A man dies of a self-inflicted gunshot wound to the head during a game of Russian roulette. Is it an accident or a suicide? A bank teller with cardiac disease dies of a heart attack when a robber points a gun at her and demands money from the till. Is it a natural death or a homicide? How these questions are answered can have far-reaching implications. Criminal cases, insurance payouts and public health decisions may be impacted by how a death is categorized.
In his role as dean of PCOM’s School of Health Sciences and director of the MS in Forensic Medicine Program, Dr. Gregory McDonald teaches students the importance of thoroughness, accuracy and looking beyond the obvious when identifying the factors that lead to a person’s death.
“This is a part of medical education that I think is somewhat neglected,” he said.
A death certificate is a document that contains identifying information for the decedent—name, race, age, residence and next of kin. The document also specifies the cause of death and manner of death.
McDonald, the chief forensic pathologist at the Montgomery County Coroner’s Office, has extensive experience completing death certificates having conducted thousands of autopsies over the course of his career. Medical examiners, coroners, the physicians who pronounce a person dead and, in some states, physician assistants or nurse practitioners may sign a death certificate. In some cases, they may also complete the cause and manner of death. This, McDonald emphasized, is why it is critical healthcare professionals receive proper training.
“It’s a legal document, a very important document,” McDonald said.
The cause of death is the physiologic issue, whether brief or prolonged, that initiated the chain of events that ultimately resulted in death. The manner of death is how the cause of death originated—natural, accidental, suicide, homicide or undetermined.
The issue, McDonald explained, is that sometimes the connection between the cause of death and manner of death may not be readily apparent.
“Let’s say someone was shot in the neck 10 years ago. They’re paraplegic or quadriplegic. They've been in and out of nursing homes and hospitals. They are surviving but they develop pneumonia and bed sores. They have urinary tract infections and ultimately sepsis sets in,” McDonald said. “The person dies and the doctor lists sepsis as the cause of death. In their mind, sepsis is a natural process so they list ‘natural’ as the manner of death.”
That, according to McDonald, is problematic if the death is not reported to the authorities since the sepsis ultimately developed as a result of the old gunshot wound.
“There's an unbroken line of causation from that injury to their death,” McDonald explained. “That would make it a homicide.”
Typically, a coroner or medical examiner should be notified about deaths resulting from criminal acts, accidents, drug overdoses, falls and other unnatural deaths.
“I tell my students to dive a little bit deeper—especially on what may seem to be a natural phenomena like sepsis or seizures,” he said. “Many of them will likely have an unnatural origin.”
He further encourages his students to err on the side of caution.
“If you are not sure if it should be reported, by all means report it,” he said. “If they report it to us and we decline to investigate, that’s on us.”
In his lectures, McDonald presents his students with various scenarios to illustrate how complicated determining cause and manner of death can be.
“It’s very well received by medical students,” he said. “It can be somewhat eye-opening.”
McDonald also discusses what can happen when a death certificate is not completed correctly. He recounts an instance in which a physician who incorrectly completed a death certificate subsequently found himself in the courtroom on the witness stand getting interrogated by an attorney.
“There’s no interest like self interest,” McDonald said. “When they realize they may have to take a day off work, and can’t see patients that day, and may get grilled by various attorneys, that gets their attention.”
More importantly though, McDonald added, he wants students to take the responsibility of filling out death certificates seriously because it is the right thing to do and because it can have an impact on public health.
“We urge them to be as specific as they can with the cause of death,” he said. “So many of them will put something like cardiorespiratory arrest. I've never seen a dead person who didn't have cardiorespiratory arrest, right? So that doesn't tell me anything. What caused that? Was it a gunshot wound to the head? Was it a heart attack? Pneumonia? I tell them to put as many things on there as they think contributed to the death.”
Accurately and precisely noting the contributing factors leading to a person’s death provides information that can be used by law enforcement, public health and other agencies to direct funding and resources towards rehabilitation, prevention and intervention.
“There’s a lot of different spokes to that wheel,” McDonald said. “All of that data starts with the pen of a pathologist.”
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