In every hospital, occasionally cases are brought to the Emergency Room who are apparently dead or actually dead (dead-on-arrival or DOA). Such cases may be due to natural cause or unnatural cause. Every doctor should be aware of the procedure to be followed in DOA cases, because such cases have legal, ethical and social ramifications.
Ethically and legally, a doctor should immediately declare a person as dead once the diagnosis of death can be clearly ascertained. Legally, the cause of death certificate has to be issued by the doctor in all natural deaths, and after medicolegal autopsy in all unnatural deaths to enable the next of kin/relatives to get the death certificate issued by the revenue authorities (Corporation in Cities; Municipality in towns; Village panchayat in villages). Socially, it is the right of the relatives to get to know the death of their loved ones the moment such an eventuality occurs.
What is the procedure to be followed in such cases that are brought dead (DOA)?
First and foremost, all cases brought dead to the hospital should be documented clearly in the “death register” or “brought-dead register”. Subsequently there should be collection of adequate history regarding events that had happened preceding the death, especially relating to any disease, drug usage, or injuries; and a complete examination of the dead body.
If there are any injuries, poisoning signs, or suspicion regarding the nature of death, the case should be registered as a medicolegal case, and the jurisdictional police must be informed. The body must not be handed over to the relatives. If the hospital has a mortuary, the dead body should be shifted there after making necessary entries in the mortuary register, and then wait for the police to arrive and take necessary action on their part. If the hospital does not have a mortuary, the dead body should be shifted to an empty and safe room, and the doctor should wait for the police to arrive and take necessary course of action.
If there are no injuries or poisoning signs, and it looks like a case of natural death, and if it was treated in the same hospital1 (by any doctor of the same hospital), then the cause of death certificate can be issued by the hospital (after perusing all the treatment notes/discharge summary/case sheet), and the dead body can be handed over to the relatives for final rites. [As per Section 10(3) of
Births & Deaths Registration Act, 1969-Where the State Government has required under sub-section (2) that a certificate as to the cause of death shall be obtained, in the event of the death of any person who, during his last illness was attended by a medical practitioner, the medical practitioner shall, after the death of that person, forthwith issue without charging any fee, to the person required under this Act to give information concerning the death, a certificate in the prescribed form stating to the best of his knowledge and belief the cause of death].
If there are no injuries, poisoning signs, and it looks like natural death, and if the case was treated by another hospital/doctor, and the documents (treatment notes/discharge summary/case sheet) available also confirm the same, the cause of death certificate should be issued from the hospital that had treated that person; and only on receipt of such a certificate the dead body is handed over to the relatives. Alternatively, the hospital which had received the brought-dead case can also issue the cause of death certificate, provided the authorized documents conclusively indicate natural death; and then the dead body can be handed over to the relatives.
If there are no injuries or poisoning signs, and it looks like natural death, and if the case was not treated by any hospital/doctor, the case has to be made medicolegal, and the jurisdictional police must be informed immediately. The body should not be handed over to the relatives. The relatives should be informed clearly that the case is made medicolegal because that is the only way to get legally a cause of death certificate.
In some hospitals, it is observed that they issue a ‘Brought dead certificate2 certifying the mere confirmation of death, but not the cause of death. Occasionally, even the burial grounds/cemeteries are found accepting such certificates. No doubt a doctor has to confirm/diagnose the death of a person, but issuing a ‘brought-dead certificate’ in place of issuing a ’cause of death certificate’ is both unethical and illegal as the person issuing such brought-dead certificate is misleading the authorities and relatives, and also keeping them in the dark about their expected role of issuing the cause of death certificate. It is also subverting the progress of medicine as the doctor is not certifying the actual cause of death. It may lead to false statistics about a disease/condition when indeed such disease/condition is actually causing death of the individuals.
So it is time that Doctors start filling the cause of death certificate based on ICD 10 nomenclatures as there are now several chapters in relation to it.
Acknowledgement: Jagadeesh N, Pillay VV. Dead-on-arrival cases. NACPFMT’s Practical Medicolegal Manual, Paras Medical Publisher, Hyderabad, 2019; 1(1):289-291.
References: 1Physician’s Manual on Medical Certification of Cause of Death, Office of Registrar General, India, Government of India, Ministry of Home Affairs, New Delhi. 5th edn, September 2012.
2Saralaya PK, D’Souza DH, Kiran J. Brought dead certificate. J Karnataka Medicolegal Soc 2004; 13(2):41-4.