DEATH CERTIFICATES (UK)

The state likes to know when someone is born, someone dies or a marriage occurs. The registrar of births, deaths and marriages keeps the local records. I am concerned with death certificates, on which is written the particulars of the dead person, including the cause of death.

If a patient has been under medical care for a natural disease and has seen a doctor within 14 days of death, then a doctor CAN write a death certificate. What is put as the cause of death (ie within the central box) need only be to the doctor’s best knowledge (ie it is not necessary for the doctor to have outside proof). Only someone on the medical register (held by the General Medical Council) can fill out the cause of death.

The cause of death is on 4 lines, labelled ‘1a’, ‘1b’, ‘1c’ and ‘2’. 1c must lead to 1b, which must lead to 1c. Somewhere among 1a, 1b and 1c there must be a DISEASE. MODES OF DEATH (such as ventricular fibrillation or heart failure) can figure, but must be qualified by a disease (ie the disease must appear in either 1b or 1c.

For instance, someone may go into ventricular fibrillation, but this is usually caused by coronary atheroma. Therefore, 1a Ventricular Fibrillation 1b Coronary Atheroma is acceptable to the Registrar of Births, Deaths and Marriages, but 1a Ventricular Fibrillation alone is not.

Under 2 are natural diseases that contributed to the death but which are unrelated to anything written under 1a, 1b or 1c.

Things that may not appear are abbreviations and unnatural causes (the latter deaths are referred to the Coroner). Section 2 is often used as a dumping ground for conditions, although I frown on this. ‘Old age’ is regarded as a legitimate disease process only in the very old (the goalposts are moving all the time).

The Medical Examiner acts as the referee, deciding what is reasonable and which cases to refer to the coroner.

THE HEART

The heart is not a pump.

It is TWO pumps.

You do not have a single circulation.

you have TWO (THREE, if you count the portal venous circulation as a separate circulation).

What the heart does is really very simple. The right side pumps blood around the lungs; the left side pumps it around the rest of the body. Those two circulations never mix, but they are linked. They may sit side by side, but essentially the left side of the heart is a pumping station downstream of the right side.

Each pump – the right side and the left side – is two chambers. An atrium (or ‘hallway’) and a ventricle (or ‘stomach’). There is a valve between the atrium and ventricle on either side, and a valve where the ventricle meets its circulation. The work of the valves is the same as all valves, to make sure that the pumped liquid goes in only one direction.

So, two pumps, each with 2 chambers and 2 valves. Simple.

Except that, for some reason, the heart is twisted around in the body, which makes it look more complex than it really is.

The right side of the heart only has to pump blood through the lungs (where it gets oxygenated), this then returns to the heart (the left side) which pumps it around the body where the oxygen is required for the cells to live.

Because the right side of the heart has relatively little work to do compared with the left, it is not as muscular. In fact, the thickness of the myocardium on the right is only a third that of the left in the normal heart.

What of the heart in the unborn baby? What of congenital abnormalities? More of these in later posts.

CHOLESTEROL

Cholesterol is a very, very complicated subject. We make it, but it’s also in foods such as dairy products, red meat and processed meat such as sausages. We NEED it [it’s found in the cell membrane of every cell in your body and its required for digestion (because it’s the basis of bile constituents, and bile is necessary for the absorption of certain foodstuffs including some vitamins), as well as being the basis of steroid hormones and vitamin D (which we DO make)].

There’s lots of talk about high density lipoproteins (HDL – ‘good’ cholesterol), intermediate density low density lipoproteins (IDL – so-so) low density lipoproteins (LDL – not so good) and very low density lipoproteins (VLDL very bad). The names come from the relatively crude method of centrifuging blood plasma, which results in separation of these molecules; those right at the bottom are HDL molecules, etc. etc..

There’s less talk of CHYLOMICRONS, but they’re also involved. Eat fatty cheese, wait a while and then take a blood sample, spin it down and the blood plasma (the liquid in which blood cells float) will be opaque because of chylomicrons containing the fat that’s been absorbed from the cheese.

