Death Notification Research Articles

Breaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention

ObjectivePatients and physicians identify communication of bad news as a skill in need of improvement. Our objectives were to measure change in performance of first-year pediatric residents in the delivery of bad news after an educational intervention and to measure if changes in performance were sustained over time. MethodsCommunication skills of 29 residents were assessed via videotaped standardized patient (SP) encounters at 3 time points: baseline, immediately post-intervention, and 3 months post-intervention. Educational intervention used was the previously published “GRIEV_ING Death Notification Protocol.” ResultsThe intraclass correlation coefficient demonstrated substantial inter-rater agreement with the assessment tool. Performance scores significantly improved from baseline to immediate post-intervention. Performance at 3 months post-intervention showed no change in two subscales and small improvement in one subscale. ConclusionsWe concluded that breaking bad news is a complex and teachable skill that can be developed in pediatric residents. Improvement was sustained over time, indicating the utility of this educational intervention. Practice implicationsThis study brings attention to the need for improved communication training, and the feasibility of an education intervention in a large training program. Further work in development of comprehensive communication curricula is necessary in pediatric graduate medical education programs.

Early detection of maternal deaths in Senegal through household-based death notification integrating verbal and social autopsy: a community-level case study

BackgroundReliable detection of maternal deaths is an essential prerequisite for successful diagnosis of barriers to care and formulation of relevant targeted interventions. In a community-level case study, the use of household-level surveillance in Senegal unveiled an apparent increase in maternal deaths, which triggered a rapid-cycle collaborative response to implement a multipronged set of quick-win and sustained interventions intended to improve quality care.MethodsPart of a multi-country effort, the Millennium Villages Project is implementing a routine community-level information system in Senegal, able to detect maternal deaths in real-time and uncover clinical and social factors contributing to mortality. Within this geographically demarcated area of approximately 32 000 inhabitants, with a well-structured health system with patient referral services, deaths were registered and notified by community health workers, followed by timely verbal and social autopsies. Using the Pathway to Survival conceptual framework, case analysis and mortality reviews were conducted for evaluation and quality improvement purposes.ResultsThe estimated maternal mortality rates rose from 67/100000 births in 2009 (1 death), to 202/100000 births in 2010 (3 deaths) and 392/100000 births (5 deaths) in 2011. Although absolute numbers of maternal deaths remained too small for robust statistical analysis, following verbal autopsy analyses in 2011, it became evident that an unexpectedly high proportion of maternal deaths were occurring at the referral hospital, mostly post-Caesarian section. Inadequate case management of post-partum haemorrhage at the referral hospital was the most frequently identified probable cause of death. A joint task team systematically identified several layers of inefficiencies, with a potential negative impact on a larger catchment area than the study community.ConclusionsIn this study, routine community-based surveillance identified inefficiencies at a tertiary level of care. Community-level surveillance systems that include pregnancy, birth and death tracking through household visits by community health workers , combined with verbal and social autopsy can identify barriers within the continuum of maternal care. Use of mHealth data collection tools sensitive enough to detect small changes in community-level mortality trends in real-time, can facilitate rapid-cycle quality improvement interventions, particularly when associated with social accountability structures of mortality reviews.

Does emotional intelligence predict breaking bad news skills in pediatric interns? A pilot study

BackgroundWhile both patients and physicians identify communication of bad news as an area of great challenge, the factors underlying this often complex task remain largely unknown. Emotional intelligence (EI) has been positively correlated with good general communication skills and successful leadership, but there is no literature relating EI to the delivery of bad news.PurposeOur objectives were to determine: 1) performance of first-year pediatric residents in the delivery of bad news in a standardized patient (SP) setting; and 2) the role of EI in these assessments. Our hypothesis was that pediatric trainees with higher EI would demonstrate more advanced skills in this communication task.MethodsForty first- year residents participated. Skill in bad news delivery was assessed via SP encounters using a previously published assessment tool (GRIEV_ING Death Notification Protocol). Residents completed the Emotional and Social Competency Inventory (ESCI) as a measure of EI.ResultsResidents scored poorly on bad news delivery skills but scored well on EI. Intraclass correlation coefficients indicated moderate to substantial inter-rater reliability among raters using the delivering bad news assessment tool. However, no correlation was found between bad news delivery performance and EI.ConclusionsWe concluded that first-year pediatric residents have inadequate skills in the delivery of bad news. In addition, our data suggest that higher EI alone is not sufficient to effectively deliver death news and more robust skill training is necessary for residents to gain competence and acquire mastery in this important communication domain.

