What is the best way to fill out a death certificate for a patient who died after developing a methicillin-resistant Staphylococcus aureus (MRSA) infection, following a non-ST elevation myocardial infarction (non-STEMI) with stent placement, and subsequent failure to thrive?

Death Certificate Completion for NSTEMI with Subsequent MRSA Infection and Failure to Thrive

For this patient who died following NSTEMI with stent placement, complicated by MRSA groin wound infection and subsequent failure to thrive, the immediate cause of death should be documented as "Failure to Thrive" or "Adult Failure to Thrive," with the underlying causes listed sequentially as: MRSA wound infection (groin), complications of percutaneous coronary intervention, and atherosclerotic coronary artery disease/Non-ST-Elevation Myocardial Infarction. 1

Recommended Death Certificate Structure

Part I - Chain of Events Leading to Death

Line (a) - Immediate Cause of Death:

• Document: "Failure to Thrive" or "Adult Failure to Thrive" or "Inanition"
• This represents the terminal condition that directly resulted in death (patient stopped eating and died within one week) 1

Line (b) - Due to (or as a consequence of):

• Document: "Methicillin-Resistant Staphylococcus aureus (MRSA) Wound Infection, Groin"
• This represents the infectious complication that precipitated the decline 1, 2

Line (c) - Due to (or as a consequence of):

• Document: "Complications of Percutaneous Coronary Intervention with Stent Placement"
• The groin infection was a direct complication of the vascular access site from the PCI procedure 3, 4

Line (d) - Due to (or as a consequence of):

• Document: "Atherosclerotic Coronary Artery Disease" or "Non-ST-Elevation Myocardial Infarction"
• This represents the underlying cardiovascular disease that necessitated the intervention 1, 3

Part II - Other Significant Conditions

Document any contributing conditions that were present but not part of the direct causal chain:

• Diabetes mellitus (if present)
• Hypertension (if present)
• Chronic kidney disease (if present)
• Other cardiovascular risk factors 1, 3

Rationale for This Approach

The causal sequence must reflect the actual clinical progression: The patient's death occurred after developing failure to thrive following MRSA infection, which itself was a complication of the stent procedure performed for NSTEMI 1. This creates a clear chain of causation from the underlying coronary disease through the intervention, its complication, and the terminal decline.

MRSA infection of vascular access sites is a recognized complication of PCI: Groin wound infections following femoral access for coronary intervention occur in 2-5% of cases, with Staphylococcus aureus being the most common pathogen 4. These infections carry significant morbidity and mortality, particularly in patients with recent myocardial infarction 2, 5.

Failure to thrive represents the terminal physiologic state: When an elderly or debilitated patient stops eating and experiences overall decline leading to death within days, this constitutes the immediate cause of death, even though it was precipitated by the infection 1.

Critical Documentation Points

Avoid vague terminology as the immediate cause: Do not list "cardiac arrest" or "cardiopulmonary arrest" as the immediate cause without specifying the underlying conditions that led to it 1, 6. These are mechanisms of death, not causes.

Specify the type of myocardial infarction: Clearly document "Non-ST-Elevation Myocardial Infarction" rather than just "myocardial infarction" to distinguish it from STEMI, as this affects epidemiological tracking and quality metrics 1, 3.

Include the infectious organism: Specify "Methicillin-Resistant Staphylococcus aureus (MRSA)" rather than just "wound infection," as this has important public health implications 5, 7.

Document the anatomic site of infection: Specify "groin" as the location, linking it clearly to the vascular access site from the PCI procedure 3, 4.

Common Pitfalls to Avoid

Do not list only the NSTEMI as the cause of death: While NSTEMI has a 30-day mortality rate of 4-7%, this patient survived the acute phase and died from complications that occurred a month later 1, 3. The death certificate must reflect the actual sequence of events.

Do not omit the infectious complication: MRSA infections, particularly in the setting of vascular procedures, are associated with significant mortality (28-38% at 30 days for MRSA bacteremia) and must be documented in the causal chain 2, 5, 7.

Do not reverse the causal sequence: The underlying condition (coronary artery disease/NSTEMI) should be listed last in Part I, with the most immediate cause listed first, working backward through the chain of causation 1.

Document timing appropriately: Note that death occurred approximately one month after the initial NSTEMI and one week after return to rehabilitation following treatment of the MRSA infection, as this timing is relevant for quality metrics and epidemiological tracking 1, 3.