Survey of the Causes of Death on the Death Certificates of DOA Patients

BACKGROUND: To the emergency physician, issuing a death certificate is becoming a burden as the DOAs(Deaths on Arrival) have increased in recent years. We analyzed the agreement on the causes of death issued by emergency physicians and attempted to find out whether emergency physicians complied with the guidelines for issuing death certificates. MATERIAL AND METHOD: A survey questionnaire containing twelve pre-selected DOA cases which were supplemented with relevant past medical history and physical examination was used. The cases, with varying causes of death, were chosen from the medical records of DOA patients who presented to the emergency department at Severance Hospital, Yonsei University College of Medicine, from January 1997 to December 2000. The questionnaires were sent to 60 emergency physicians(22 specialists and 38 residents) at 22 university-affiliated teaching hospitals and 2 general hospitals across the nation. They were asked to identify the most probable direct cause of death for each of the 12 cases. The same questionnaire was sent to medical examiners at the National Institute of Scientific Investigation and to a Korean emergency physician at Albert Einstein College of Medicine in New York, USA. We also included an open question about the optimal age for the use of 'senility' as a cause of death. RESULTS: All 60 emergency physicians responded to the survey. The average number of causes of death per case was 9.7(7~14). The range of concordance of causes of death was 23.3% to 66.6%. Out of a total of 720 causes of death given by the emergency physicians, 35(4.9%) failed to adhere to the death certification guidelines. Also, 210 causes of death were not listed in the Korean classification of standard causes of death. Interestingly, the medical examiner answered 'unknown etiology' and the emergency physician in the USA answered 'cardiopulmonary arrest' or 'respiratory arrest' in most cases. Regarding 'senility' as a cause of death, 22 physicians(36.7%) thought the optimal age was over 80 years. CONCLUSION: A significant lack of agreement exists in determining the cause of death for the DOA patients arriving at emergency departments. Therefore, an all-out effort is essential to find ways to improve and resolve this situation. As the death certificate is a legal document and a basis for vital statistics, emergency physician should seek a rational consensus to improve and resolve these inconsistencies.

Serum Neuron Specific Enolase as Early Prognostic Marker of Neurologic Outcome after Cardiac Arrest

BACKGROUND: The purpose of this study was to determine that the assessment of serum neuron specific enolase(NSE) could provide a reliable early predictor of neurologic outcome after cardiac arrest. METHODS: Prospective, observational study was performed from April 1996 to March 1998 at a university teaching hospital ED. Serum NSE concentrations were analysed twice at 24 and 48 hours after return of spontaneous circulation(ROSC). Neurologic outcome was categorized using cerebral performance category(CPC). RESULTS: Twenty-nine patients(16 were men) were enrolled during the study period. The mean age was 50.8 years. Nine(31%) of them showed good outcome defied as CPC 1-3, and 20(69%) patients showed bad outcome defied as CPC 4-5. In the good outcome group, the serum NSE was revealed 33.8+/-9.3 ng/ml at 24 hours, 34.0+/-4.73 ng/ml at 48 hours. While in the bad outcome group, it was 99.5+/-11.7 ng/ml and 114.6+/-15.8 ng/ml. The NSE at 48hr after ROSC was more prescise than that of 24hr. When the cutoff value of 50 ng/ml at 48 hr, the sensitivity was 82%, and specificity was 93%. CONCLUSION: This study suggest that the serum NSE may represent a valuable, noninvasive, and useful clinical tool for prediction of neurologic outcome after cardiac arrest.