Is this usual?

What is the name of your state? Virginia

My spouse died on 9/19 in an emergency room. The death certificate was signed by his personal physician and not the attending ER physician. I thought this was rather peculiar, so I called the family physician and asked whether he had been called to the ER, but he said he had not been, just read the ER doc's notes and made a call as to cause of death.

Since I am trying to settle the bills, I called the hospital and asked where the bill was, since it had been a month. The billing clerk first said the bill had been sent to the insurance co, then retracted her statement and said the bill had not been "dropped." I asked why, and she said the attending ER doc had not submitted a final diagnosis. That threw me and I said the final dx was death and there was a dx given on the death certificate, so what was the problem?

Then I asked to speak to the risk manager, who said the ER doc was on paternity leave and would not be back for six weeks. She said he had 21 days from the date of death to dictate orders, but he must have been busy thinking about his child's impending birth and forgotten to dictate his charts.

Is this usual? Or is this odd? I also had to pay a 50.00 medical examiner fee, as part of the funeral bill. There was a bandage of some sort on my spouse's chest, which I could see under his shirt. His chest had not been cracked or anything in the ER, so I am guessing there was some sort of medical examination after death and before embalming, since embalming does not entail opening body cavities.

I guess I would just like to rest a little easier about this, but something isn't sitting right with me.

lady alone said:

What is the name of your state? Virginia

My spouse died on 9/19 in an emergency room. The death certificate was signed by his personal physician and not the attending ER physician. I thought this was rather peculiar, so I called the family physician and asked whether he had been called to the ER, but he said he had not been, just read the ER doc's notes and made a call as to cause of death.

Since I am trying to settle the bills, I called the hospital and asked where the bill was, since it had been a month. The billing clerk first said the bill had been sent to the insurance co, then retracted her statement and said the bill had not been "dropped." I asked why, and she said the attending ER doc had not submitted a final diagnosis. That threw me and I said the final dx was death and there was a dx given on the death certificate, so what was the problem?

Then I asked to speak to the risk manager, who said the ER doc was on paternity leave and would not be back for six weeks. She said he had 21 days from the date of death to dictate orders, but he must have been busy thinking about his child's impending birth and forgotten to dictate his charts.

Is this usual? Or is this odd? I also had to pay a 50.00 medical examiner fee, as part of the funeral bill. There was a bandage of some sort on my spouse's chest, which I could see under his shirt. His chest had not been cracked or anything in the ER, so I am guessing there was some sort of medical examination after death and before embalming, since embalming does not entail opening body cavities.

I guess I would just like to rest a little easier about this, but something isn't sitting right with me.

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My response:

Have you buried him yet?

IAAL

Of course I did. It's been a month. Is there an apparent reason for your question or am I simply missing the irony?

What was the cause of death? Was your husband under care for the condition which lead to his death or was the cause of death obvious? Lack of a death certificate can dely your settling his affairs and so his PCP signed the certificate, if there is a change, it can be amended in the future.
Was there an autopsy, this should be information you can get, usually they ask for permission to do one and they may even try to talk you out of one depending on the circumstances? You have not given us enough information to answer your question.

Is this unusual?

The cause of death was "acute coronary insufficiency." He had no underlying conditions and had been in good health. He was 47. I asked about an autopsy and was told there was no need for one. I just thought it was strange that his own doc signed off on the death certificate, b/c he had no coronary disease and hadn't been treated for anything and had just gotten a DOT physical and passed with flying colors.

I don't understand the hospital's response. Records can make or break a hospital and death records are usually scrutinized carefully, so I find it difficult to believe the ER doc simply forgot, and I don't understand how the regular doc could just sign the death certificate without good notes and discharge summary from the attending.

There is still not enough information to give you an answer without a thorough review of hte medical records, healthy people do drop dead wihtout reason and an autopsy may not yeild an answer or there may be a reason for avoiding an autopsy, no one can tell based on this. I suggest starting with his doctor and ask for their reasons for signing the death certificate and to explain that to you, ask for them to request complete copies of the hospital records including full disclosure reports on ECG's etc. Is there a family history of low blood pressure or sudden death?
I'm sorry for your loss and all the trouble you are having settling these issues, it can only bring more pain when that is what you are trying to avoid.

rmet4nzkx said:

it can only bring more pain when that is what you are trying to avoid.

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My response:

Which brings me to my original question - - Did you bury him yet?

Since your answer to that was "Yes", then move on. You have nothing to gain from any of this information.

IAAL

IAAL is correct, as usual; however, to ease your mind...people die from acute coronary insufficiency and no one is to blame. It is perfectly OK for the primary MD to fill out the paperwork (death certificate information) by reading the ER notes; that's what the coroner would have done.

I'm sorry for the loss of your loved one. Acute coronary syndromes are most difficult on the loved ones who are left behind due to the very nature of the sudden event(s) and the sudden loss that robs the loved ones of the chance to begin to accept what is happening.

Best wishes,
EC

Of course individuals die from coronary insufficiency and there is no "blame." I did call the PCP when I rec'd the death certificate from the funeral director and asked him how and why he came to sign the certificate. He said that's just what "they do." Nonetheless, I fail to comprehend how he could have assigned a cause of death w/o a discharge summary from the ER physician. Notes are notes, but the discharge summary provides the basis for the cause of death.

And no, there was no low blood pressure, no other coronary disease in the family, non-smoker, average weight, good cholesterol, overall good health. I asked to see the records, but the risk manager told me I would have to wait until the discharge summary was signed.

