I am at present engaged in quality research about death in Hospitals (Norway). Last year it was claimed that errors or adverse events is linked to nearly 1/3 of deaths in Norwegian hospitals in 2010 (see attachment, there is a short summary in English in the text). Currently we review all deaths in our own hospital (Haukeland University Hospital), and we strive to find good definitions for what we could define as a sudden and/or unexpected death. Suggestions?
In Romania: death in hospital is considered "sudden and unexpected" and forensic autopsy is required if it occurs during or shortly after a medical or surgical procedure. There is no time limit specified for what "shortly" should be considered. Usually few hours, up to 24 hours. Also, sudden death is declared if death occurs shortly after hospitalization and there was no time for definite clinical diagnosis.
Sudden death is usually termed if the patient dies unexpectedly after a normal medication or surgical procedure. This is opposite to the scenario wherein death is predictable after failure of one or more vital organs of the patients and the patients are generally in ICU for prolonged time.
Sudden and unexpected death is collapse and cessation of all organ functions in an apparently healthy looking (but might have an undiagnosed fatal illness) or previously healthy individual. Provided the individual dies within 24 hours of the collapse.
All sudden and unexpected deaths need an autopsy to establish the cause of death. Such deaths can be due to internal (undiagnosed disease eg MI, aneurysm etc) or external (RTA, suicides, poisons etc) causes and there can be a lot of emotional, psychological and mental distress on family members. The family members will need bereavement counseling to assist them to cope with the sudden and unexpected loss
Sudden, unexpected death is the death of a previously healthy (apparently) person within 24 hours not related to trauma, assault or violence (as poisoning). It is amenable to obligatory autopsy everywhere. Most of these deaths turn to be natural death secondary to unrecognized fatal illness or defect.
How come? if some one is a cancer patient since years and is subjected to health deterioration for long time. Can such person will term his own death as sudden? Never. Because he might be waiting for death since many years.
Sudden death is defined as a natural, unexpected fatal event occurring within 1 h of the beginning of symptoms, in an apparently healthy subject or one whose disease was not so severe enough as to predict such an abrupt outcome.
@ Sara Excellent answer. But if death occurs within 65 minutes after occurring the symptoms, then will it be a sudden or expected death?
You should be aware that quite a lot of definitions of sudden death do exist, including the one of WHO, and the time of death occurrence since the beginning of symptoms is sometimes referred as 24 h. What I gave you here is the simplest and the most widely used definition (Goldstein, 1982).
Recently I heard someone argue for scrapping the term 'sudden/unexpected' in favour of a more general assessment of the 'risk of dying'. If patients have advanced, progressive or incurable conditions then they may die suddenly, but not unexpectedly! Some prognostic assessment tools: Palliative Performance Scale (http://www.collaborativecurriculum.ca/en/modules/PPS/PPS-thepalliativeperformancescale-01.jsp); Supportive & Palliative Care Indicators Tool (http://www.palliativecareguidelines.scot.nhs.uk/careplanning/spict.asp)
@ Sara. So you consider Goldstein definition is more authentic than that of WHO?
Any scientific justification in this regard will surely help all researchers especially Prof. Hans Flaatten who is striving to solve this mystery. That is the reason Prof. has decided to know as how the sudden death is defined across the nations and cultures.
The definition given by Mohy El Masry is very correct and most authentic especially for those medical personnel who deal such situations in the hospitals. Moreover it is correct definition according to most experts of Forensic-Legal Medicine.
Then by all means, cite the definition and post the citation! In my experience, "expected" depends in part on who is doing the expecting. I have frequently found patient's families who find the death sudden and unexpected when their loved one has had tenuous health for many years and has been hauled back from the brink several times, yet never have they considered that one time soon rescucitation will not be sucessful. So they look for someone outside the family to blame. Usually the doctors who "failed".
We should distinguish three basic categories of death from natural causes: sudden death, unexpected death and expected death.
Nota Bene. Sudden death might occur completely without any symptoms (for such deaths we use term flash death, naturaly there is no relationship to lightning).
WHO definition contains the word "unexpected". There is the difference between unexpected and sudden.
Another point to consider is so called unwitnessed "sudden" death from natural causes. What diagnostic clue we should use for categorisation and verification.
In Romania we are using the following definition: Sudden death is a natural event appearing unexpected and quickly, in one or less than an hour from the beginning of new clinical situation, to any patient known or unknown before as having a certain disease. That means that we understand it like an irreversible and unexpected syncope.
