Pathology Outlines - Cause, manner, mechanism of death & death certificate

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Cause, manner, mechanism of death & death certificate


Resident / Fellow Advisory Board: Lorenzo Gitto, M.D.
Deputy Editor-in-Chief: Patricia Tsang, M.D., M.B.A.
Michelle Stram, M.D., Sc.M.

Minor changes: 11 November 2021

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PubMed search: classification forensic pathology cause of death [TIAB]

Michelle Stram, M.D., Sc.M.
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Cite this page: Stram M. Cause, manner, mechanism of death & death certificate. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/forensicscauses.html. Accessed November 28th, 2021.
Definition / general
  • Cause of death: natural disease or injury that led to physiologic changes resulting in death
    • Acute event (e.g., motor vehicle collision, gunshot wound to the head, sudden death in previously healthy individuals)
    • Chronic event (e.g., complications related to atherosclerotic cardiovascular disease, malignancy, etc.)
  • Manner of death: circumstances surrounding death (how the death came about / how the injury or disease leads to death)
    • Mainly based on scene investigation, interviews with next of kin, review of medical history / records, autopsy and ancillary studies (studies (toxicology, histopathology, vitreous chemistry, microbiology, etc.)
  • Mechanism of death: immediate physiologic derangement resulting in death (e.g., hemorrhage, sepsis, asphyxia), which is not etiologically specific
  • Accurate and timely determination of the cause and manner of death are important for many reasons, including for the benefit of the decedent's family, vital statistics, public health implications and the medicolegal system
Essential features
  • Cause of death (COD) is the natural disease or injury that led to physiologic changes resulting in death
  • Manner of death (MOD) is the classification / categorization used for how the death came about
    • MOD commonly has 5 categories:
      • Natural
      • Homicide
      • Suicide
      • Accident
      • Undetermined
    • Some jurisdictions have an additional MOD: therapeutic complication
    • Medical examiner cases can also be pending further studies
  • Mechanism of death is the immediate physiologic derangement resulting in death (e.g. hemorrhage, sepsis, asphyxia), which is not etiologically specific
  • COD and MOD are determined based on the circumstances of the death, examination of the body and ancillary studies as appropriate
  • Accurate and timely determination of the cause and manner of death are important for many reasons, including for the benefit of the decedent's family, vital statistics, public health implications and the medicolegal system
  • Medicolegal manner of death "homicide" stated on the death certificate has no direct bearing on criminal prosecution or insurance settlements
    • Homicide and murder have not the same meaning
    • "Murder" is used in criminal law matters but cannot be used as a manner of death
    • While all murders are homicides, not all homicides are murders
  • Death certificates serve as legal documentation that death occurred and in aggregate, provide mortality statistics for public health purposes, which influences allocation of funding for research and public health initiatives
Cause of death
  • Must be a direct, continuous sequence of events unbroken by any efficient intervening cause and without which the end result would not have occurred
  • Must be an etiologically specific disease or injury
  • Following terminology must be distinguished (BMC Health Serv Res 2007;7:183):
    • Immediate cause of death: final disease or condition that leads to death
    • Underlying / proximate cause of death: other conditions that precede and initiated the train of morbid events that ultimately culminate in the immediate cause of death
    • Intervening cause: any condition that interrupts or exacerbates the chain of proximate causation
    • Contributing factors to death: other conditions that play a role in the death process but are not the primary cause of death
  • Autopsy is an essential tool to identify the cause and manner of death correctly (Am J Forensic Med Pathol 2003;24:313)
    • Clinical autopsy (hospital autopsy): performed to diagnose the disease which led to a natural death (Med J Armed Forces India 2005;61:258)
    • Medicolegal (forensics) autopsy: performed to provide information about the identity, cause of death, time of death, circumstances of death, etc. to support the law enforcing agencies to solve a possible crime (Med J Armed Forces India 2005;61:258)
Manner of death
  • Classification / categorization used for how the death came about; a judgment based on the examination and circumstances surrounding the fatal event (J Med Toxicol 2017;13:111)
  • In most jurisdictions, 5 categories are used:
    • Natural: due entirely (or nearly so) to natural disease processes
