Determining the Cause of Death: A Scientific Perspective

[jack action]

There is an old local politician who died today. He was 85 years-old. He caught Covid in his nursing home, it rapidly escalated and he died of complications (in around 24h).

Here's the thing: he already had a pulmonary condition (the reporter did not specified). He was an avid smoker all of his life until he quit at 82 years-old.

Should his death be attributed to smoking or to Covid? Or maybe just simply of old age?

 

[StevieTNZ]

Isn't that for the Coroner to decide?

 

[Astronuc]

There is an old local politician who died today. He was 85 years-old. He caught Covid in his nursing home, it rapidly escalated and he died of complications (in around 24h).

Here's the thing: he already had a pulmonary condition (the reporter did not specified). He was an avid smoker all of his life until he quit at 82 years-old.

Should his death be attributed to smoking or to Covid? Or maybe just simply of old age?

Many patients who become seriously ill with COVID-19 have one or more comorbities. Having a comorbidity increases the risk of mortality or poor outcome.

Perhaps the politician who quit smoking could have lived a few more years, but COVID-19 apparently lead to a quick demise. The result of death could be cardiac arrest, pulmonary failure, stroke, or organ failure, or other causes related to lack of oxygen in the blood, or septicemia, which leads to organ failure.

 

[hutchphd]

The cause of death was COVID-19. The mechanism of death was multiple organ failure . The manner of death was natural causes.

 

[jack action]

The cause of death was COVID-19.

Couldn't it be that the cause was a weak immune system?

If someone who has hemophilia dies after bleeding to death, we don't say "cause of death: paper cut", we say hemophilia is responsible for the death.

Paper cuts happen often, most people have the capacity of recovering from it easily. If one dies from one, there is certainly something abnormal with that person.

This is where I'm lost in these categorizations.

 

[hutchphd]

I am not an MD (nor a JD) but I believe the cause of death would be "paper cut". Of course the hemophilia would be included in the mechanism.
What would be the cause if the hemophiliac was hit by a locomotive?

 

[Stephen Tashi]

Should his death be attributed to smoking or to Covid? Or maybe just simply of old age?

If you mean "should" in the legal sense, death certificates (that I've seen in the USA) are permitted to list multiple causes. We'd have to consult the regulations and guidelines that govern filling out death certificates to find out what "should" be done in that sense.

If you mean "should" in the sense of "What is a correct description of the physical process?" or "What is a correct description from the point of view of determining public health policy?", then these are complicated and probably controversial questions. "Causation" itself is a difficult concept to define.

 

[russ_watters]

Couldn't it be that the cause was a weak immune system?

I think you're reaching to add an extra step, or emphasizing one over another, when multiple can contribute.

See also:
Cause of death: Faulty brakes.
Cause of Death: Cheeseburgers. Lots of cheeseburgers.

For the purpose of measuring the disease, it needs to be recorded somewhere. And so do the comorbidities.

 

[Ygggdrasil]

Copied from a previous thread on COVID-19, performing back of the envelope calculations to estimate how much virus infection accounts for deaths among the elderly vs their underlying health conditions:

The life expectancy for an 80-89 year olds in China is 6.58 years. Median time to death for fatal COVID-19 patients was observed to be about 20 days from the onset of symptoms, and for people over 80, the mortality rate was 14.8% in studies of the Chinese outbreak. I don't think 14.8% of all people >80 years of age are going to drop dead in the next three weeks. (There are 23 million 80+ year olds in China, so this would correspond to 3.4 million deaths over three weeks. Based on the previously quoted 7 out of 1000 people dying per year in China (pop 1.4 billion), you would only expect to see 0.56 million total deaths of all ages in China over three weeks.) Modeling survival as an exponential decay with a half-life of 6.58 years, we would only expect to see about 0.61% mortality among octogenerians over a three week span (even if you double the period to six weeks as 20 days is only the median time to death, you still only expect 1.2% of octogenerians to die of natural causes in that time span). Thus, COVID-19 may increase mortality among octogenerians by over an order of magnitude.

