In the aforementioned cases, the authors suggest two ways of certifying the cause of death. First is to sign out the cause of death as "excited delirium" and then list "struggle," "cocaine intoxication," etc., as contributory causes. The other way is to sign out the cause of death in a descriptive manner, e.g. "Cardiopulmonary arrest during violent struggle in individual under influence of cocaine, alcohol, etc." In individuals with psychoses, this is listed either as a contributory cause or incorporated in the descriptive diagnosis.
The greater difficulty is designating a manner of death. Because of the effects of the violent struggle, one cannot classify such a case as a natural death. The choice then is either homicide or accident. Since a violent struggle has occurred with interaction between two or more individuals, the best classification of the manner of death is probably homicide. A good argument for an accident can be made, however. If the case is called a homicide, it is necessary to explain that the designation does not indicate that there was necessarily any criminal activity involved. The difference between homicide and murder should be carefully explained.
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