated by the coroner or pro curator fi scal, and those undertaken after a medical request (a hospital PM ). The coroner s PM (or procurator fi scal in Scotland) is undertaken to fi nd out how someone died and to inform the decision on whether an inquest is needed or not. The next of kin is informed, but not asked for permission, as the law requires a PM to be performed. A hospital PM is usually undertaken at a doctor s request to provide more information about an illness or the cause of death. Consent must be given by the patient before they died, o r by the next of kin after their death. The hospital bereavement offi ce can assist with th is should you be asked to gain consent. Table 2.8 Causes and modes of death Modes of death (avoid these terms) Causes of death (use these terms) Cardiac arrest, syncope Myocardial infarction, cardiac arrhythmia Sepsis, hypovolaemia, hemorrhage, anaphylaxis Con gestive cardiac failure, pulmonary oedema Bronchopneumonia, pulmonary embolism, asthma, chr onic obstructive pulmonary disease Cerebrovascular accident Cirrhosis, glomerulonephritis, diabetic nephropathy Carcinomatosis, carcinoma of the \200 Hypotension, shock, off -legs Heart failure, cardiac failure, ventricular failure Respiratory failure, respiratory arrest Collapse Liver failure, renal failure, uraemia Cachexia, exhaustion _OHFP.indb 97 _OHFP.indb 97 30/05/2014 16:17 30/05/2014 16:17 98 CHAPTER 2 Life on the wards Cremation forms1 Statute While individual crematoria or regions may have slightly diff eren t looking cremation forms, they all follow a similar pattern and ask very similar questions . Guidance on how to complete cremation forms is freely available online,2 though the berea vement offi ce will also be able to guide you and answer your questions. Cremation form nom enclature The main form to be completed for adult cremation is Cremation 4 (Form B in Nor thern Ireland) \200\223 see box. The senior doctor (who must be fully registered for more than 5 years) who checks and verifi es the details in Cremation 4 subsequently completes C remation 5 (Form C in Northern Ireland). Other cremation forms are available for stillbirt hs, and for the cremation of body parts.1 Eligibility For deaths in hospital, it is expecte d that the person com- pleting Cremation 4 treated the deceased during their last illness a nd to have seen the deceased within 14 days of death. Medical practitioners completing Crem ation 4 must hold a license to practice with the GMC, which includes temporary or provision al registration. Examining the body If you are completing a cremation form you were previou sly required to see the body to check the patient \200\231s identity (wrist band and physic al appearance) and examine them to see if they have any implant which may cause a problem d uring cremation (see Table 2.9). Under the proposed 2014 reforms, this responsibility will transfer to the Medical Examiners. If you are required to view the body, check the notes, E CGs and X-rays for possible implants, but also examine the patient for scars or palpable im plants (pacemakers are usually, but not always, on the anterior chest wall). If you believe there is an implant talk to the mortuary staff who will be able to remove it. Remuneration Under arrangements prior to 2014, junior doctors were paid around 70 for completing the form (see b p38); this fee is under review as part of the 2014 reforms. Any fee comes from the patient \200\231s relatives via the funeral director who keeps the money if you fail to take it. The reason you are paid is because this is not a standard NHS service and you are taking responsibility for the fact the body will not be able to be exhumed for evidence if there is any doubt in the future as to the cause of death. Table 2.9 Problematic implants for the cremation of human remains Pacemakers; implantable cardioverter defi brillators; cardiac resynchronisation therapy dev ices; implantable loop recorder Ventricular assist devices Implantable drug pumps including intrathecal pumps Neurostimulators and bone growth stimulators Hydrocephalus programmable shunts Any other battery powered implant Fixion nails (intramedullary nails for fi xing lon g bone fractures) Brachytherapy implants 1 In Scotland, the information previously contained on the cremation form will be included on the revised MCCD from 2014 onwards. Arrangements in the rest of the UK are under review. 2 eg For England and Wales: (cid:27)www.justice.gov.uk/downloads/burials-and-coroners/crema - tions/cremation-doctors-guidance.pdf OHFP.indb 98 OHFP.indb 98 30/05/2014 16:17 30/05/2014 16:17 99 DEATH Completing Cremation 4 Most of the questions are self-explanatory: \200 Details of the de ceased: Name, address, occupation \200 Date and time of death, place of death \200 Are you a relative of the deceased? \200 Have you, so far as you are aware, any pecuniary int erest in the death of the deceased? Were you the deceased s usual medical practitioner? Generally it is the patient s GP who is regarded as the usual medical practitioner. \200 Please state for how long you attended the deceased during their last illness? eg 5 days Please state the number of days and hours before the deceased s death that you last saw them alive? eg 1 day, 12 hours Please state the date and time that you saw the body of the deceased and the examination that you made of the body? eg date, time, external examination to confi rm identify and check for implantable devices From your medical notes, and the observations of yourself and others immediately before and at the time of the deceased s death, please describe the symp toms and other conditions which led to your conclusions about the cause of death. Outline t he symptoms in the period leading up to the patient s death; include the date of admission to hospital Has a post-mortem examination been made? Usually the answer to this is no, but if it has, tick yes and give details Please give the cause of death. Copy what appears on the MCCD \200 Did the deceased under go any operation in the year before their death? If yes, give brief details Do you have any reasons to believe that the operation(s) shortened the life of the deceased ? If yes, the case should be discussed with your seniors/Medical Examiner/coroner s offi ce /procurator fi scal Please give the name and address of any person who nursed the deceased during their last il lness. Usually enter the name of the sister responsible for the ward where the patient died , eg Sister Jayne Smith, Ward 26 \200 Were there any persons present at the moment of dea th? If yes, give details, as above If there were persons present at the moment of death, did those persons have any concerns regarding the cause of death? If yes, give details \200 In view of your knowledge of the deceased s habits and constitution do you have any doubts whether about the character of the disease or condition which led to the death? Yes or no Have you any reason to suspect the death of the deceased was: violent (yes or no) or unnatural (yes or no)? Have you any reason at all to suppose a further examination of the body is desirable? If yes, give details Has the coroner been informed about the death? If yes, give details \200 Has there been a ny discussion with a coroner s offi ce about the death of the deceased? If yes, give details Have you given the certifi cate required for the registration of death? If no, give the details of who has completed the MCCD \200 Was any hazardous implant placed in the body? See Table 2.9. \200 If yes, has it been removed? Yes or no \200 Sign, date and enter your contact details. _OHFP.indb 99 _OHFP.indb 99 30/05/2014 16:17 30/05/2014 16:17 100 CHAPTER 2 Life on the wards