Does the 14.8% represent the proportion of the >80 year-olds that are worse off in health? The study of life expectancy among the elderly in China found that ~ 11.8% of octogenerians were disabled (they require assistance in the essential activities of daily living like bathing, dressing, eating, or going to the bathroom). Among disabled octogenerians, life expectancy is only 1.1 year. Still, you would only expect to see 3.6% of that population die over the course of three weeks, nowhere near the 14.8% mortality seem among all infected 80+ year olds (regardless of whether they have additional health problems). Even the 70-79 age group (mortality rate of 8%) has twice the expected death rate of disabled octogenerians.

The health conditions that pre-dispose COVID-19 patients to greater mortality do not come close to explaining the observed mortality of the disease.

 

[jack action]

The health conditions that pre-dispose COVID-19 patients to greater mortality do not come close to explaining the observed mortality of the disease.

This is the kind of politically-correct statements I have a problem with. Well-presented stats that leads us in the direction that Covid is the important factor here. But I'm sure someone can build up the same kind of statistics from the smoking point of view and end it with:

The health conditions that pre-dispose smoking patients to greater mortality do not come close to explaining the observed mortality of the bad habit.

But when you look a the stats, you also see a clear relation between death and age. Smoking or not, Covid or not.

The most common age for a human to die: 86. Half of the people on this Earth right now, won't go over 80. Dying at 85? Pretty much a normal outcome (dare I say an achievement?), no matter what you die of. Dying of old age.

I can see though causes of death that are not related to age: Arrow through your heart, drinking a glass of ammonia, a 10-stories free fall. No matter your age, the outcome is more or less similar for anyone. Even then, an 80 year-old person that mix up the brake and gas pedals and die in a car crash can still be linked to old age. Something he would have never done when he was 30.

Can old age be an acceptable cause of death? Following the same objective way of analyzing statistics like you did, it seems to be.

 

[jim mcnamara]

The attending physician is responsible for writing the cause of death. Not you. Not me. Trying to assert that we are 'over-attributing' deaths to Covid-19 somehow is equally political. If that is your assertion. Which I believe.

And logically pointless. The argument you are making is very like this Nursery Rhyme--
maybe a kind of a reductio ad absurdum:

For the want of a nail a horseshoe was lost
For the want of a horseshoe a rider was lost
For the want of a rider the skirmish was lost
For the loss of the skirmish the battle was lost
For the loss of a battle the war was lost
For the loss of the war a kingdom was lost

 

[russ_watters]

This is the kind of politically-correct statements I have a problem with. Well-presented stats that leads us in the direction that Covid is the important factor here. But I'm sure someone can build up the same kind of statistics from the smoking point of view and end it with:

Can old age be an acceptable cause of death? Following the same objective way of analyzing statistics like you did, it seems to be.

I'd much rather see you actually dig into the stats and point to the numbers than just say you're sure it can be done (and even implying you've done it when you haven't). Because otherwise you're just handwaving away the statistical analysis and replacing it with an un-substantiated opinion, as if the two conclusions are equally valid. They aren't.

 

[Vanadium 50]

Consider the case where out of 521 deaths, 10 have disease X but not Y, 10 have Y but not X, 1 has neither and 500 have both. Do you agree this is a possible outcome? If not, why not?

Do you agree that in this situation, your chances of dying of either disease are not independent of having the other? If not, why not?

Do you agree that this situation can come about without even knowing who "really died of X" and who "really died of Y"?

 

[jack action]

Consider the case where out of 521 deaths, 10 have disease X but not Y, 10 have Y but not X, 1 has neither and 500 have both. Do you agree this is a possible outcome? If not, why not?

Do you agree that in this situation, your chances of dying of either disease are not independent of having the other? If not, why not?

Do you agree that this situation can come about without even knowing who "really died of X" and who "really died of Y"?

Agree. Agree. Agree.

Consider 521 lives. Out of them there will be 521 deaths, regardless of the cause. Here is a graph representing death occurrence vs age (blue line being the median):

Regardless of the cause, can we agree something is happening at around age 86? Doesn't this give a meaning to 'old age', whatever that is? Or should it be ignored all together?

