I may (or may not) owe Christopher Ferrara an Apology ... or more appropriately - the Guidance for Certifying COVID-19 Deaths

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JMJ

 

 I think I may have been a little harsh in my review of Christopher Ferrara's article (link). Specifically, in his exposition of the death of his Father.

I dissected his claims as below:

Let's unpack the facts:

• Father's age: 96y
• Contracted COVID-19
• Treated with hydroxychloroquine and zinc
• No symptoms after administration of hydroxychloroquine
• Died
• Cause of death
• Death Certificate: respiratory failure due to COVID-19
• Mr. Ferrara: kidney failure due to chronic dehydration
• Impute dishonesty based on the higher hospital reimbursement rates for COVID-19 related deaths.

... but one thing that I didn't know about what the guidance for reporting a COVID-19 or as it seems the death of a person who had tested positive for COVID-1.

So I still would like to know where he comes up with the alternative cause of death ... but I think I understand a little better the guidance from the WHO and a few other sources. The following example is from the WHO guidance document here (link).

WHO Guidance

The guidance documents are interesting and after my quick review, there appears to be pretty good alignment in practices from the WHO et al as to how to document COVID-19 deaths.  So the guidance is for someone to have a causal chain reaction that starts with COVID-19. 

It is also important to note that the WHO guidance includes the following:

A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma). There should be no period of complete recovery from COVID-19 between illness and death.

A death due to COVID-19 may not be attributed to another disease (e.g. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19.

So, a positive COVID-19 test is not required - the Doctor's can make a diagnosis based on symptoms and other diagnostics.  However, if a person dies from trauma of a Car accident and had COVID-19, this is not to be counted as a COVID-19 death.

If the death certificate for Mr. Ferrara's Father did not start with this, or wasn't filled in properly, then I would owe him an apology.

I suspect that in Canada the collection of data is analyzed for these types of errors.

P^3

Other Notes etc.

So, in my search I looked for posted guidance for correctly completing death certificates. I found one from the College of Physicians and Surgeons of British Columbia (link). posted in April 2020.

Guidance for certifying COVID-19 deaths

The following information was submitted by the BC Vital Statistics Agency and Statistics Canada to ensure deaths due to COVID-19 are properly certified for data accuracy.​

With the World Health Organization declaring COVID-19 a pandemic and subsequent increasing mortality from the virus worldwide, there is increased importance on certifying these deaths correctly. 

1. Recording COVID-19 on the medical certificate of cause of death

• COVID-19 should be recorded on the medical certificate of cause of death for all decedents where the disease caused, or is assumed to have caused, or contributed to death.

2. Terminology

• The use of official terminology, as recommended by the World Health Organization (i.e. COVID-19) should be used for all certification of this cause of death.
• As there are many types of coronaviruses it is recommended not to use “coronavirus” in place of COVID-19. This will help to reduce uncertainty for coding and monitoring these deaths which may lead to underreporting.

3. Chain of events

• Due to the public health importance of COVID-19, when it is thought to have caused or contributed to death it should be recorded in Part I of the medical certificate of cause of death.
• Specification of the causal sequence leading to death in Part I of the certificate is also important. For example, in cases when COVID-19 causes pneumonia and fatal respiratory distress, both pneumonia and respiratory distress should be included along with COVID-19 in Part I. Certifiers should include as much detail as possible based on their knowledge of the case, medical records, laboratory testing, etc.
  
  Example:
  
  Immediate cause: Acute respiratory distress syndrome
  Conditions leading to the cause: Pneumonia, COVID-19

4. Co-morbidities

• There is increasing evidence that people with existing chronic conditions or compromised immune systems due to disability are at greater risk of death due to COVID-19. Chronic conditions may be non-communicable diseases such as coronary artery disease, COPD, and diabetes or disabilities. If the decedent had existing chronic conditions, such as those listed above, these should be listed in Part II of the medical certificate of cause of death. 
  
  Example:

Other significant conditions contributing to death but not related to the disease or conditions causing it:

1. Coronary artery disease
2. Type 2 diabetes
3. COPD​

 I did some more digging and found the following guidance from the Government of Canada (link): (Note: Originally I thought this was just about guidance for general death certificates - however this is guidance for correctly completing a death certificate when someone was euthanized).

