What medicine causes natural death

Thanatology

Abstract

Thanatology deals with death, dying and burial of humans from a forensic medical point of view. Changes to the human body are documented and assessed during the post-mortem examination and forensic autopsy. After a person dies, signs of death can be used to determine death and narrow down the time of death. In the assessment, a distinction is made between safe and unsafe changes, and early and late changes in the cadaver. Signs of vitality are indications that a person was still alive at the time of a damaging effect. Supravital reactions are an expression of the preserved body functions in a corpse (e.g. preserved pupillary reactions can be detected up to 17 hours after death) - they provide helpful hints for narrowing down the time of death.

Examination and autopsy

Outside inquest[1][2]

General

  • Definition: Medical examination of a deceased to establish and determine the details of the circumstances of the death
  • Initiator: Medical hospital staff, relatives, nursing home management, finder of a corpse
  • Responsibility: Licensed doctor
    • Individual legislation by federal state
    • Exception: Schleswig-Holstein
    • Special case: emergency medical services
  • Time: Immediately
  • Place and requirements
    • At the place of discovery[3]
    • With the corpse completely undressed
    • With sufficient lighting
  • particularities
  • Instruments: gloves, tweezers, thermometer, stethoscope, flashlight if necessary
  • Filling out the death certificate (see also the death certificate checklist)
    • After carrying out the external inquest
    • Information
      • Personal details
      • Home address
      • Birthday and place
      • Last attending physician
      • Time and place of death,
      • Who identified the dead person
      • Any warning notices (e.g. risk of infection)
      • Type of death (natural, non-natural, unexplained)
    • Another procedure

execution

  • Determination of death or attempts at resuscitation
  • Identification: Through own knowledge, by relatives or by means of identification documents
  • Description of the corpse and the area surrounding the corpse
    • Location of the corpse
    • State of clothing
    • General and care condition
  • Stripping the corpse and removing plasters and bandages
  • Systematic examination of the corpse
    • Odor: General and from mouth / nose
    • head
    • Rest of the body
      • Skin: edema, pressure points, abrasions, electricity marks, wounds, hematomas, traces of smoke, scars or injection sites
      • Further body orifices: anus, genitals
    • Sure Signs of Death: Early and Late Corpse Apparitions
      • Dead spots: position, color, intensity, extent, push-back, relocatability, correspondence with the location
      • Rigor mortis: expression in large / small joints
      • Dryness: lips, genitals, eyes
      • Low rectal temperature
      • Putrefaction
      • Insect infestation
    • Supravital reactions to narrow down the time of death

autopsy

  • Clinical autopsy
    • Purpose: Medical clarification of the natural cause of death and the pre-existing diseases
    • Responsible doctor: Usually carried out by a pathologist
    • requirements
      • Natural way of death
      • Consent of the deceased during their lifetime or the legal guardian of the dead (= related person)
      • Exceptions at state level
  • Forensic autopsy
    • Purpose: Legal and medical clarification of an unnatural or unexplained death
    • Responsible doctor: Always carried out by two doctors, at least one must be a forensic doctor
    • requirements
      • Death certificate with an unnatural and unexplained death
      • Order of the public prosecutor / court

An unnatural or unexplained death must be reported to the police. The public prosecutor's office can then order a forensic autopsy!

According to the Code of Criminal Procedure (Section 89), the opening of the corpse must always extend to the opening of all three body cavities (skull, chest and abdominal cavity), as far as the condition of the corpse permits!

Swim test

Swimming tests are carried out as part of an autopsy on the lungs and gastrointestinal tract to prove whether a stillborn has already been alive.

Lung swim test

Gastrointestinal swim test

Identifying a corpse[4]

If the identity of a deceased cannot be determined from documents or relatives, the police must be informed. This then initiates a process to determine the identity. In forensic medicine, the deceased is identified via:

  • External features of the corpse
    • gender
    • Body length, build and weight
    • The length and color of the hair on the head
    • Eye color
    • Skin abnormalities: wrinkles, scars, nevi and tattoos
  • Dentition findings
    • Detection of presence and condition
    • Comparison with dental findings
  • Implants: e.g. dental implants, pacemakers
  • skeleton
    • Determination of gender, height and age
    • If necessary, also the lying time

Checklist death certificate

This section provides assistance in filling out the death certificate. Since the Funeral Act is a matter for the federal states, the law and structure of the corpse certificate vary between the federal states. Most of the time, the same information must be given across countries.

General[2]

  • Carrying out the post-mortem examination and completing the death certificate: Only by a licensed doctor
    • Duty: Every doctor on request
    • If medical measures are suspected as the direct cause of death: Do not involve the treating physicians in the death survey!
  • "Act of high medical responsibility"
    • Strict legal requirements
    • No influencing by institutions of any kind
  • Exact structure of the death certificate: variable depending on the federal state
    • Non-confidential part
    • Confidential part

The funeral law and the structure of the death certificate vary from state to state!

procedure[2][5][6]

Filling out the death certificate

General information on the death certificate

  • Personal details of the deceased (name, address, date and place of birth and gender)
  • ID
    • Own knowledge
    • Inspection of personal details (identity card / passport)
    • Details of relatives / third parties
    • Not possible
  • Time of death
    • Known
      • According to our own findings
      • According to information from third parties / relatives
    • Unknown / found dead: time the body was found

Non-confidential part of the death certificate

Confidential part of the death certificate

  • Last treating doctor or hospital
  • Safe death signs
  • Resuscitation Treatment: Yes / No
  • Cause of death or information on the medical history with ICD-10 coding
    • Immediate causes of death
    • Previous illnesses
      • Consequential ailments: e.g. infections (pneumonia, urocystitis, wound infections), metastasis (e.g. brain metastases, lung metastases), infarcts (myocardial infarction, ischemic insult)
      • Basic disease: e.g. diabetes mellitus, coronary heart disease, heart failure, chronic kidney failure, malignant underlying disease, arterial hypertension
    • Other major illnesses or changes at the time of death
    • More details: Epicrisis
    • External causes
    • Accident category
    • Assistance: causal chain of cause of death
    • Assistance: Model of the types of death
  • Necessity or performance of an autopsy
  • In women
  • In stillborn babies and children under one year of age
    • Information about place of birth and body weight and length at birth
    • Presence of a multiple birth
    • Possibly diseases of the mother during pregnancy
  • In newborns who died within the first 24 hours after birth
  • Evidence for a non-natural death: Inform the responsible police authority

Help with filling in

Causal chain: cause of death

The causal chain describes a comprehensible (ie "causal") chain of underlying illness, secondary illnesses and the immediate cause of death. In fact, it is not easy to fill in the causal chain, especially at the first medical examinations, if, for example, a multimorbid person has died and no clear cause of death can be directly assigned.

  • Immediate cause of death (the ICD-10 coding must always be included!)
  • Consequential ailments: Final cause of death as a result of
  • Basic disease: secondary diseases through
  • Other major diseases

Case studies of a causal chain

This table serves as an example and is not intended as a template for writing. It is very important to fill out the death certificate conscientiously, also with regard to the effects on the cause of death statistics.

If the cause of death cannot be determined, speculation should be avoided and “cause of death unclear” should be stated!

Model of the types of death[7]

When creating a causal chain, it helps to proceed in a structured manner and, for example, to use the model of dying types.

  • Linear death type
    • The underlying disease leads to a secondary disease in the same organ system, which (possibly via further secondary diseases) leads to the final cause of death
    • Example 1: Depression → Substance abuse with suicidal intent → Acute liver failure → Death