Completion of Medical Certificates of Cause of Death (MCCD) and Verification of Death (VoD)
There have been many strands running around various aspects of the death process, with many expressing concerns regarding the potential workload that could fall on GPs in the coming weeks, particularly as we face uncertain times in the face of COVID-19. To be clear, I am in no doubt that all of these concerns are on the implicit basis that increased workload relating to those already dead will divert our thinly stretched workforce away from providing critical care to those still living. The underlying fear is that administrative considerations may lead to excess deaths. There is also understandable frustration at the lack of clarity surrounding the rules, who administers them, and how they fit together.
The process is split into many different parts that are driven and regulated by different laws and differing bodies, making it extremely difficult to navigate change. We have been working on trying to gain clarity in much of this, and where that clarity defines aspects that we believe should be changed we have been attempting to do that. In that regard we have been in discussions with relevant authorities and I thank the hard working staff at the BMA and also Dr. Peter Holden (Chair of PFC) and Dr. Julius Parker (policy lead for Contracts and Regulations) who have advised and assisted in this.
Completion of MCCDs
As a profession we must accept that policy makers face the challenge of balancing the utilitarian need to minimise the diversion of medical staff away from patient care with the societal need to ensure that deaths are properly accounted for. The system must operate in a way that minimises waste while maximising dignity and probity.
Policy makers have introduced broad changes to the post mortem process that go a long way to facilitating these goals, but there are further changes that we would like to see as defined in feedback from the profession. Our three main asks in relation to the process for producing a MCCD are as follows:
1. Including telephone calls as an acceptable form of “attending” the patient prior to death within the new 28 day time limit.
2. Including senior members of the wider clinical team within the group that is acceptable as having “attended” the patient within the 28 day limit.
3. Accepting video examination of the body after death.
Following meetings with the Chief Coroner and NHSE we have today written to the Home Office and Ministry of Justice to request these changes to the current process. The letter is attached. The purpose of this letter is to attempt to expand the circumstances in which a doctor can reasonably produce a MCCD without the expectation that the coroner will become involved.
If these requests go unheeded then the current position will continue. This is that a MCCD may be completed without reference to the coroner if the MCCD is signed by a doctor and:
1. a doctor has seen (either in person or by video call) the patient within 28 days of death; or
2. a doctor has seen the body after death
If both of these conditions are failed then a MCCD may still be issued by the doctor, but it should make clear that the deceased was seen neither before nor after death. It is the legal responsibility of the registrar to refer the death to the coroner, although standard custom and practice is that the doctor signing the MCCD usually does this. The reason for this convention is that the coroner can only issue a Form 100A (the accompanying coronial paperwork that allows the death to be registered in such cases) if they understand the clinical picture and the reason why the doctor is happy to issue a MCCD without having seen the deceased. The registrar is not able to do this. Leaving this to the registrar to initiate is likely to introduce delay and further distress for the family.
We understand that the infrastructure available to coroners differs considerably (due to them being hosted by local authorities with differing priorities and budgets), but we would strongly encourage all coroners to make available an easy and responsive line of communication for doctors to discuss cases that may require a Form 100A.
As doctors we have an ethical duty to consider that the subject matter involved here relates to situations of the deepest personal loss and that all cases must be handled with sympathy and professionalism. That must be set in the balance against our duties to the living. We would encourage all parties to operate in a collaborative manner and to avoid taking binary approaches to this complex area.
Verification of Death
This has been the subject of enormous debate which has often been quite emotionally charged.
English Law is very clear that any “competent adult” may pronounce life extinct. In this context the legal meaning of a competent adult is clear and simply means an adult that is not suffering from mental illness, learning difficulties or is in some other way impaired in their normal judgement. Debates around training therefore seem somewhat sterile on this point. The main question is that while the law allows for a competent adult to pronounce life extinct it does not force them to do so. An adult may therefore be allowed to pronounce death, but may not wish to. This is where our discussions with partner organisations have centred.
It has become custom in our society to expect the GP to visit upon death. There are many reasons why this may be desirable under normal circumstances, very often for the purposes of supporting the grieving family and the maintenance of doctor - patient relationships in the context of family medicine. However, we have a duty to challenge these concepts in these exceptional times, notwithstanding the sensitivity of the subject.
Sadly, we are experiencing significant reticence on the part of the leadership of other professional groups to step forward on this, and we remain fearful that if patients and families are caught in a stand-off that GPs will end up being the “verifier of last resort” and that this will draw care away from the sick who need it. On that basis we have approached the RCGP to explore the development of a draft protocol that a clinician might use remotely to take, for example, a care home worker through the steps required for safe verification of death.
It is hoped that this might be an approach around which we can all agree, thereby providing our community care colleagues with the reassurance they need without compromising our ability to care for the sick. We hope that such guidance might be recognised as a pragmatic and sympathetic way to balance the competing needs of the sick, the deceased, their families, clinicians and our community colleagues.