Medical certification of death in South Africa--moving forward.

Despite improvements to the Death Notification Form (DNF) used in South Africa (SA), the quality of cause-of-death information remains suboptimal. To address these inadequacies, the government ran a train-the-trainer programme on completion of the DNF, targeting doctors in public sector hospitals. Training materials were developed and workshops were held in all provinces. This article reflects on the lessons learnt from the training and highlights issues that need to be addressed to improve medical certification and cause-of-death data in SA. The DNF should be completed truthfully and accurately, and confidentiality of the information on the form should be maintained. The underlying cause of death should be entered on the lowest completed line in the cause-of-death section, and if appropriate, HIV should be entered here. Exclusion clauses for HIV in life insurance policies with Association of Savings and Investments South Africa companies were scrapped in 2005. Interactive workshops provide a good learning environment, but are logistically challenging. More use should be made of online training resources, particularly with continuing professional development accreditation and helpline support. In addition, training in the completion of the DNF should become part of the curriculum in all medical schools, and part of the orientation of interns and community service doctors in all facilities.

The Confidential Enquiry into Maternal Deaths in South Africa: a case study.

The Confidential Enquiry into Maternal Deaths (CEMD) in South Africa has been operational for 15years. This case study describes the process of notification and independent assessment of maternal deaths, predominantly in facilities. In the earlier years of the Enquiry, institutional maternal mortality ratio increased and was 176.2 per 100000 live births in the 2008-10 triennium; thereafter it decreased to 146.7 in the 2011/12 period. The slow progress was due to the significant contribution of HIV/AIDs to maternal mortality and challenges in implementing the recommendations that were devised from the findings of the Enquiry. Nevertheless, the CEMD process has been maintained and strengthened so it is currently able to perform routine maternal death surveillance at both national and district levels, identify deficiencies within the health system, generate reports and also provide early warning about alarming trends such as the increasing numbers of deaths due to caesarean-section-associated haemorrhage.

Mortality differences according to marital status among men and women in Kuwait

Higher mortality among unmarried persons compared with currently married ones has been reported in many previous studies. There is paucity of such studies in developing countries. We analysed the association between marital status and mortality in Kuwait, an oil-rich Gulf Muslim country. Data were obtained from the Public Authority for Civil Information that has maintained a linked record database of population characteristics with death notifications since 2005. Deaths during 2005–2010 were aggregated for the analysis. Age-specific death rates and standardized mortality ratios (SMRs) were calculated according to marital status (married, never married, divorced and widowed), age (15–49, 50–64 and 65+), gender, and nationality (Kuwaiti vs. non-Kuwaiti). Among Kuwaiti nationals, the SMRs for widowed, divorced, and never married were 1.75, 1.68 and 1.15 compared to the married. Higher mortality was found among unmarried men and women at almost all ages. These findings may be indicative of considerable public health problems such as higher disability and depression among the unmarried.

Reconstructing the Loss: Bereaved Parents in Personal Commemorative Films

The aim of this study was to find answers to the question of how Israeli parents who have lost their child in battle or in a terror attack reconstruct their life story, as revealed in personal commemorative films. Twenty personal documentary commemorative films were systematically and thematically analyzed. Through exposing the themes of last shared experience, death event, and notification of death, the research sheds light on the self-healing process that enables parents to build a bridge in their narrative. The commemorative films provide a framework for reconstruction work adding to the new body of research in the field of video and cinema therapy.

Adolescent mortality in South Africa: An analysis of unnatural causes of deaths by sex, 2000-2009

Despite South Africa being a peaceful democracy for the past 18 years, mortality due to unnatural and violent causes still occur among the youth, who are aged between 15 and 34 years old (Presidency of the Republic of South Africa 2009). However, this is not specific to South Africa; with developed countries experiencing the same trend. In developed countries, Christoffe (1994) found that death due to unnatural causes, specifically related to violence, had increased especially among the youth. South Africa is now moving towards the same transition that is currently experienced by developed nations in the world: violent deaths as a major cause of death amongst the youth which includes some adolescents (10-19 years old) (Norman, et al, 2007). With this in mind, this paper aims to examine the different levels of male and female adolescent mortality due to five unnatural causes of death. Data from South African Death Notification Forms is analysed for the years 2000-2009. Cause-specific mortality rates and proportional mortality ratios are produced. Results show adolescents are dying from events of undetermined intent, transport accidents’ and self- harm, especially males. The selected causes of death are contributing up to 27% of all adolescent male mortality and almost 12% of all female mortality in 2009. The results of this paper allude to crime, violence and safety issues in South Africa.