In the Czech republic we follow similair definition as was labeled by Dr. Dumitrache. Iď like to underline, that sudden death is an unforessen situation from natural causes with very rapid fatal outcome in a person that was considered to be healthy (but person was only seemingly healthy). Death occurs within one hour from the beginning of symptoms or instantaneously without any symptoms.
I think the research sincerely calls on those responding to think outside the box! We know the standard medical definitions of sudden and/or unexpected death but I think we should add the definition from our experiential learning through out the years and also from what the general population defines such deaths. I still stick to my previous definations
I’m sorry I don’t understand you very well Dr DC. Would you please be more specific, witch point of the definition should be debated. If you were to ask me, this is the scope of a definition: to make things clear for everybody and assuring we are talking about the same things. Is there a specific situation you encountered about witch you believe is not very well covered by the definition?
"I think the research sincerely calls on those responding to think outside the box! " Well said Dr. Dickson.
Interesting topic. You should check out the Gold Standards Framework (http://www.goldstandardsframework.org.uk/), where patients eligible for palliative care are identified with a neagaive answer to the question for caregivers "would you be surprised is the pt would die within a year?" Our studies (search Abarshi, Block, Echteld...) suggest that there are at least two levels of surprise. The first deals with the surprise question as stated above. When patients die within the realm of this expectation, one wouldn't expect 'unexpected' deaths to occur. Still they do--patients still may die sooner than may be expected from the course of their illness. E.g., stage 4 cancer, but stable, and sudden death by sepsis. This is the second level of surprise. You may want to think about these different levels of surprise when putting together a definition...
All the best,
Michael
The term unexpected death sholud be used for situations, where death from natural causes occurs surprisingly in a person with diagnosed but stabilized disease. Person's clinical condition was not considered as life-threatening.
In concordance with the definition I’ve mention, this is unexpected death. Having a known disease predisposing to complications related to the disease per se or the treatment, sometime leading to death, fits quite well the definitionof unexpected death. But for instance if you are performing an appendectomy for appendicitis and on the seventh day after surgery the patient dye, so, at once, having nothing before and the cause is pulmonary embolism let say, how do you name these?I believe it's sudden death even so pulmonary embolism could be related to the postoperatory imobilisation.
The term sudden death should be used for the natural death that occurs speedy and unexpected in a healthy person or in a person with diagnosed but stabilized disease.
Generally forensic implications of sudden death are correlated more to its circumstances ( such as work or sport activity ) rather than its causes. In all cases is very important to carry out a scrupulous autopsy and histologic, toxicologic and genetics analysis.
Sudden death = natural non violent death that occurs within one hour from the beginning of symptoms or instantaneously without any symptoms in a previously health person or in a person with undiagnosed symptomless disease or functional abnormality.
Unexpected death = natural non violent speedy death that occurs in a person with a known diagnosed diesease, but whose disease was not so severe enough as to predict an abrupt outcome. We should differ sudden and unexpected death.
In my hospital (in Uganda), much as we investigate case by case of sudden death, we don't routinely keep truck of the cases. We share the same definition (non accidental or violent death) in an otherwise healthy person. However, when we say healthy, it does not rule out illnesses that may not have been taken serious/recognized. In addition, people take long to go to hospital. They usually wait until the symptoms are not bearable.
I worked on an article with Dr. Satish Kedia on cultural explanations of unexplained death among adults and found this citations on his work: BANGUNGOT AMONG FILIPINO MEN: FOLK EXPLANATORY MODELS OF SUDDEN UNEXPLAINED DEATH SYNDROME (SUDS). I recall in doing research for his work that it is considered a common plight among healthy men in Asian communities, including Asian Americans. I even found graphic novel depictions in Tagalog where a man suddenly died in his sleep from a nightmare. There is a great deal of research to be found if you use the proper key words; this is just one angle you may take to discover more on how culture may influence perception and thereby documentation of illness and death.
We are currently running a surveillance study on sudden unexpected death in infants aged less than 7 days. For more information please go to our website www.apsu.org.au and click on the "Studies" tab. You will find information about the study there including a practical definition we are using.
"Sudden death" and "Unexpected death" are terms that are uncomfortable to me. They don't say anything! There is no universal explanation of those terms either. Although there are coded in the ICD, they imply uncertainly on the cause of death.
