The cause of death is the injury or disease which begins the train of events that ultimately leads to death. The cause of death may be separated into a proximate cause and an immediate cause. The proximate cause is the initial event and the immediate cause is the last event prior to death. For example, a beam falls on the back of a man working at a construction site and he becomes paralyzed. As a result of the paralysis, he loses bladder control and becomes prone to develop urinary tract infections. Years after the accident he develops a particularly severe kidney infection, becomes quite sick, and dies. In this case, the proximate cause of his death is the injury which left him paralyzed. The immediate cause is the infection of the kidney (pyelonephritis).
It is important to note that the length of time between the proximate and immediate cause does not change the final diagnosis of cause of death as long as there is an unbroken chain of events between the two. The time frame may be minutes, days, or years. An excellent history and investigation are critical in determining the proximate cause of death, ensuring the train of events between the proximate and immediate cause are not broken.
The mechanism of death is the biochemical or physiologic abnormality resulting in death. The mechanism of death in the above case is septic (infection in the blood with symptoms) shock. Other mechanisms of death include arryhthmias of the heart, shock, or exsanguination (bleeding). The mechanism of death is not the cause of death and should not appear alone on the death certificate. For example, in someone with a gunshot wound to the head, the specific injuries of the brain and resultant swelling (cerebral edema) do not need to be included on the death certificate. The cause of death is the gunshot wound to the head.
The manner of death is the circumstance surrounding the death. Traditionally the manner is classified as one of the following: homicide, suicide, accident, natural, or undetermined. In the above case of the man dying from sepsis as a result of the paralyzing injury, the manner of death is accident.
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