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array:24 [ "pii" => "S2387020622001231" "issn" => "23870206" "doi" => "10.1016/j.medcle.2021.10.011" "estado" => "S300" "fechaPublicacion" => "2022-04-08" "aid" => "5860" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2021" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Med Clin. 2022;158:333-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775321006709" "issn" => "00257753" "doi" => "10.1016/j.medcli.2021.10.016" "estado" => "S300" "fechaPublicacion" => "2022-04-08" "aid" => "5860" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2022;158:333-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo especial</span>" "titulo" => "La certificación de la muerte por eutanasia" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "333" "paginaFinal" => "335" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Death certification in euthanasia" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3036 "Ancho" => 2167 "Tamanyo" => 842720 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ejemplos de certificación de la causa de la muerte en el CMD en los casos de muerte por eutanasia. En el ejemplo A se supone que la «enfermedad grave e incurable» o el «padecimiento grave, crónico e imposibilitante» que motivó la solicitud de la prestación de la ayuda para morir fue una esclerosis lateral amiotrófica, mientras que en el ejemplo B lo fue una demencia por cuerpos de Lewy (manifestado previamente en un documento de instrucciones previas).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carles Martin-Fumadó, Eneko Barbería, Josep Arimany-Manso" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Carles" "apellidos" => "Martin-Fumadó" ] 1 => array:2 [ "nombre" => "Eneko" "apellidos" => "Barbería" ] 2 => array:2 [ "nombre" => "Josep" "apellidos" => "Arimany-Manso" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020622001231" "doi" => "10.1016/j.medcle.2021.10.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622001231?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775321006709?idApp=UINPBA00004N" "url" => "/00257753/0000015800000007/v1_202204120957/S0025775321006709/v1_202204120957/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2387020622001139" "issn" => "23870206" "doi" => "10.1016/j.medcle.2021.11.004" "estado" => "S300" "fechaPublicacion" => "2022-04-08" "aid" => "5880" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Med Clin. 2022;158:336-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical report</span>" "titulo" => "Clinical characteristics of children hospitalized for COVID-19" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "336" "paginaFinal" => "339" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Características clínicas de los niños hospitalizados por COVID-19" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rosa María Luz Romero, Marta Illán Ramos, Arantxa Berzosa Sánchez, Belén Joyanes Abancens, Elvira Baos Muñoz, José Tomás Ramos Amador" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Rosa María" "apellidos" => "Luz Romero" ] 1 => array:2 [ "nombre" => "Marta" "apellidos" => "Illán Ramos" ] 2 => array:2 [ "nombre" => "Arantxa" "apellidos" => "Berzosa Sánchez" ] 3 => array:2 [ "nombre" => "Belén" "apellidos" => "Joyanes Abancens" ] 4 => array:2 [ "nombre" => "Elvira" "apellidos" => "Baos Muñoz" ] 5 => array:2 [ "nombre" => "José Tomás" "apellidos" => "Ramos Amador" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622001139?idApp=UINPBA00004N" "url" => "/23870206/0000015800000007/v1_202205040609/S2387020622001139/v1_202205040609/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020622001218" "issn" => "23870206" "doi" => "10.1016/j.medcle.2021.10.010" "estado" => "S300" "fechaPublicacion" => "2022-04-08" "aid" => "5835" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 0 "subdocumento" => "rev" "cita" => "Med Clin. 2022;158:327-32" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Chimeric antigen receptor T-cell (CAR-T) therapy in patients with aggressive B-cell lymphomas. Current outlook after a decade of treatment" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "327" "paginaFinal" => "332" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Terapia con linfocitos T con receptor de antígeno quimérico (CAR-T) en pacientes con linfoma de célula B agresivos. Perspectiva actual tras una década de tratamiento" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1162 "Ancho" => 2833 "Tamanyo" => 238143 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical trials with CAR T-cell therapy for patients with aggressive non-Hodgkin's lymphomas according to the therapeutic line.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">1: first-line of treatment; 2: second-line of treatment; 3: third-line of treatment; CAR T-cells: Chimeric Antigen Receptor T-cells; CT: chemotherapy; R-CHOP: rituximab, cyclophosphamide, doxorubicin hydrochloride (hydroxydaunomycin), vincristine sulfate (oncovin), and prednisone; R-GEMOX: rituximab, gemcitabine/oxaliplatin; R-Pola-Benda: rituximab, polatuzumab, bendamustine.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">*Clinical trials available at <span class="elsevierStyleItalic">clinicaltrials.gov</span>: ZUMA-12, NCT03761056; Transcend World, NCT03484702; ZUMA-7, NCT03391466; BELINDA, NCT03570892; TRANSFORM, NCT03575351; PILOT, NCT03483103; ALYCANTE, NCT04531046; TIGER, NCT04161118; PORTIA, NCT03630159; ZUMA-6, NCT02926833; PLATFORM, NCT03310619.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eva Catalá, Gloria Iacoboni, Pere Barba" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Eva" "apellidos" => "Catalá" ] 1 => array:2 [ "nombre" => "Gloria" "apellidos" => "Iacoboni" ] 2 => array:2 [ "nombre" => "Pere" "apellidos" => "Barba" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775321006345" "doi" => "10.1016/j.medcli.2021.10.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775321006345?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622001218?idApp=UINPBA00004N" "url" => "/23870206/0000015800000007/v1_202205040609/S2387020622001218/v1_202205040609/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Death certification in euthanasia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "333" "paginaFinal" => "335" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carles Martin-Fumadó, Eneko Barbería, Josep Arimany-Manso" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Carles" "apellidos" => "Martin-Fumadó" "email" => array:1 [ 0 => "carles.martin@comb.