Such term should only be used in forensics grounds. Such terms are not admissible or be extremely rare within hospital care, unless there is no time enough to evaluate the patient, or the hospital is engaged in death investigation activities.
It could be nice to have a report written in English to better understand your dilemma.
There are only two organs which are implicated in sudden death : the brain and the heart. Concerning the heart, acute cardiac arrest may be caused by myocardial infarction or by ventricular tachycardia. The brain mechanisms of sudden death, most of time, implicate a brutal increase in the intracranial pressure by either subarachnoid or cerebral lobar haemorrhage, or induced by large swelling cerebral infarction.
I think that this my attached paper can be useful contribution to your interesting invitation to debate about stillbirtrh as a serious obstetrical and public health problem.
With regards
Lucijan Mohorovic
I am not agree that "sudden death" IS related to brain and heart issues. Heart has a predominant role, but any organ can be involved! Coronary heart disease has a huge role (about 60% of the cases), but there are other heart diseases involved! Subirana et al (PMID: 10523884) reported that among adult. heart pathological findings were found in 90% of the Catalonia population...
Other authors report less, but I am strongly against "sudden death" concept!
That is true, but what about cases withuot no evidence of pathomorphological changes?Are they "sudden death"?
Sincerely yours
Lucijan Mohorovic
"Unexplained death" diagnosis exist in the ICD codes. ICD-10 describes it in the codes R95-R99 as poor diagnosed diseases... I am not working with registers or those registers, but I plan to do in the future.
In Thailand. It's common. Sudden death in the young by cardiac arrthymia .
In Pediatrics, two distinctions are made between sudden infant death syndrome (SIDS) and sudden unexpected infant death (SUID). The former implies that a cause cannot be found even after a thorough history and death scene investigation including an autopsy. SUID implies that the child died "unexpectedly" of a known treatable or preventable cause. If the cause of a preventable or treatable death is obvious or determined by autopsy, then this is a sudden unexpected death e.g. overdose in hospital, head trauma, missed cases of meningitis, preventable dysrhythmias etc. As science advances, more cases that today are classified as sudden infant death syndrome will in future be classified as SUID implying that a cause has been determined.
Your comments on sudden cardiac death are very important. I personally have Dialated Cardiomyopathy, stage III, and can tell you that most people equate sudden death as emanating from a heart attack. My case is unusual, since I have no other risk factors except genetics (arteries clear and flexible, no history of smoking or substance abuse, no hypertension, etc.). For myself, my doctor is doing a great job of preventing SCD from ventricular tachycardia, as a result of the cardiomyopathy. My point here is that heart failure is not necessarily an endpoint of chronic health abuse over the years and stratification of the events leading to the SCD may be helpful (I may be presumptious here). Great work!
Sudden death is unexpected demise of an otherwise healthy individual without clinical manifestations of an underlying disease. I truly agree that a majority of these sudden death syndromes are cardiac in nature. Interestingly, the so- called BRUGADA SYNDROME which is attributed to a channelopathy disorder has been a subject of much investigation and research
The definition of sudden and unexpected death is generally defined as a sudden, unexpected, natural death within an hour of symptom- onset for witnessed event. If un-witness, subjects should have been observed alive within 24 hours of their death. This has to occur in persons without prior conditions that would appear fatal. In order to make a diagnosis of sudden cardiac death, there will be lots of things to do.
Sudden means that there is a short time between the start of symptoms and death. It is usually considered in term of hours. Easy when the death is witnessed. Difficult to define when the death is unwitnessed. Unexpected refers to condition of death. A person with severe left ventricular dysfunction may die suddenly, but it is expected; Unexpected means that there is no known comorbidity that would cause the person to die. It does not mean that there is no cause, but that it was unknown previously. Cause of sudden unexpected death can be difficult to determine even by autopsy (arrhythmias leave no trace and even hyperacute myocardial infarction maybe difficult to diagnose) so that there is another qualifier, which is explained/unexplained SUD.
A pop-up appears when one moves to record something here, encouraging one to write high quality asnwers. My answer is contained in the attachment which involves a SUNDS incident in Thailand in April 2004, and is mostly the writings contained in the Thai Newspaper The Bangkok Post.
Sudden and unexpected death is that type of death that cannot be explained scientifically. Death that occur without visible pathology, such death may even have no findings at autopsy. We still need a lot of research on sudden and unexpected deaths, knowing that health is not merely the absences of disease but a state of physical, mental, and spiritual well -being. Man is an embodiment of body, soul and spirit.