So, now I go back to my life.

lady alone said:

Of course individuals die from coronary insufficiency and there is no "blame." I did call the PCP when I rec'd the death certificate from the funeral director and asked him how and why he came to sign the certificate. He said that's just what "they do." Nonetheless, I fail to comprehend how he could have assigned a cause of death w/o a discharge summary from the ER physician. Notes are notes, but the discharge summary provides the basis for the cause of death.

And no, there was no low blood pressure, no other coronary disease in the family, non-smoker, average weight, good cholesterol, overall good health. I asked to see the records, but the risk manager told me I would have to wait until the discharge summary was signed.

So, now I go back to my life.

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Your husbands PCP is qualified to read the notes of the ER doc and make a conclusion or Dx re the cause of death, and in this case seems appropriate under the cicumstances. Healthy people can and do die of "acute coronary insufficiency" You have the death certificate and eventually will have the records once the discharge summary is ready, it is possible that then there will be an amendment, but not likely. But you have the death certificate and can move forward based on it rather than wait for the ER doc to return and complete the discharge summary. 4 people in my family died sudden deaths, all were healthy, my father had just had a complete physicial a few days before, no did the autopsy find a cause of death, he was DOA thus the autopsy and LQT doesn't appear in our family otherwise nor any other sudden deaths, although we do have low blood pressure. Knowing more won't bring your husband back, I am sorry for your loss.

Thanks.....it's all just such a mess and I certainly wasn't prepared. At least most of the paperwork was in order, and the rest will just be a slow, steady slog up the hill. It was just so shocking and I stood there like an idiot when it was happening and failed to react, as I had been trained to do, and had done many times for other people. So I am really beating myself up and need to let it rest.

Sorry about your loss, too.

The highly trained emergency professionals with access to all the best drugs and equipment were unable to save his life; you need to forgive yourself for not being able to do so either.

The bandage on his chest may well have been related to something they did during the resuscitation attempt, such as a central intravenous line to administer medications. If this is bothering you, ask at the funeral home whether he arrived with it or if it was related to the embalming process.

As for the death certificate: we'd like to believe that there is certainty in assigning a cause of death, but in reality it is just a guess unless there is an autopsy. It is routine for the treating physician to sign the certificate, since he/she would be most aware of any conditions that might lead to sudden death. Heart attack is the most common cause of sudden death in adults of your husband's age, so even though there were no clear signs ahead of time, it is highly likely that is what happened to him. By the way, routine physicals often fail to pick up impending heart problems.

As for the emergency MD not completing his notes: it is required that he complete those records, both by the federal government and the state he practices in. However, this is an issue medical records people struggle with all the time. If you feel as if you must take action, you could file a complaint against him with either the state medical board or the state licensing agency that licenses hospitals. The medical board is unlikely to do much about it; the licensing agency will do an investigation and require the hospital to ensure the record is completed.

May I also suggest you consider grief counseling? You can call the department of Social Services at the hospital and ask for a referral, or call your Employee Assistance Program if you work. Coping with the death of a loved one is always difficult, but especially so under these circumstances. Grief counseling provides an opportunity to work through all those loose ends and come to some measure of acceptance. You deserve it.

RE: is this usual

I am sorry for your loss and I hope things are improving for you. It is not my intention to reopen issues you have put to rest, but perhaps this might help reassure you.

I think there is a strong possibility that the bandage on your husband's chest covers an incision made during a limited autopsy. Although each state has different statutes that describe the circumstances under which a post-mortem exam is mandatory (the most obvious being when foul play is suspected) the vast majority all contain some provision for some level of investigation when a death is sudden and unexpected. For instance, there is a huge number of drugs and poisons that mimic a cardiac event. Screening for each and every one of them would be much more time consuming - and expensive - than verifying the presence of cardiac disease. Connecticut and Alabama have the most stringent requirements: in Connecticut, the body of an otherwise apparently healthy individual who has not been examined by a physician within 24 hours of death must undergo an autopsy performed by the State Medical Examiner, although the law does allow the ME to cede responsibility to the hospital pathologist and to determine the scope and extent of the examination.

Autopsies performed under these conditions do not require the consent - or often notification - of the next of kin. A "limited autopsy" can consist of as little as post-mortem blood tests; analysis of hair or tissue or, as may have happened in your husband's case, an incision of length sufficient only to confirm death due to coronary insufficiency. It isn't as if the entire heart would have needed examination: the verification of plaque in a major vessel by manual palpitation would probably be sufficient.

And if this was, in fact, what transpired, it could very well have caused the delay in completing the medical record.

The suggestion about grief counseling was a good one - I hope there is peace and contentment in your future.

You are probably correct about the limited autopsy. I viewed and attended to my husband's body after death and there was no central line or open chest from extraordinary measures.

I guess what has bothered me is that Virginia statute calls for an autopsy in the event of sudden death in an otherwise healthy individual precisely to r/o foul play. I had thought he would be autopsied, and was prepared to give my consent. When it appeared that there was no pressing need, and after just being fatigued, I didn't push the issue.

It just surprised me about the blase attitude about the death certificate, the final dx, the billing....and maybe that's because it was all personal to me and it was just a job to them. I don't recall ever having the same feelings, but every area is different.

So, I have put it to rest and just gone back to work. You are an eloquent writer and thinker, and I thank you for your detailed explanation.