Trying to assert that we are 'over-attributing' deaths to Covid-19

It is not only about Covid. In the OP, there is also smoking. Can we say that someone who died at 85, died of smoking? It took 65 years of smoking to kill him? Or was it just natural organ failure that happens to anyone in their eighties?

 

[Averagesupernova]

@jack action to me your position is very irresponsible. Yes we can all agree that people with health problems and older people are at a greater risk from Covid, or for that matter any illness. So where are we supposed to draw the line? I have known people who lived to over 100 and actually got a lot of enjoyment out of life well up to the end. Had those people gotten Covid I'm pretty sure their lives would have been cut short based on what I recently saw happen to an otherwise healthy 90 year old who will be buried tomorrow. It looks to me as if you are saying old people just don't matter.
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Now from the legal end of things, messing with what is a cause of death is a very slippery slope. A hemophiliac gets shot in the leg and dies where a non hemophiliac would have lived. Can the shooter now not be charged with murder?

 

[Astronuc]

It is not only about Covid. In the OP, there is also smoking. Can we say that someone who died at 85, died of smoking? It took 65 years of smoking to kill him? Or was it just natural organ failure that happens to anyone in their eighties?

It could have been influenza, or pneumonia, or some other infection, for which the condition of the lungs (from smoking) would be a complication, precursor, or comorbidity. Based on limited reports I've read in the media, comorbidities are included with the cause of death, whether COVID-19, influenza, pneumonia, or whatever. I don't know if COVID-19 is treated different, as it is a novel infection compared to influenza or pneumonia, which often occurs.

My grandfather lived to 103.5 and was finally let go after his third pulmonary infection. Ostensibly, he died of natural causes, as his body had lasted as long as it could. Had he survived his third infection, which would have been extraordinary, he probably would have been bedridden, which he did not want. So in the end, the family and doctors honored his DNR as he wished.

 

[russ_watters]

Regardless of the cause, can we agree something is happening at around age 86? Doesn't this give a meaning to 'old age', whatever that is?

Yes, 'dying of old age' is a real thing -- it's just not very specific. The human body has a lot of parts that deteriorate with age, mileage or misuse, and it is usually possible to pinpoint the one that went bad to directly cause the death. My grandfather died at 94 due to congestive heart failure, which is basically just a more specific and scientific way of saying that he was old, so his heart stopped.

It is not only about Covid. In the OP, there is also smoking. Can we say that someone who died at 85, died of smoking? It took 65 years of smoking to kill him? Or was it just natural organ failure that happens to anyone in their eighties?

Smoking doesn't kill you directly, it causes damage to your body, which then kills you. So you wouldn't say someone "died of smoking", you'd say they died of emphysema or lung cancer, or whatever. These things look a lot different from "natural organ failure" -- which is also vague and usually can be described more specifically.

You do agree that there's value in understanding the specifics, don't you? If someone tells you "my car died so I got rid of it", don't you want to know more specifically what happened?

 

[russ_watters]

Back to this scenario:

There is an old local politician who died today. He was 85 years-old. He caught Covid in his nursing home, it rapidly escalated and he died of complications (in around 24h).

Here's the thing: he already had a pulmonary condition (the reporter did not specified). He was an avid smoker all of his life until he quit at 82 years-old.

Should his death be attributed to smoking or to Covid? Or maybe just simply of old age?

I have an aunt in a similar situation. She's 80, smoked most of her life, is on supplemental oxygen and often uses a wheelchair if she has to go somewhere more than 20' away. If she gets anything more than a mild case of COVID, she'll probably die. But her life expectancy at this point is probably no more than a year anyway, right? Well, maybe and maybe not -- she's been on that supplemental oxygen and using a wheelchair for something like 5 years. It's a crapshoot at this point.

It's impossible to tell or predict for any individual just how much of their life COVID took or could take. Statistics is the only way to analyze it.