    • Homicide: due to a volitional act of another person with the intent to cause fear, harm or death and some negligent acts, even when a person did not intend to cause harm
      • Examples of negligent acts designated homicide: caretaker leaves illicit drug on a table which a toddler consumes and dies from an overdose; intoxicated adult falls asleep on top of an infant, resulting in asphyxiation of the child
      • Homicidal manner does not indicate a criminal homicide, which is determined by the legal process and not by the certifier of death
    • Suicide: due to injury that occurred with the intent to induce self harm or cause one's own death
    • Accident: due to injury when there is no evidence of intent to harm
    • Undetermined: inadequate information regarding the circumstances of death to determine manner
      • Example: individual found unconscious with large subdural hemorrhage; in the absence of information on the events leading up to death, it may not be possible to determine if the hemorrhage is due to accidental fall, homicidal violence, etc.
  • Medical examiner cases can also be pending (pending further studies), while the results of special studies such as toxicology, histology, medical record review or police investigation are being performed
  • When death is due to a combination of natural and unnatural events, preference is generally given to the unnatural cause
    • Example: a man suffers a myocardial infarct while swimming in the ocean, loses consciousness and drowns; the manner of death is ruled accidental, as he may have survived if the fatal myocardial infarct had occurred on land
  • "But for" principle asks the question: "But for the inciting injury (or event), would the decedent still be alive?"
  • In most jurisdictions, deaths due to motor vehicle collisions are considered accidental in manner
  • While acute alcohol or drug toxicity is considered an accidental death, deaths due to consequences of chronic substance abuse (hepatic cirrhosis due to ethanol abuse, endocarditis secondary to IV drug use) are conventionally considered natural in manner
  • Deaths due to improper use of medical devices or improper therapy (e.g. malfunctioning morphine drip, incorrectly calculating dosage and administering 100 times the dose of a medication, resulting in death) are considered accidental
  • Therapeutic complication (TC): refers to deaths caused by predictable complications of appropriate therapeutic procedures (J Forensic Sci 2006;51:1127)
    • Some jurisdictions (New York City) have this additional manner of death
    • TC differs from accident; accident would apply for grossly inappropriate therapy or unanticipated complications that should not have occurred
    • In jurisdictions that do not have TC as a manner of death, deaths due to complications of medical therapy that are reasonably expectable (e.g. neutropenia due to chemotherapy, digoxin toxicity) are considered natural
  • Medicolegal classification of the manner of death is mainly for statistical purposes
    • Manner of death stated on the death certificate has no direct bearing on criminal prosecution or insurance settlements
Mechanism of death
Death investigation
Examination of the body
  • Evaluation for evidence of natural disease and injuries (acute and remote)
  • May consist of external examination of the body or external and internal examination of the body (autopsy) (J Med Toxicol 2017;13:111)
  • Dissection and evaluation of organs
  • Photographic documentation
  • Ancillary studies
  • Toxicology
  • Histopathology
  • Vitreous chemistry
  • Microbiology / virology
  • Molecular genetic testing
  • Neuropathology or cardiac pathology consultation
  • Death certificate
    • Purpose
      • To legally document that death occurred (Clin Med Res 2015;13:74)
      • To provide mortality statistics for public health purposes, which influences allocation of funding for research and public health initiatives
    • Certifier of death
      • Physician, medical examiner or coroner who completes the cause of death section on the death certificate, including information regarding the circumstances of death
      • Cause of death and circumstances represent the certifier's opinion
      • Not legally binding and can be changed if new information regarding the death is introduced
    • How to complete the death certificate
      • Cause of death should always be listed
      • If an acute mechanism of death is known, this can be stated in the first line of part I, with the underlying cause of death listed in the second or third line of part I, as appropriate
      • Conditions which contributed to the death but are separate from those in part I can be included in part II
    Death certificate examples
    • Incorrect cause of death: respiratory arrest
    • Correct cause of death: respiratory arrest due to pneumococcal pneumonia; or complications of pneumococcal pneumonia; or pneumococcal pneumonia
    • Manner: natural

    • Incorrect cause of death: cardiac arrest
    • Correct cause of death: acute myocardial infarct complicating hypertensive and atherosclerotic cardiovascular disease
    • Manner: natural

