Notes and Definitions for Physicians

1. Cause, Mechanism, and Manner of Death:
1. The cause of death is the disease or injury responsible for initiating the lethal sequence of events. A competent cause of death is etiologically specific.
2. The mechanism of death is the altered physiology and biochemistry whereby the cause exerts its lethal effect. Mechanisms of death lack etiologic specificity and are unacceptable as substitutes for causes of death. Common mechanisms of death include congestive heart failure, cardiac arrhythmias, asphyxia, sepsis, exsanguination, renal failure, and hepatic failure. The term "cardio-respiratory arrest" is meaningless for purposes of death certification; it is a description of being dead, not a cause of death.
3. The manner of death explains how the cause arose: natural, accident, homicide, or suicide. Natural deaths are defined as those that are caused exclusively by disease; accidental deaths result from an environmental tragedy (e.g. struck by lightning).
2. Proximate vs Immediate Cause of Death: The underlying or PROXIMATE cause of death is that event which initiates an expected, foreseeable and unbroken series of ultimately fatal physiologic disturbances. It is of no concern how long before death this event occurred. Of importance is that an unrelated event (independent supervening factor) did not occur which initiated a fatal response independent of the event identified earlier. 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 man sustains a transabdominal gunshot wound with perforation of the colon. In spite of treatment over a period of three months, he develops peritonitis, septicemia, disseminated intravascular coagulation, hepatic and renal failure, bronchopneumonia, and the 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 Office of the Medical Examiner.
3. In instances of suspected poisoning or drug overdose, it is essential that samples of blood, urine, and gastric lavage, obtained at or about the time of admission to the hospital, be retained for appropriate chemical testing. Any potential Medical Examiner case should have all submission samples retained.
4. All indwelling tubes, intravascular catheters, and drains should remain undisturbed in situ following the death of a person who is a Medical Examiner case.
5. Complications of Diagnostic and Therapeutic Procedures: It is recognized that any diagnostic or therapeutic procedure has attendant risks. Generally, a known and recognized complication will not be a Medical Examiner case. Fatal complications that are not expected or are likely completely preventable would come under the ME jurisdiction.