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Eneko" "apellidos" => "Barbería" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Josep" "apellidos" => "Arimany-Manso" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Área de Praxis, Servicio de Responsabilidad Profesional, Colegio oficial de Médicos de Barcelona, Consejo de Colegios de Médicos de Catalunya, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institut de Medicina Legal i Ciències Forenses de Catalunya, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Comisión Nacional de la Especialidad de Medicina Legal y Forense, Consejo Nacional de Especialidades en Ciencias de la Salud, Ministerio de Sanidad, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La certificación de la muerte por eutanasia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3036 "Ancho" => 2167 "Tamanyo" => 631281 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Examples of cause of death certification in the MCCD in cases of death by euthanasia. In example A it is assumed that the “serious and incurable disease” or “serious, chronic and disabling condition” that motivated the application for aid-in-dying was amyotrophic lateral sclerosis, while in example B it was Lewy body dementia (previously stated in an advance healthcare directive document).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The Organic Law 3/2021 of 24th March on the regulation of euthanasia<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> came into force on 25th June 2021, making Spain the sixth country in the world to have a law regulating euthanasia.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Law 3/2021 aims to provide a legal response, recognising the right of every person, in compliance with the principle of patient autonomy, to request and receive the provision of assistance in dying.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, its implementation has raised a number of new issues, some of them of a medical-legal nature, which need to be addressed. Among these, the certification of death in situations where euthanasia has been applied stands out for its essentially practical character.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Law 3/2021 includes a first additional provision: <span class="elsevierStyleItalic">On the legal consideration of death</span>, which establishes, similarly to what happens in other countries,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> that “<span class="elsevierStyleItalic">Death as a consequence of the provision of assistance in dying shall be legally considered as a natural death for all purposes regardless of the coding applied to it</span>”. However, Law 3/2021 does not make any proposal to complete the medical certificate of cause of death (MCCD). It is in the <span class="elsevierStyleItalic">Manual of good practice</span> prepared by a Technical Committee of the Ministry of Health,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> where Section 5.4. deals with the death certificate and establishes both the obligation of the responsible doctor to prepare it and what its content should be. Specifically, it includes:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">As immediate cause: provision of aid-in-dying.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">As the initial or underlying cause: the underlying condition leading to a “serious and incurable disease” or a “serious, chronic and disabling condition”.</p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">Surely, the aim of such a recommendation is, in line with the rest of Law 3/2021 and in accordance with the principles of the Mortality Reference Group of the World Health Organisation, to avoid additional suffering for the relatives in the process of death registration, for which it is necessary to issue a MCCD.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> From a medical-legal point of view, the application of external means to produce death, even in a very specific context and conditions as established by the Law, would have to be classified as a violent death from the point of view of its medico-legal aetiology.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> If it had been considered as such, the Criminal Procedure Act would have to be applied, which would have resulted in the prosecution and the practice of a forensic autopsy to establish the causes and circumstances of death. However, the law aims to avoid the legal prosecution of these deaths, taking a more humane approach by expediting the legal procedures for registration and burial.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Thus, due to the consideration of natural death, once the aid-in-dying benefit has been exercised, the procedure for the registration of the death in the Civil Register must be, as in all cases of natural death, by means of a MCCD.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The completion of the MCCD, as a medical-legal document, is a medical act of great legal significance, as it allows the registration of the person as deceased in the Civil Registry and his/her subsequent burial. Moreover, it has a major health impact, as mortality is one of the parameters used in the design and assessment of health policies.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There is evidence that the completion of the MCCD in daily practice raises doubts.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> For this reason, it is important that efforts are made to provide adequate training for the professionals responsible for its completion,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> as well as to establish recommendations for cases that are expected to be difficult, as was the case with the COVID-19<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> pandemic and as is expected to be done soon by the Organización Médica Colegial and in ICD-11, which will include specific coding for death by euthanasia, both of which are still to be specified at the time of writing this article. After the approval of the euthanasia law in 2002 in Belgium, which has been considered an essential reference for Spain with regard to euthanasia,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> the lack of clear guidelines regarding the mandatory content of the MCCD in cases of euthanasia has been pointed out as one of the main causes for the under-reporting of euthanasia cases in MCCDs.