 

[Ygggdrasil]

This is the kind of politically-correct statements I have a problem with. Well-presented stats that leads us in the direction that Covid is the important factor here. But I'm sure someone can build up the same kind of statistics from the smoking point of view and end it with:

The health conditions that pre-dispose smoking patients to greater mortality do not come close to explaining the observed mortality of the bad habit.

My argument was based on statistics about life expectancy. For smoking, the statistics make a very clear argument as well: life expectancy of smokers is ~10 years shorter than that of non-smokers.

The most common age for a human to die: 86. Half of the people on this Earth right now, won't go over 80. Dying at 85? Pretty much a normal outcome (dare I say an achievement?), no matter what you die of. Dying of old age.

I can see though causes of death that are not related to age: Arrow through your heart, drinking a glass of ammonia, a 10-stories free fall. No matter your age, the outcome is more or less similar for anyone. Even then, an 80 year-old person that mix up the brake and gas pedals and die in a car crash can still be linked to old age. Something he would have never done when he was 30.

As other's have said, for any single individual, it's hard to say what the exact cause of death was. This, however, does not make it impossible to count the number of deaths associated with a particular cause.

Consider as an example a coin flipping contest where a cheater has managed to sneak in a weighted coin that flips head 75% of the time (versus 50%). You face off against him and lose. Did you lose because he had a weighted coin? You would have had a 50% chance of losing to him if he were using a fair coin, so it's not guaranteed that you would have won if he weren't cheating. However, if the cheater plays 100 matches, you could pretty confidently estimate that he won 25 more matches than he should have (but not be able to point out which 25 matches he won unfairly). This is why statistical and probabilistic thinking is important for approaching these types of questions.

In a similar way, we can look at statistics to estimate the number of deaths we can associate with particular causes. For example, if you compare the average number of deaths (from all causes) from 2020 from the average number of deaths from past few years, you will see that there have been many more deaths in 2020 compared with previous years. Now, not all of these excess deaths are due to COVID-19, but these statistics provide a good starting point for estimating the number of deaths due to COVID-19 (especially when they can be compared to other ways of estimating the number of deaths due to COVID-19).

In a similar way, by comparing the mortality observed with smokers and non-smokers, the CDC can estimate that more than 480,000 deaths per year in the US are due to smoking.

Can old age be an acceptable cause of death? Following the same objective way of analyzing statistics like you did, it seems to be.

Finally, deaths can have multiple causes. For many of the COVID-19 deaths, the deaths occurred both because the people were old and because the people had COVID-19. It's certainly true that old people with COVID-19 would have much higher survival rates if they were old people without COVID-19 or if they were young people with COVID-19. Why focus on COVID-19 as a cause rather than age? We can do thing to prevent people from getting COVID-19 whereas we currently have no way of preventing people from being old.

 

[Scott Mayers]

Couldn't it be that the cause was a weak immune system?

If someone who has hemophilia dies after bleeding to death, we don't say "cause of death: paper cut", we say hemophilia is responsible for the death.

Paper cuts happen often, most people have the capacity of recovering from it easily. If one dies from one, there is certainly something abnormal with that person.

This is where I'm lost in these categorizations.

I get the concern. I think a lot of this comes down to the practical political expediency of formal pronouncements. But the statistical comparisons using lots of metadata helps to narrow down the major contributing factors assigned (but can be incorrect in fact).

For Covid, the nature of how the quantity of deaths occurring coincide with a better likelihood of this as being justly assumed in the chaos suffices to trust the medical professions pronouncements. And given the conservative 'entreprenuer' mindset is to NOT be concerned about the nature of the pandemic for their intrinsic belief in exploiting relative weaknesses of others as per their normal business philosophy and practices, the fear of seeing restrictions placed upon them in law will tend to motivate them to intentionally deny the obvious factors that contribute to those political restrictions.

Since we cannot tell if or when one is arguing sincerely for skepticism of mortality, the best we can do is to gamble faith in the medical pronouncements rather than hold off for debate.