Essentially, because cholesterol is required all over the body, and because it’s not very soluble in blood, it’s taken hither and thither by lipoproteins. Think of them as Uber cars. HDL is good because of where it takes the cholesterol.

When you go to the doctor and have your cholesterol level measured, it will be a measure of total cholesterol, in all the different lipoprotein types. Too much is associated with atheroma formation in blood vessels (see previous posts), and that’s linked to death by heart disease or stroke (aka CEREBROVASCULAR disease – the clue’s in the name).

Sterols and stanols in foods can lower cholesterol A LITTLE because most of the cholesterol in your body is made by you. They work by competing with cholesterol in the diet. STATINS work by lowering your own cholesterol production and are therefore more effective.

Cervical Cancer

In the UK, there are just over 3,000 cases of cervical cancer diagnosed each year, of which it is estimated that over 99% (that’s not a typo) are preventable, although over 800 people die from it each and every year. The highest incidence is in those aged between 25 and 29 (and that ain’t a typo either) so, in other words, it is a disease of the young. It is associated with smoking and other factors, but it is caused by the Human Papillomavirus (HPV).

Men carry the virus and pass it on to their sexual partners.

HPV is everywhere. There are over a hundred different types and they’re numbered. They cause things as benign as skin warts but they also cause cancers, such as penile cancers (yes, there is such a thing), anal cancer (nasty) and cervical cancer. Some types are troublesome, but benign. Some types, though, cause the cancers. Types 16 and 18 cause cervical cancer.

Cervical screening aims to spot the changes that lead up to cancer, because HPV works slowly, over a course of years, but it isn’t easy. This much is known. The changes that lead to cervical cancer begin in the TRANSFORMATION ZONE (TZ) of the cervix. where the nature of the covering of the cervix abruptly changes from SQUAMOUS (multilayered) to GLANDULAR (single cell layer). They are known as CERVICAL INTRAEPITHELIAL NEOPLASIA, which for the sake of simplicity is known as CIN (pronounced ‘sin’ and I know not if that is a deliberate choice of pronunciation). CIN1 is mild, CIN2 and CIN3 are high grade. Progression to cancer (which is invasive and potentially spreads) is not inevitable, but you don’t want high grade CIN.

The cervical screening test is embarrassing and uncomfortable. The person taking the sample tries to scrape off cells from the TZ. They are then put into a machine that washes the cells and spreads them on a slide. A human being then has to scan that slide and look for cells that mean CIN is present. If they see them, a punch biopsy may be taken to confirm the diagnosis of precancerous changes; the punch biopsy will be looked at by a medically-qualified pathologist.

If high grade CIN is diagnosed, the usual treatment is LOOP EXCISION OF THE TZ (LETZ), which aims to cut out the abnormal area and can be done in out-patients; it is again uncomfortable and embarrassing. In the great majority, that will cure the patient and they won’t develop cancer.

HPV vaccination has been introduced, the aim being to stop HPV 16 and 18 causing the cancer. HPV testing is also undertaken on samples. Soon, everything will change, and it will be for the better. Fewer cases, fewer cervical smears, fewer deaths. But only if that letter calling patients to be tested is not ignored.

Cervical cancer is a horrible way to die.

Ischaemic Heart Disease

A lot of times, the pathologist puts ischaemic (same as ‘ishemic’) Heart Disease down as the cause of death. It’s a term that encompasses a whole host of related conditions, all of which are caused by chronic lack of blood to the heart muscle. I’d better explain the medical meaning of ‘chronic’, which is confined to the meaning ‘long term’. ‘Acute’ means ‘short term’. When a doctor uses those words, there is no implication of strength.

So, ischaemic Heart Disease (often shortened to IHD) merely means the heart muscle (‘myocardium’, remember?) has not had enough blood over a long period of time – years, even decades. The cells that make up the myocardium (‘myocytes’) die but, unlike in a myocardial infarction, they don’t die all at once. The body’s response to any long-term shortage of blood is to make fibrous tissue (‘fibrosis’), but the heart still has a job to do.