    • Incorrect cause of death: cardiac arrest
    • Correct cause of death: acute myocardial infarct complicating hypertensive and atherosclerotic cardiovascular disease
    • Contributing condition: acute cocaine intoxication
    • Manner: accident (substance use disorder)

    • Incorrect cause of death: bowel obstruction
    • Correct cause of death: bowel obstruction due to metastatic colonic adenocarcinoma
    • Manner: natural

    • Incorrect cause of death: bowel obstruction
    • Correct cause of death: bowel obstruction due to adhesions complicating exploratory laparotomy for gunshot wound of torso
    • Manner: homicide (shot by other)

    • Incorrect cause of death: cirrhosis
    • Correct cause of death: hepatic cirrhosis complicating chronic alcohol use disorder
    • Manner: natural

    • Incorrect cause of death: anoxic encephalopathy
    • Correct cause of death: anoxic encephalopathy complicating acute intoxication by the combined effects of heroin, fentanyl and ethanol
    • Manner: accident (substance use disorder)

    • Incorrect cause of death: urosepsis
    • Correct cause of death: urosepsis complicating quadriplegia due to spinal cord injury from remote gunshot wound of torso
    • Manner: homicide (shot by other)

    • References: CDC: Physicians' Handbook on Medical Certification of Death [Accessed 25 February 2021], CDC: Improving Cause of Death Reporting [Accessed 25 February 2021], Indiana Coroners' Association: Cause of Death and the Death Certificate [Accessed 3 March 2021]
    Death certificate images

    Contributed by Michelle Stram, M.D., Sc.M.
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    Blank sample death certificate


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    Forensic sample death certificate


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    Hospital setting sample death certificate

    Board review style question #1
    A 30 year old man with a past medical history of opioid abuse is found in his locked, secured apartment sitting on the floor of his bedroom with several glassine envelopes containing white powder. A complete autopsy is performed, which reveals an atraumatic male with a normal BMI (BMI 20.1; height 6' 1/2"; weight 150 lbs), normal heart (340 grams, left ventricle 1.2 cm) and marked pulmonary congestion (combined lung weight 1,300 grams); the remaining organs were unremarkable. Toxicology reveals the presence of fentanyl and morphine in his femoral blood and 6-MAM (6- monoacetylmorphine) in his urine.

    What is the manner of death in this case?

    1. Accident
    2. Homicide
    3. Natural
    4. Suicide
    Board review style answer #1
    A. The manner of death is accident. This is an accidental overdose (cause of death: acute intoxication by the combined effects of fentanyl and heroin) in a young man with substance use disorder.

    Comment Here

    Reference: Cause, manner, mechanism of death & death certificate
    Board review style question #2
    A 41 year old man has a past medical history of receiving a gunshot wound to his torso, which partially transected his spinal cord when he was 32 years old. He sustained the injury when a disgruntled former employee shot him along with several other people working at a warehouse facility. He has used a wheelchair since the injury and resides in a nursing facility due to complications of his gunshot wound. He has had multiple bouts of urinary tract infections secondary to urinary catheterization. He develops urosepsis, which is complicated by pneumonia and his family transitions him to palliative care. 3 days later, he dies from sepsis and pneumonia.

    What is the manner of death in this case?

    1. Accident
    2. Homicide
    3. Natural
    4. Suicide
    Board review style answer #2
    B. The manner of death is homicide. The decedent developed urosepsis secondary to the urinary catheterizations, which he required due to his paraplegia. The underlying cause of his paraplegia was the gunshot wound of the torso, which injured his spinal cord. The length of time between the injury and death does not change the manner, whether an individual dies immediately due to a gunshot wound, in the trauma bay or years later due to complications of the gunshot wound, as long as the injury led to a direct, continuous sequence of events unbroken by any efficient intervening event. Evaluating the cause of death using the "but for" principle is useful in this case: but for the gunshot wound, would the decedent have been paraplegic, requiring urinary catheterizations? The infectious complications of catheterization are a known risk factor and consequence of paraplegia, which were directly due to the decedent's spinal cord injury, which occurred because he was shot in the torso (cause of death: remote gunshot wound of torso with injury of spinal cord resulting in paraplegia complicated by urosepsis and pneumonia).

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    Reference: Cause, manner, mechanism of death & death certificate
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