Note I am assuming you have motive to question this even though this may not be the case? I too have asked the 'how' of medical determinations given these too can (and likely do) get abused for some political or possible economic motivations of those who bias favor of some particular cause in light of potential indeterminate realities when looking at this logically and without those biases. At least, with respect to the dead, they can no longer care yet complain about faulty diagnosis. But what other options could you propose to improve accuracy of the declarations?

 

[jack action]

But what other options could you propose to improve accuracy of the declarations?

I wish we were presented with probabilities, which is what science can only do in such cases. And I wish, after being informed, we respect the decisions of the individuals, which would be based on this knowledge, but also on their particular cases which can rely on so many other sources of information.

For example, if I meet my grandmother, there is a probability that she will get Covid (What is it? Science may gave me an answer). This probability will vary according to a lot of factors (How many people do I usually meet? Do I wear a mask?, Did I wash my hands? Again science may be able to evaluate this).

But if I don't visit her, there is also a probability she'll get depressed, maybe even have suicidal tendencies (science cannot do much here, at least as in a general case point of view). This is an individual case where both probabilities (getting Covid vs suicide) must be confronted. I know my grandmother and I can compare those probabilities and make a decision. Anyone can, you don't need to be a scientist to do that. The key to make a good decision is to be well informed. Still, it is not a guarantee of the outcome.

But right now, we are presented with probabilities disguised as facts: Do this you get Covid, do that you don't. And we punish people who don't do the 'right' thing. Right now, where I live, the numbers are slightly going up and people are asking about the Holidays: How many parties can we have? How many people? Can grandma come? And for the last few days, politicians went from "4 days of party allowed" to "2 parties max within those 4 days", and now it looks like it might get more strict. And people are frustrated at it: "Tell us what it is!" But they can't! It's scientifically impossible!

Because the true answer is: No meeting other people, no Covid transmission. From there on, the more people you meet, the more chance Covid will be transmitted (maybe science could put numbers on those probabilities). That is the only valid info. There are no "10 people is OK, but 11 is too much."

I hate that statistics & probabilities (S&P) are presented as indisputable facts when it is not. I also hate the fact that it is not made clear that S&P is only part of science, and the weak part of science, should I add. And the more you look for blame on people who don't 'gamble' the same way as scientists do, the more you have conspiracy theories and people losing faith in science. This is my greatest fear from all of this Covid experience: People distrusting science a little bit more. What do you guys think about that? Do you see a link between the raise of conspiracy theories and the use of science for micro-managing personal life decisions?

And I took Covid here as an example, but smoking is another great example. It is this confrontation of those statements usually presented as simple facts that I wanted to discuss in this thread.

 

[Averagesupernova]

@jack action there are a handful of things to pick out of your last post but the first thing that comes to mind is that your post does not deal with your original concern of what is the cause of death. I think that had been covered fairly well. No matter how poor the choices an individual has made in the past concerning their health, the straw that breaks the camel's back is considered the cause of death. Other things attribute to it, but that doesn't mean we can simply pick one of them instead. To do so opens up a whole new can of worms as I pointed out in my last post about a would be or not murder charge.
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I also think the suicidal thing with Grandma is a bit of a stretch. The fact that granny may take a bottle of pills because she can't see X family member(s) has far less reaching consequences than if someone gives her Covid and she croaks but not after giving Covid to other people in the community she lives in. Apparently this level of personal responsibility escapes a large segment of society. The inability to see how one's own actions affects others on a large scale compared to only affecting said individual's small world illustrates a very clear picture of immaturity, greed and self centeredness.

 

[DaveE]

This is why I hate most philosophical arguments. MDs, MEs, coroners, etc. are responsible for describing, as accurately as they can, why someone died. That is all. Yes, they could make an error. Yes, it could be complicated, even without dumb-#$@ philosophical questions tacked on.

Sorry to interrupt, y'all may continue without me.

Here is a pretty good description of what goes into a death certificate.
http://publichealth.lacounty.gov/wwwfiles/ph/media/media/rx-may2014.pdf

 

[hutchphd]

@jack action what is your point?
The presentation of simple criteria for complicated questions is not perfect, but if you have a better idea put it forward.
I am a ~70 year old guy with a few age related concerns. If I get COVID 19 and die in 4 weeks the cause of death is clear. Even though there is a possibility I could stroke out in six weeks regardless.

