C A U S E

O F DEATH
(COD ASSIGNMENT)
M O H A M A D F UA D B I N M O H A M A D A N UA R
NAT I O NA L I N S T I T U T E O F H E A LT H (NIH)

 DISCLAIMER

Slide background putih = Slide asal

Slide background hitam = Slide tambahan

 INTRODUCTION

D
ibentangkan semasa Mesyuarat Khas Ketua
Pengarah Kesihatan (KPK) dan dipersetujui untuk
perlaksanaan pada 13/02/2017
Dimulakan pada September 2017

Terima kes VA pertama pada Januari 2018 dengan senarai

nama kes kematian bagi Ogos 2017 (VA Ogos 2017)

Pembangunan e-soal selidik pada 2020



A
nalisa data kematian 2014 yang dilakukan oleh Jabatan
Perangkaan Malaysia (DOSM) mendapati : 48.5% kematian
adalah merupakan kematian Tidak Disahkan Secara Perubatan
dan dari jumlah ini hampir 60% dikodkan sebagai ‘sakit tua’.
– Peratusan ini jelas memberi maklumat terhad / kurang tepat tentang
penyebab kematian sebenar di Malaysia.
– Hanya 51.5% kematian disahkan secara perubatan

V
A yang dilakukan pada 2017 (data Ogos-Disember) telah berjaya
meningkatkan peratus kematian yang disahkan secara perubatan
dari 52.8% pada tahun 2016 kepada 57.9% pada tahun 2017.
Bagi 2018 VA meningkatkan peratus MCD dari 57.9% (2017) kepada
68.2% (2018) - Laporan DOSM 2019

S asaran : ke arah
perubatan pada 2025
80% kematian di Malaysia disahkan secara

N CD Global Target : penurunan 25% kematian pra-matang

pada tahun 2025. Pada 2016 (anggaran WHO) 48% - sasaran pada 2025
turun kepada 36%.

S DG : penurunan 30% kematian pra-matang pada tahun 2030

Data will be divided based

on 1) I/C address -> 2)
Death address -> 3) Adress
of pemaklum
 IN TRODU C TION
• The accuracy of death ascertainment is highly dependent on the tool,
quality of interview and procedures used to assign causes of death
• Causes of death have been defined as all those diseases, morbid conditions
or injuries that either resulted in or contributed to death (or the
circumstances of the accident or violence that lead to the injuries)

In the epidemiological framework of the Global

Burden of Disease study each death has one
speci c cause. In their own words: ‘each death is
attributed to a single underlying cause — the cause
that initiated the series of events leading to death’
fi

S e k s y e n ini u n t u k d i l e n g k a p k a n o l e h p e g a w a i p e r u b a t a n d e n g a n m e n y a t a k a n r i n g ka s a n
p e n e m u a n berdasarkan soal selidik ya n g telah dilakukan (demografi, p e n e m u a n positif d a n
p e n e m u a n negatif yang akan m e m b o l e h k a n diagnosa p e nye b a b kematian dibuat).
This s e c t i o n is m e a n t for t h e m e d i c a l officer t o s u m m a r i z e t h e findings f r o m t h e q u e st i o n n a i r e
( d e m o g r a p hy, positive a n d negative findings w h i c h will help in diagnosing the c a u s e of death).

S E K S Y E N 8: S U M M A RY N O T E
S E C T I O N 8: NOTA K E S I M P U L A N

Guidelines for COD assignment

• Carefully screen all modules for relevant information

• Make a separate record of all the positive evidence

• Use diagnostic guidelines to identify causes of deaths

• The negative evidence (the absence of a particular

sign/symptom) might be indicative or helpful in judging
cause.
• Precedence should be given to available medical opinion on
the cause of death, if it can be corroborated with the details
of symptoms and events described by the relatives

Example of Diagnostic Guidelines

 Pulmonary Tuberculosis
Chronic cough of long duration with fever A N D any of the
following signs @ symptoms :
❑ Blood in sputum
❑ Chest pain
❑ Breathlessness
❑ Loss of appetite
❑ Chronic weight loss
❑ Treatment history of TB

 Stomach Cancer

Vomiting / Vomiting of blood. D ifficulty in swallowing AN D

mass in upper abdomen AND any of the following :
❑ Pain in abdomen
❑ Weight loss
❑ Enlarged liver
❑ Black stools

 Lung Cancer

Chronic cough and blood streaked sputum (eventually

leading to haemoptysis) AND any of the following :
❑ Breathlessness
❑ Chest pain
❑ Hoarseness of voice
❑ Rapid loss of weight

Manual_for_Cause_of_Death_Assignment.pdf

P age 36-45
*Pdf page : 39 - 48
Do & Don’t in COD assignment
 Do’s
• Use common sense and best diagnostic guideline.

• Read the narrative, history and other information very

carefully.
• Corroborate what a health care provider may have said on
the questionnaire with some other signs or symptoms in
the checklist.
• Do look for important negatives in the history. These can
narrow down several possible causes to one or two.

• Do think from a public health perspective. Common causes

are important indicator.
• Do not afraid to state that no cause can be assigned.

• Write only one cause on each line of the death certificate.

• Write understandable word, and do not use any

abbreviations or acronyms.

Statistic on Causes of Death, Malaysia, 2021

 Don’ts
• Do not make a random diagnosis if none is found

• Do not try to make a pathological diagnosis (eg : various

type of myocardial infarction)
• Do not rely on risk factors alone for making a diagnosis
(cirrhosis occurs not only among alcohol drinkers but also
among non-drinkers)

Cause of Death Certificate

 Underlying, Immediate, Intermediate
Cause
• I M M E D I AT E – “the final disease (condition) or complication
resulting from the underlying cause of death, occurring closest
to the time of death, and directly causing death.”