Note the international pathogenetic insights regarding the causalities of sleep apnea and cardiac disorders as cause of sudden cardiac death in sleep apnea patients.
From a pathogenetic viewing the causes of sudden infant death and the apnea-related sudden cardiac death in adults are identical.
hypoxia> sympathetic overstimulation> Sudden Cardiac Death
In the UK police become involved in "sudden deaths". This includes deaths from accidents, suicides, outdoors, in the workplace and when the death is not expected ie terminal care arrangements are not in place. In my role as police surgeon (aka forensic medical examiner, clinical forensic practitioner) to decide if I can issue a certificate of death or not. Most of the time the cause of death is obvious. Some of the time deaths require further investigation by the procurator fiscal and post mortems are needed. This includes deaths from "privation and neglect" such as occurs in mentally ill people or alcoholics. In some cases death was not particularly expected at that time but was not unexpected either eg in chronic illness, in old age. Under these circumstances many relatives do not wish to have a post mortem and the deceased person as said so in life, and I don't blame them. The issue of a well thought out certificate of death can help the family cope at a difficult time. There remains a small number of cases where the death is not obvious either before or after a post mortem and toxicology studies.
The sudden death is not always the unexplained death. We use this term to emphasize 1) the time of a natural non-violent death immediately or within 24 h after the onset of symptoms; 2) its occurrence in an apparently healthy individual. The term "instant death" is sometimes used to denote the instantaneous (within minutes) irreversible cardiac arrest.
"Sudden death" is often perceived as cardiac death only, which is not true. Certainly, there are several other causes. The cardiac arrest is not exactly the same and constitutes a potentially reversible condition, while the sudden cardiac death is an outcome. In this connection, a final diagnosis should indicate the disease that caused death, but not the sudden death itself.
In the UK, the most important contribution to the issue of whether deaths can be attributable to problems of care (I think using 'sudden and unexpected' is attracting comments that aren't quite on the topic you're after Hans) was published by Hogan (Hogan H, Healey F, Neale G et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf (2012) doi10.1136/bmjqs-2012-001159).
I also think a paper building on the Hogan paper and its accompanying editorial are important (Girling AJ, Hofer TP, Wu J, Chilton, Nicholl JP, Mohammed MA, Lilford RJ. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study. BMJ Qual Saf (2012) doi:10.1136/bmjqs-2012-001202. Kaveh G Shojania. Editorial: Deaths due to medical error: jumbo jets or just small propeller planes? BMJ Qual Saf 2012 21: 709-712 originally published online July 24 http://qualitysafety.bmj.com/content/21/9/709.full.html).
The NHS will begin to measure "Hospital deaths attributable to problems in care' (https://www.wp.dh.gov.uk/publications/files/2012/11/121109-Technical-Appendix.pdf page 91) in 2013/14. Sorry to add so many citations but I hope this is helpful.
Like you, I'm involved in reviewing deaths in an acute hospital. We have a defintiton of 'unexpected death' we use for this. Happy to share this and debate further if that's helpful.
I don't accept that suddeen and unexpected death is an unexplained one. It is rather a death that occured without any previous notice and which does not meet the natural course of the disease. For instance: A patient without any known heart conditions who dies suddenly from heart attack in the middle of a hip replacement operation. Or another patient undergoing tonsillectomy and dies suddenly out of uncontrolled bleeding.
You raise an interesting area for further research. A problem is that many sudden deaths do not occur in hospital. I have been following the health care of a village population in Papua New Guinea for the last 50 years. In the 1960s there were virtually no cardiovascular diseases revealed either in admissions to the local city hospital, or in the primary care presentation in the village. In the last 5 years, records indicate that there have been more than 10 strokes (9 in females) admitted to the hospital; one myocardial infarction. But in the village, 12 men aged less than 60 years have died suddenly with little warning (such as chest pain). Most have been engaged in some basic activity (gardening, mending a net) and died within a minute or two. There is diabetes, hypertension and obesity underlying this new epidemic; it will not be revealed through hospital records, you need a community listening post.
Dear Hans,
did you check if these deaths were correlated to an increase of PM2.5 or less in the air? If there was a peak of these emissions, it is probable that you find these debris of in the coronary or in the brain. Probably these deaths are part of nanopathologies. Dr. Antonietta Gatti (Visiting Professor of the Department of state. USA) [email protected]
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