English

INTRODUCTION: Estimation of post-mortem interval is an important goal in forensic medicine. After death, many physiochemical changes occur in a regular sequence and can be used to arrive at an approximate time of death. Present Study was conducted to observe post-mortem eye changes presented with different PMI. A detailed knowledge of post-mortem eye changes with time is necessary for providing healthier cornea thereby playing a vital role in eye banking services to the community. SUBJECTS AND METHODS: The study was conducted on adult autopsy cases. In those including natural deaths, RTA & others, hanging, drowning and burns. Post mortem ocular changes such as corneal haziness, pupillary changes, fundus changes and intraocular pressure were studied. RESULTS: Almost all eyes presented with hazy cornea except those (22 cases) examined within 6 hrs of PMI, low intraocular pressure and variable pupillary changes (depending on PMI) and 22 cases with cattle track appearance of fundus. CONCLUSION: As observed Extended Post mortem interval has worst effect in eye especially on cornea. Though eye donation has gained its popularity. But public awareness regarding earliest notification of death to nearest eye bank and speedy network of eye bank services plays vital role in healthier corneal harvesting there by helping in eliminating corneal blindness. As with the period, the cornea loses its translucency and become a waste organ. Please do not burn your eyes.

PPO.11 Perinatal mortality in Ireland: A national clinical audit

BackgroundPerinatal mortality has decreased in high-resource countries but cause of death, especially for stillbirths, is often unexplained. The Irish National Perinatal Epidemiology Centre (NPEC) established a national clinical audit on...

ABSTRACT 189

Background and aims: Nowadays, children continue to die because of scarcity of available organs for transplants. Policies to increase the notification of brain death (BD) impact positively the process of organ donation for transplantations in pediatric patients. Aims: To describe the evolution of BD diagnosis and organ donation experience in a reference general hospital PICU in an interval of 6 years. Methods: Were selected for a retrospective study the medical records of children (<18years) admitted in a referral Brazilian PICU between 2007 and 2012 that had confirmed the diagnosis of BD. Demographic data, cause of death, organ donation, cause for not donation. The local Ethical and Research committee approved the study. Results: BD represented 12% (34/238) of all deaths in the period, with median age of 30 months (IQR 12 – 84), 67% males. The main etiology of BD was acute neurosurgical lesion (47%). Only 50% of the deceased patients were medically suitable for organ donation. Oncological and infectious diseases were the main contra-indications to organ donation. Familiar consent to organ donation occurred in six (35%) of the 17 suitable cases. After consent was granted, organs were procured from all six donors, for an average of 2.8 organs transplanted per donor. Conclusions: Even in a referral hospital for transplants it is observed a high refusal rate for organ donation. Based on these results new local policies were implemented (2013) aiming to increment the local rate of organ donation.

Physical capability in mid-life and survival over 13 years of follow-up: British birth cohort study

Objectives To examine associations between three commonly used objective measures of physical capability assessed at age 53 and a composite score of these measures and all cause mortality; to investigate...

Burden of AIDS in a Brazilian state.

To estimate the burden of a disease implies the simultaneous quantification of the impact of early mortality and the health problems that affect the individual's quality of life, and this evaluation can be particularly important in a disease such as AIDS that has become a long-term disease. The purpose of this study was to determine the burden of disease due to AIDS in the Brazilian Southern State of Santa Catarina. An ecological designed study was performed using death and AIDS notifications data for 2009. The disability adjusted life years (DALYs) were estimated by the sum of years of life lost (YLL) and the years lived with disability (YLD). The YLL was estimated as the difference between the life expectancy from birth and the age at death with the application of a discount rate of 3% per year. The YLD was estimated as the product of the Burden of Disease Study's weight for AIDS of 0.167 and its average duration of 108 months in Brazil for the incident cases. The YLL, YLD and DALY rates were calculated per 100,000 inhabitants by sex and age groups. There were 2034 notified cases and 689 deaths due to AIDS reported. There were 15,756.5 YLLs estimated, resulting in 257.5 YLLs/100,000 inhabitants, and 4554.1 YLDs were estimated, resulting in 74.4 YLDs/100,000 inhabitants. The DALY was estimated at 20,310.6, with a rate of 331.9 DALYs/100,000 inhabitants. The highest rates were observed in males in the age groups 30-44 and 45-59 years. The burden of AIDS was high and was observed mainly in adults, with a predominance in males.