• I N T E R M E D I AT E – “a disease (condition) or complication

occurring somewhere in time between the underlying cause of
death and the immediate cause of death”.

• U N D E R LY I N G – “the disease (condition) that initiated the

train of morbid events leading directly to death.”

 Cause of Death Statement

Approx. Interval
Part 1 – Statement of Cause(s) of Death between onset
and death
Immediate Cause
•
Part 1 A. Most recent condition (resulting from B)
Another Intermediate Cause
B. An older condition (resulting from C)
Intermediate Cause
C. An even older condition (resulting from D)
D. The first (oldest) condition causing the others above.
Underlying Cause

Part 2 - Other Significant Conditions – Conditions contributing to death but not resulting
in the underlying cause of death in Part 1

Part 2

Cause of Death and the Death Certificate, Hanzlick, 2006

 Approx. Interval
Part 1 – Statement of Cause(s) of Death between onset
and death
Immediate Cause
• 2 days
Part 1 A. Pneumonia

B. Lung Cancer 6 months

C. Breast Cancer 10 years

D.

Part 2 - Other Significant Conditions – Conditions contributing to death but not resulting
in the underlying cause of death in Part 1

Part 2
DM, HPT, HCL

E xamples
Example from Questionnaire
Example 1
Lelaki 20 Tahun
Demam selama 5 hari sehingga meninggal
Pewaris juga kata demam si mati seperti sejuk
mengigil Diagnosis
Ruam dekat anggota kaki dan tangan Demam
Denggi
Ada gatal-gatal kulit

Kelihatan pucat
Turun berat badan secara sedikit
Ada muntah
Sakit kepala selama 3 hari

 Example 2
Lelaki 58 tahun Diagnosis
Sakit sehingga meninggal selama 2 bulan Diabetic Foot
Demam dalam 5 hari berterusan secara sederhana Ulcer (DFU)

Terdapat kudis bernanah di kaki

Kebas di kaki Specific Diagnosis

Sembab di muka dalam sebulan
a) Sepsis
Sentiasa sukar bernafas dan tidak berbunyi tetapi b) Diabetic Foot
tidak tahu tempoh Ulcer (DFU)
Others:
Nafas secara laju tetapi tidak tahu tempoh
Hypertension
On treatment : Hypertension, Diabetes mellitus

 Example 3
Perempuan 60 tahun Diagnosis
Terjatuh di tangga Fall

Lumpuh bahagian bawah badan

Terlantar selama 2 tahun

Terdapat kudis bernanah di bahagian Specific Diagnosis

punggung a) Sepsis
Susut berat badan secara sederhana b) Sacral sore
c) Fracture
Tidak tahu tempoh ketidak sedaran si mati d) Fall
On treatment: Diabetes mellitus Other: D M

 Example 4
Lelaki 25 tahun
Si mati selalu penat, selsema dan batuk mengikut pewaris
Pewaris juga mengatakan si mati kerap buat ujian darah tetapi tidak
memberitahu keputusan.
Susut berat badan yang ketara Diagnosis
HIV/AIDS
Ada ruam di badan

Deman yang kerap dalam tempoh seminggu dalam dua tahun

mengikut pewaris
Cirit birit selama dua bulan
Ada bengkak di kelenjar ketiak
Batuk berdarah selama sebulan Terdapat
kudis-kudis di bahagian badan

 CONTOH TEMURAMAH
TERBUKA DARI WARIS
Female, chinese, 46 year old
Underlying D M , Hypertension, Leptospirosis, Renal Disease
2017;
- Fever & cough 3/7, collapsed at home, brought to Hospital X
- Hospital doctors informed to relative, lung full of virus causing patient to have difficulty breathing, patient was
transferred to a referral hospital (Hospital XY) for I C U admission. Stayed in I C U for 1/52, then transferred to general
ward for 2/7.
- Patient was diagnosed with Leptospirosis and transferred back to Hospital X to complete antibiotic for 3/52.
- After discharged, patient can still walk but not active
- Relative noticed patient’s ankle was swollen and was brought back to Hospital X . At the hospital, doctor diagnosed with
Renal Disease. Only admitted for 3/7 then discharged home and started on routine hemodialysis.

- Patient then defaulted H D for 3/12, and then having loss of appetite. Family members admit patient to Hospital Z (private
hospital), Patient was discharged stable and well, can talk to everyone.
- Then 2.30 pm, patient sleep for 30 minutes, and suddenly collapsed and passed away.

 LOOKING FORWARD
• MA I/C go through excel data, 1/52 selepas diterima - validate data:
alamat kawasan operasi, no. tel pemaklum masih in-service (informed
next-of-kin, nanti ada Dr pula yg akan call), ada rekod buku/kad OPD si
mati di klinik, *trick T/OUT
• Public still unaware of VA conducted by KKM - lack of promotion?
• VA done during pengesahan kematian? - Bawa buku kosong, amik
details, tulis tarikh kematian, dan catat peristiwa yg berlaku (MA
health site or MA hospital)
• Data pemaklum sesetengah kes sebelum ni adalah cremation center
punya personal
• Collaboration with hospital medical record department? (if pt ever
hospitalised before) - Hosp Kulim computerised??

T H A N K YO U
Mohamad Fuad Mohamad Anuar
Emel: mfuad.manuar@moh.gov.my; 0333628737