Cause of death: COVID-19 but he might have had a stroke soon...

Also whinging that public health determinations having definite targets represent a form of "political correctness" seems more than wrong. From where I sit they represent the best efforts by dedicated professionals to make public communications that help keep me from being intubated.

 

[russ_watters]

I wish we were presented with probabilities, which is what science can only do in such cases. And I wish, after being informed, we respect the decisions of the individuals, which would be based on this knowledge, but also on their particular cases which can rely on so many other sources of information.

For example, if I meet my grandmother...

Here's the thing: Someone in their 80s might figure they are likely to be able to celebrate more Thanksgivings if they attended this one than if they skipped it, and decide to go. And they'd be right in their logic. Probably by a couple of orders of magnitude.

But it can't work that way, and I think you already understand why, since we've discussed it before. Getting or not getting the virus is not an individual choice, so the mitigation efforts can't be either. Your grandmother isn't the only one affected by her choice. In a very real sense, your grandmother and others like her making that choice will rob others of future Thanksgivings. That's why these policies have to be made by governments, not be left to individual choices.

 

[bobob]

If someone who has hemophilia dies after bleeding to death, we don't say "cause of death: paper cut", we say hemophilia is responsible for the death.

I don't think that would be correct. The proximate cause of death is the paper cut and that could be legally important. Imgine that you know someone with hemophilia and you decide to kill him by giving him a paper cut. I don't think you could be charged with the murder unless the cause of death was ruled to be bleeding to death due to the paper cut and that you knew it would kill him due to his hemophilia. If the cause of death were ruled to be hemophilia, you couldn't be held responsible for that. Hemophilia itself is not a cause of death, bleeding until you lose enough blood to die is. The bleeding would be caused by the paper cut.

 

[jack action]

But it can't work that way, and I think you already understand why, since we've discussed it before. Getting or not getting the virus is not an individual choice, so the mitigation efforts can't be either. Your grandmother isn't the only one affected by her choice. In a very real sense, your grandmother and others like her making that choice will rob others of future Thanksgivings. That's why these policies have to be made by governments, not be left to individual choices.

So if an 80 year-old person is in house on fire, we shouldn't go and get her out, because the Covid policy of confinement say we shouldn't for the greater good? The point is that you cannot have a policy that covers every possible cases. People in the action must used their better judgement according to the probability of something bad happening. Yes, it can be acceptable to put the Covid policy aside. And if people are well informed of what is happening, you don't need a policy, people can make the right decisions on their own.

And I'm sure that anyone who is angrily arguing in this thread would change their mind if the well being of one of their children or grand children would be in jeopardy because of a Covid policy. Between a ''someone may get Covid' vs a 'my kid will certainly get...', kids will come first. This is just a good probability analysis. And I'm sure their lives won't have to be on the line, just losing a job, a house, mental health or schooling problems, or the like could be sufficient. No one will make me believe someone will sacrifice their kids for the 'greater good'. And if they are ready to do that, yes, I'm judging them. Don't do that.

 

[russ_watters]

So if an 80 year-old person is in house on fire, we shouldn't go and get her out, because the Covid policy of confinement say we shouldn't for the greater good?

That's nonsense, Jack. It doesn't work that way and I'm sure you know that.

And I'm sure that anyone who is angrily arguing in this thread...

I've been very dispassionate in this thread, Jack (in large part because I get and often agree with a strong individual liberty position), but I suggest based on the above ridiculous scenario that you aren't.

 

[jack action]

That's nonsense, Jack. It doesn't work that way [...]

Agree. That is the point.

I've been very dispassionate in this thread

The comment wasn't aimed at you.

 

[russ_watters]

Agree. That is the point.

Then I guess your point is lost on me. I don't see how a nonsensical example can help us understand how real decisions are made. It looks like a really bad stawman to me, not a useful thought exercise/example.