The JSLM ‘Guidelines for Notification of Unnatural Death’: Comparison with the systems of reporting death in other countries

'Guidelines for Notification of Unnatural Death', published by the Japanese Society of Legal Medicine (JSLM) in 1994, has been sometimes criticised by many doctors and lawyers. In various countries, laws specify the type of deaths that should undergo post-mortem examination. The centralized system of reporting death deals with treatment-related deaths. Although the JSLM Guidelines are based on such international norms, the dispute over reporting unnatural deaths in Japan goes against the dominant global trend. One way of solving these issues is to ensure that the police transform their own death investigation apparatus to delink it from criminal investigations. And we need to press for a system that can give the information obtained in investigations back to society, such as to the medical world or other public organisations.

Procedura powiadamiania o śmierci pacjenta —“In Person, In Time…”

Informing of a patient's death is difficult for physicians as well as patient's families. Breaking bad news is part of clinical experience of physicians and existential experience of patient's close relatives. The professional manner of death notification may effectively reduce the level of stress and other negative emotions in both parties involved. Special information procedures defining cardinal rules of professional death notification have been devised to help physicians in this process. One of them, created in the United States in the 1990s, is the communication protocol - "In Person, In Time" - Recommended Procedures for Death Notification", discussed in the present paper.

Community Notification of Maternal, Neonatal Deaths and Still Births in Maternal and Neonatal Death Review (MNDR) System: Experiences in Bangladesh

Objectives: The aim of the study was to examine the process of community maternal, neonatal deaths and still births notification within the Bangladesh government health structure using the Maternal and Neonatal Death Review (MNDR) system. The study also explored the feasibility and acceptance of community death notification in the MNDR system. Methods: The study was under-taken in the Thakurgaon district of Bangladesh during 2010. During the study a mix of both qualitative and quantitative information was collected. A review of the documentation process of community death notification was undertaken and focus group discussions (FGDs) with community members, health care providers and managers in a sub-district were conducted, with in-depth interviews (IDIs) with district heath and family planning managers. Quantitative data were collected from community death notifications in the district during January to December 2010. Results: The death notification process was implemented by the government health care system within the Thakurgaon district. Field level health and family planning staff collected maternal and neonatal death information, recorded the death on the notification form and reported back to the Upazila (sub-district of the district) focal point at the Upazila health complex (primary health care centre). Community people were encouraged to share their death information to field level health staff. The health and family planning managers in the district periodically discussed the maternal and neonatal deaths and prepared remedial action plans in high death notified areas. In 2010, 59 maternal deaths, 739 neonatal deaths and 633 still births were reported in Thakurgaon district. District health and family planning departments performed community death notification as part of their routine daily work and integrated these procedures with other field level activities. Conclusion: Community death notification under the MNDR system was found to be achievable and acceptable at the district level using the existing government health system. The simple death notification process used to capture community level maternal, neonatal deaths and still births provides a guide for planning corrective actions for better health outcomes for the community.

Autopsy as a tool for problem based learning, experience from a limited resource setting

Introduction Undergraduate learning at the University of Nairobi School of Medicine relies on mixed modes, which include didactic lectures, tutorials and clerkships. This paper presents the use of autopsy for undergraduate medical problem based learning within undergraduate clerkships. Materials and methods Medical students were grouped into clerkship groups, with 20 students each. Following an introductory session from the author, students participate in four sessions consisting of a full autopsy and determination of cause of death. Student discussions based on predetermined objectives facilitated by the author were accomplished while examining autopsy photomicrographs on a projection microscope. Results Participation by students was over 85% in all sessions. The students reported that the sessions instilled a positive view of autopsy pathology, understanding of pathologic processes and clinical-pathological correlation. They demonstrated appropriate completion of autopsy reports and death notification forms. Conclusion Autopsy is useful for competence based learning specifically for death notification, basic disease processes, clinical and laboratory diagnosis of disease. Implementation science competence based learning interventions.