The problem is, fibrous tissue is useless as a pump, which means that the surviving myocytes have to work harder. To put it simply, it’s a bit like bench-pressing weights day in and day out; the muscle gets bigger. When the patient dies, the pathologist finds a big heart and when the heart muscle is examined, it’s pale because of the high content of fibrous tissue.

The problem is that the fibrous tissue isn’t an efficient electrical conductor. As a result, arrhythmias occur; an ‘arrhythmia’ is a rhythm that is different to the normal regular ‘sinus’ rhythm. Sometimes, the patient can live with an arrhythmia, and therefore the patient may came to the attention of a healthcare professional. If the first arrhythmia is asystole (the heart just stops) or ventricular fibrillation (see before), then the chances are, the patient dies

But why is there not enough blood? Because of coronary atheroma again. When doctors talk of ‘coronary artery disease’ they almost always mean ‘atheroma’.

Heart Attack

What is a ‘heart attack’?  Is it the same as ‘heart failure’? How does a ‘heart attack’ come about? Is a heart attack the same as a ‘coronary’?

To answer the second question first, heart failure and a heart attack are NOT the same; heart failure is when the heart is no longer up to the job of pumping blood around the body (more of which at a later date). A heart attack, known technically as ACUTE MYOCARDIAL INFARCTION, or an MI, is when part of the heart muscle (the ‘myocardium’) dies (an ‘infarction’). Why does it die, though?

The heart needs blood, as does every part of you. It gets it from 3 coronary arteries (the name comes from the same route as ‘coronet’ meaning ‘crown’, because they look (if you squint hard) like a crown around the heart. Unfortunately, they’re prone to ATHEROMA (about which more at a later date) which narrows them by causing plaques to form on the internal surface.

Angina is heart pain caused by a reduction in blood flow to the heart and is often caused by atheroma. Those who get it are lucky, but most people don’t get it. The first sign that they have atheroma affecting the coronary arteries is when a sudden block occurs in one of them, and the blood supply to a part of the heart muscle suddenly stops. The muscle dies and that is a ‘heart attack’.

Why does the blood supply suddenly stop? Usually because the blood clots on an atheromatous plaque, and that blocks the artery completely. So, a ‘heart attack’ is the same as a ‘coronary’, but medics talk of an MI.

Unfortunately, the pathologist won’t see any change in the heart muscle if the patient dies quickly after the MI. She/he won’t see much with the naked eye for quite a few hours, even if it’s examined down the microscope. The clot in the coronary artery is the clue.

But why do people actually die from a heart attack?

Normally, because the heart’s rhythm changes catastrophically due to the shock of the heart muscle death. It may stop beating completely (ASYSTOLE) or it may just twitch uncontrollably (VENTRICULAR FIBRILLATION).

But most people who die of heart disease don’t suffer from a heart attack…

Introduction

Just so that you know that I know what I’m talking about, I’ve been a pathologist for 34 years and I’ve performed over 5,000 post mortem examinations. In the UK, just over 530,000 people died in 2017. You WILL die. I WILL die. It comes to all of us. It affects all of us, because Death will visit our loved ones.

My aim is help you by giving you information, by taking your hand and leading you through the medical jargon and (necessary) procedures that a society has to have when someone dies.

Here are the bald statistics from 2017 in the UK:

150,000 died of cancer

150,000 died of heart or blood vessel disease

73,000 died or respiratory disease

68.000 died of some form of dementia

21,000 died of external causes (including accident, deliberate self-harm and assault of some kind)

But what do those words actually mean? What is ‘cancer’? What does ‘heart or blood vessel disease’ actually involve?

And then there are the procedures. What is an ‘inquest’? When is one required? What is a coroner? Why are suicides different to other forms of death when it comes to the inquest? When does an inquest have to have a jury?

Lots of questions. The answers are fascinating.