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Responsibilities of Practicing Physicians When the Medical Examiner Declines Jurisdiction

If a patient attended by a local physician dies at home (except as described under "Expected Home Deaths"), EMS and the appropriate law enforcement agency respond to the scene and communicate the circumstances to the Medical Examiner's Office which may also respond depending on the situation. All these agencies must agree that there is

• No suspicion of trauma or foul play
• No medication missing
• All evidence is consistent with a natural death.

If these agencies are satisfied, the physician be notified by phone or FAX that his patient has died, that the Medical Examiner is declining jurisdiction, and that death certification will be his/her responsibility.  Death certification is a responsibility of the attending physician when the death does not fall under Medical Examiner's jurisdiction as stated in Statute 406.

All that is required is a certification of the cause of death "to the best of my knowledge" as stated on the death certificate in Box 22 a. It is merely an opinion reflecting one's best medical judgment.

Specifically, the Medical Examiner will not take jurisdiction because:

• The attending physician is on vacation or otherwise unavailable. In such cases death certification will be the responsibility of the covering physician. If Dr. Smith is covering for Dr. Jones, Dr. Smith would be unable to refuse to care for a patient who became ill because he "did not know him" or "had not seen him recently". It would be Dr. Smith's responsibility to review the medical record and/or interview the patient and family, and determine the appropriate course of treatment. Similarly, the other activities of Dr. Jones' practice, including death certification, are now Dr. Smith's responsibility.
• The attending physician doesn't "feel comfortable" or "doesn't know why he/she died".  Death certification is a responsibility of the attending physician when the death does not fall under Medical Examiner's jurisdiction as stated in Statute 406. All that is required is a certification of the cause of death "to the best of my knowledge" as stated on the death certificate in Box 22 a. It is merely an opinion reflecting one's best medical judgment.
• The attending physician is not willing to sign the death certificate.  Physicians are sometimes under the erroneous impression that if they refuse to sign a death certificate the Medical Examiner must do so. This is not the case. Jurisdiction will not be accepted unless the death falls under circumstances described in Statute 406.

 Various professional and legal penalties apply when physicians refuse to carry out their responsibilities.

NOTES AND DEFINITIONS FOR PHYSICIANS

1. Cause, Mechanism, and Manner of Death

a) The cause of death (proximate cause) is the disease or injury responsible for initiating the lethal sequence of events. A cause of death should be etiologically specific.

b) The mechanism of death is the altered physiology and/or biochemistry whereby the cause exerts its lethal effect. Mechanisms of death lack etiologic specificity and are unacceptable as substitutes for causes of death. They may not stand alone on a death certificate. Common mechanisms of death include sepsis, exsanguination, renal or hepatic failure, and disseminated intravascular coagulation. The term "cardiorespiratory arrest" is meaningless for purposes of death certification and should not be used. It is not a cause of death, but merely a description of being dead.

c) The manner of death explains how the cause arose and is classified as accident, homicide, suicide, natural or undetermined. Natural deaths are defined as those which are caused exclusively by disease. All deaths which are not known to be exclusively natural fall under the jurisdiction of the Medical Examiner.

2. Proximate versus Immediate Cause of Death

The underlying (proximate) cause of death is that event which produced the fatality by initiating a natural and continuous sequence of events unbroken by an efficient intervening cause and without which the end result would not have occurred. Immediate causes of death are complications and sequelae of the underlying cause. There may be one or more immediate causes, and they may occur over a prolonged interval, but none absolves the underlying cause of its ultimate responsibility. For example, a gunshot wound to the abdomen which perforates the bowel may initiate a sequence of events over a period of months which includes peritonitis, sepsis, disseminated intravascular coagulation, hepatic and renal failure, bronchopneumonia, and adult respiratory distress syndrome. The gunshot wound is still the underlying or proximate cause of death and such a fatality must be reported to the District 21 Medical Examiner.

3. Delayed deaths whose proximate cause is listed in Florida Statute 406 must be reported even if the actual death occurs months or even years following the precipitating event.

4. In instances of suspected poisoning or drug overdose, it is essential that samples of blood and urine obtained at the time of hospital admission be retained for chemical testing by the Medical Examiner.

5. All indwelling tubes, intravascular catheters, and drains should remain in situ. If intravascular catheters are removed, it would be helpful to circle the site. The same applies to other needle puncture sites. This is particularly important if death is known or suspected to be the result of intravenous drug abuse.

6. All organ and tissue donations from patients who are Medical Examiner cases must first be cleared with the District 21 Medical Examiner's Office before approaching the next-of-kin.