Guidelines for death certificates

1.0 Definitions

Terminology for death certification and reporting can vary across Canada. For the purposes of these guidelines, definitions are as follows:

1. Medical assistance in dying:
   • the administration of a substance by a medical practitioner or nurse practitioner to a person, at their request, that causes the person's death (provider-administered); or
   • the prescription or provision of a substance by a medical practitioner or nurse practitioner to a person, at their request, for the person to self-administer to cause their own death (self-administered).
2. Medical Certificate of Death: the legal record of a person’s death and its circumstances, completed at the time of death by a medical professional or other authorized person. The information collected is consistent across Canada.
3. Registration of Death: a more detailed record of death containing personal information about the deceased. Non-medical information is typically obtained from the next of kin and provided by the funeral director. The format and information collected differ across provinces and territories.

2.0 Background

On June 17, 2016, An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) passed into law. Section 3.1 of the Act states, “The Minister of Health, after consultation with representatives of the provincial governments responsible for health, must establish guidelines on the information to be included on death certificates in cases where medical assistance in dying has been provided, which may include the way in which to clearly identify medical assistance in dying as the manner of death, as well as the illness, disease or disability that prompted the request for medical assistance in dying.”

In Canada, death reporting and investigation falls under the jurisdiction of individual provinces and territories. All deaths are registered by the vital statistics registrar of the province or territory in which the death occurred. Each calendar year, Statistics Canada receives a subset of this information electronically and compiles it as a part of national vital statistics for publication. Cause of death statistics are coded in accordance with the World Health Organization’s International Statistical Classification of Disease and Related Health Problems (ICD-10), and are an important source of information for public health research and surveillance. The ICD-10 does not currently contain codes for medical assistance in dying.

3.0 Purpose

These guidelines address the completion of the Medical Certificate of Death where a patient has received medical assistance in dying, to facilitate the identification of cases of medically-assisted deaths and to encourage consistency in approaches across provinces and territories.

4.0 Principles

These guidelines seek to:

1. Respect the division of powers between federal, provincial, and territorial governments by serving as a non-binding reference;
2. Enable the identification of cases of medically-assisted deaths, for the purpose of accurate record-keeping regarding vital statistics in Canada;
3. Be consistent with the existing purposes and processes for death certification in Canada, including:
   • using the World Health Organization’s ICD-10 classification system for cause of death;
   • establishing an accurate record of the circumstances of death; and
   • respecting the privacy of the deceased individual;
4. Minimize the need for changes to current practices and procedures.

5.0 Guidelines

1. Part 1 of the Medical Certificate of Death should be completed such that:
   • the immediate cause is recorded in line 1a) as the toxicity of the drugs administered for the purposes of a medically-assisted death; and
   • the underlying cause of death is recorded as the disease or condition that initiated the train of morbid events leading to the medically-assisted death.
2. Part 2 of the Medical Certificate of Death should be completed such that:
   • medical assistance in dying is recorded along with other significant conditions that may have contributed to death but were not part of the sequence of events leading to it; and
   • it is specified whether medical assistance in dying was provider-administered or self-administered, in accordance with the circumstances.
3. Manner of death should be certified as natural if such an option exists.

6.0 Considerations

Implications for life insurance claims: Provinces and territories should determine whether legislative/regulatory changes are needed to ensure that medical assistance in dying is not grounds for rejecting a life insurance claim.

Privacy protection: While information on the cause and manner of a person’s death is currently only available in limited circumstances, provincial and territorial governments may consider further privacy protections for patients receiving medical assistance in dying if deemed appropriate.

7.0 Example

SAMPLE - Cause of death

Here's a snapshot of the guidance from the College of Registered Nurses Newfoundland Labrador (link). ... To save time, I tried copy page so we'll see if blogger spits it out...

 

 Finally, I found the WHO guidance document here (link). The theme that is coming out is consistent with the ones above and CDC. The course of a death registered as a COVID-19 death need to start with COVID-19 as the root cause or underlying cause of death.

 

 

Misc Links that popped up in the searches

https://health-infobase.canada.ca/covid-19/vaccine-safety/ 

https://www.oligotherapeutics.org/facts-about-mrna-vaccines-and-the-decades-of-research-that-went-into-creating-them/ 

 https://www.who.int/standards/classifications/classification-of-diseases/emergency-use-icd-codes-for-covid-19-disease-outbreak

 https://www.cebm.net/covid-19/death-certificate-data-covid-19-as-the-underlying-cause-of-death/

https://www.cdc.gov/nchs/covid19/coding-and-reporting.htm

 https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf