My mother died recently. I received the death certificate. I disagree with her cause of death. The doctor who completed her worksheet did not know her well. The death certificate has a diagnosis that she never had that was handed down from her previous doctor. It omitted a long-standing, chronic disease. Why am I bothered? Because I would complete death certificates on a routine basis, for I am a hospice physician. I believe in accuracy. I spend time trying to uncover the puzzle of someone’s medical life the best I can. No, most death certificates are not accurate. They are annoying to complete, especially when you are in a tug-of-war with the health department. Wording and timing are the beasts.
The danger of inaccurate medical history
So, I think some doctors take the easy way out. Not accurate but easy, no call back, just attest. I feel we owe the patient, the family, and the generations to come, accuracy. Part of that starts with historical diagnoses. “Past medical history,” how accurate is that? I go through patients’ documented histories all the time. I recheck if the problem is still present. I look at one-time diagnoses that get put in past history. Should that be there? Does it matter? Yes, it does, especially if there is nothing to confirm the diagnosis in the present. For example, my mother was given the diagnosis of chronic obstructive pulmonary disease (COPD). She never had a pulmonary function test, was never symptomatic, and had no signs of it on chest X-rays. But it persisted and got passed along and ended up on the death certificate.
Navigating the clinical cycle as an advocate
I was not my mother’s doctor. The doctors who took care of her knew that I was a physician. I would gently advocate for my mother, especially in the last year before her death, but I really tried not to circumvent her care. However, when the care was not appropriate, I did speak up. But any advocate would. During her last year, I fired her longtime primary care doctor (although the doctor did not know it). She stopped really caring for my mom. My mom was just in the cycle, I had to bring her in for forms to be completed, for a yearly physical (which was of no good use), and tons of unrevealing lab tests. And the kicker was that my mom had a 20-year history with this doctor. Do the protocols, reimbursement, and lack of time supersede a doctor-patient relationship of long-standing? That hurt my heart. I had to change her care.
It was difficult to provide a succinct medical history to a new provider, because at my mom’s age it was extensive. Many things were in the past and not that significant. That should be what “past medical history” should really stand for. There should be different terms like “recent medical history” or “significant medical history” for more accuracy. That is what I dig for when I have to fill out a death certificate on a hospice patient whom my relationship is new and short.
Fixing the burden of bloated medical records
My last rant is the diagnoses themselves. The International Classification of Diseases, Tenth Revision (ICD-10) is so complicated and trite at times, with a one-word change giving a diagnosis a whole new meaning. This is absurd accuracy and frustrating at its best. We have all seen the arcane diagnoses of “hit by a whale” or “spacecraft collision injuring occupant, sequela.” However, I posit that we make patient diagnoses accurately simple. Not easy. Purge diagnoses that do not matter anymore. Revisit with patients to see if the issue still exists. That does mean talking to them, having a relationship with them. It may mean spending time combing through past records to get a better picture. I have found very important information doing this. A recent non-hospice patient I saw while doing a locums assignment presented with what appeared to be a lower respiratory infection. The X-ray showed to my surprise that he had had a coronary artery bypass graft (CABG) and automated implantable cardioverter-defibrillator (AICD) placed. It was nowhere in his past record.
I know we physicians are busy and overwhelmed. But as a daughter who lost her mom, the last important record needs to be true.
Karen Glover is a palliative medicine physician.