Maternal and Neonatal Death Review (MNDR): A Useful Approach to Identifying Appropriate and Effective Maternal and Neonatal Health Initiatives in Bangladesh

Objectives: To identify the effects of Maternal and Neonatal Death Review (MNDR) in terms of improving maternal and neonatal health at the community level in Bangladesh. Methods: Both quantitative and qualitative methods were undertaken for collecting data in Kashipur Union, Bangladesh. Death notifications from households, subsequent data collections from a focus-group discussion (FGD), a group discussion (GD) and in-depth interviews (IDIs) were obtained using structured tools and guidelines. Results: A total of four maternal deaths, 21 neonatal deaths and 15 still births were reported in the MNDR death notification system at Kashipur Union in 2010. Data were presented to local programme managers, who took various initiatives including awareness programmes, pregnancy registration, antenatal care, birth planning, and also the revitalization of a community clinic. The coverage of antenatal care, delivery in clinics, postnatal care and referral of complications increased through the active participation of the community. Community healthcare providers, care recipients and members of the community expressed satisfaction with the quality of maternal and neonatal services. In the preceding two years, maternal and neonatal deaths substantially reduced in Kashipur (in 2011 maternal death = 1, neonatal death = 20, still birth = 8; in 2012 maternal death = 1, neonatal death = 8, still birth = 13). Conclusions: The MNDR system successfully delivered notification of all maternal and neonatal deaths in the defined area and collected information for the formulation and implementation of specific interventions, which resulted in visible and tangible changes in care-seeking and client satisfaction.

Maternal mortality in Central Province, Kenya, 2009-2010.

IntroductionMaternal mortality for Kenya was 488/100,000 live births in 2009. Maternal mortality estimate for Central Province is unknown. We retrospectively reviewed data between 1st July 2009 and 30th June 2010 to estimate the hospital based maternal mortality ratio, characterize deaths by time, place and person and describe possible causes of deaths in Central province, Kenya.MethodsWe abstracted data using a standard form from maternal death notification and review forms and the district reproductive health reports. Data was entered and analyzed using Microsoft Excel.ResultsThere were 89,512 live births and 111 deaths. The facility-based maternal mortality ratio was 124/100,000 live births. Seventy-three (66%) deaths had been audited. Thirty seven (33%) were aged 25 to 34 years. The mean age was 31years (±6). Thirty seven (33%) had a parity of less or equal to 2. Most case deaths (19%, n = 21) had attended 2 or less antenatal visits. The main gestation was below 37 weeks with 48% (n = 53). The main mode of delivery was vaginal (26%, n = 29). Majority (35%, n = 32) case deaths had delivered a live birth. Thirty seven (33%) mothers had been stable on admission. The main reason for admission waslabor with 12% (n = 13). Thirty-eight (34%) died within 24 hours after admission. Majority (27%, n = 30) were admitted antepartum but 39% (n = 43) were postpartum at the time of death. Thirty-five (32%) died of hemorrhage and 8(7%) Eclampsia.ConclusionMaternal mortality is of public health importance in the region. Most deaths occurred within 24 hours after admission. Third delay was important. Bleeding and Eclampsia were the main causes of death. A third (34%) of notified deaths were not reviewed.

Causes of Death in Patients Treated at a Tertiary Hospital in the Limpopo Province: a Retrospective Study from 2008-2010

The aim of this study was to determine mortality rates and identify associated causes at a tertiary hospital situated in the Limpopo province of South Africa. Death notification forms from Pietersburg Mankweng Hospital Complex were retrieved and reviewed for the period 1 January 2008-31 December 2010 in this cross-sectional study. Data were collected using a data collection form designed for the study. There were 5 232 deaths, on which there was complete information for 5 147, which was then analysed. The average death rate was 6.8 deaths per 1 000 patients, based on the number of patients admitted during the study period. The age of the deceased ranged from 15-104 years, with a mean of 49.1 ± 18.6 years. While only 2.4% of deaths occurred in teenagers, over two thirds occurred in people aged 20-59 years. Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), cancer, cardiovascular disease, trauma and tuberculosis were the top five most common causes of death, and were responsible for 61.2% of all recorded deaths. Trauma was the most common cause of death in teenagers, and HIV/AIDS the most common cause in young adults and adults. Cardiovascular disease was the main cause of death in the elderly. Overall, the triple burden of infectious diseases, noncommunicable diseases (NCDs) and injury remain the leading causes of death in patients at the study site. Innovative injury prevention strategies and interventions to control the spread of infectious diseases are urgently required. Cancer screening services and culturally appropriate lifestyle programmes are needed to address NCDs.