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The format of the MCCD remained unchanged and the only instruction given to physicians was that euthanasia should be recorded as natural death.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The same situation exists in Spain, so that if clear indications are not given about the mandatory nature of its completion and its content, there is a risk of high underreporting in the MCCD, which prevents the incidence of euthanasia practice from being known. On the other hand, the most widespread alternative to this type of certification is to have a specific checkbox for euthanasia, as is done in the Netherlands, and to have clearer instructions regarding the certification of this type of death, thus achieving better and higher quality certification.</p><p id="par0050" class="elsevierStylePara elsevierViewall">However, while the modification of the MCCD (also the electronic MCCD) to include a specific box for euthanasia is being studied in Spain, and as a complement to this possible modification, it is important that the professionals in charge of filling in the MCCD have clear recommendations on 3 points:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Mandatory certification.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Content of the certification (cause of death).</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Completion of the MCCD box on violent death.</p></li></ul></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Mandatory certification</span><p id="par0070" class="elsevierStylePara elsevierViewall">One of the arguments put forward for not certifying euthanasia deaths in detail is the applicant’s own privacy. In this regard, it should be recalled that the MCCD is the official document certifying the death of a person, which is intended for the authorities and official bodies, as well as for the relatives themselves. In this sense, the MCCD always contains several pieces of information that would be considered sensitive and that the doctor is required to record (it is, in fact, an exception to professional confidentiality). Since it is an official medical certificate, the reality of specific facts must be proven, such as, in this case, death by euthanasia. To do otherwise would not be good practice and would, to some extent, conceal the reality of the phenomenon for statistical purposes. Given that Law 3/2021 gives it the character of a natural death for legal purposes, its certification through a MCCD is mandatory.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Cause of death</span><p id="par0075" class="elsevierStylePara elsevierViewall">With regard to the causes of death, it is essential to state the fact that it is a death by euthanasia, as well as the illness or illnesses that have motivated the request for euthanasia. In line with the <span class="elsevierStyleItalic">Manual of Good Practices</span> of the Ministry of Health,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and in order to facilitate subsequent coding, it is recommended that, in one way or another, the word <span class="elsevierStyleItalic">euthanasia</span> or the term <span class="elsevierStyleItalic">provision of aid-in-dying should be included in</span> the immediate cause of Part I of the MCCD. In this way, it would not be considered as the basic cause of death and it is guaranteed that the basic cause is the one which led to the decision of euthanasia, as stated in Law 3/2021. This basic cause should generally coincide with the initial or underlying cause in Part I, and it is here that the underlying condition leading to a “serious and incurable disease”, or a “serious, chronic and disabling condition” must be stated (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Signs of violent death</span><p id="par0080" class="elsevierStylePara elsevierViewall">It has already been stated that Law 3/2021 expressly grants the character of natural death for legal purposes to deaths by euthanasia, despite the fact that from a medical-legal point of view it would be a violent death. For this reason, doubts may arise as to whether and how Part I, which expressly asks whether there is evidence of a violent death, should be filled in. If filled out in the affirmative, it could result in the death being prosecuted. However, this is precisely what the additional provision of Law 3/2021 seeks to avoid, so the recommendation should be either to leave this section blank or to tick “No”.</p><p id="par0085" class="elsevierStylePara elsevierViewall">This is without prejudice to the fact that any death can be prosecuted if the corresponding complaint is filed and the corresponding judge or investigating magistrate admits it for processing. In such a case, by court order, the investigation of the cause and circumstances of death would be carried out by means of an autopsy at the corresponding Institute of Forensic Medicine.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that there have been no external sources of funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Mandatory certification" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Cause of death" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Signs of violent death" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 4 => array:2 [ "identificador" => "xack599505" "titulo" => "Acknowledgements" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-07-20" "fechaAceptado" => "2021-10-05" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martin-Fumadó C, Barbería E, Arimany-Manso J. La certificación de la muerte por eutanasia. Med Clin (Barc). 2022;158:333–335.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3036 "Ancho" => 2167 "Tamanyo" => 631281 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Examples of cause of death certification in the MCCD in cases of death by euthanasia. In example A it is assumed that the “serious and incurable disease” or “serious, chronic and disabling condition” that motivated the application for aid-in-dying was amyotrophic lateral sclerosis, while in example B it was Lewy body dementia (previously stated in an advance healthcare directive document).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ley Orgánica 3/2021, de 24 de marzo, de regulación de la eutanasia. 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