One of the most important methods of mortality surveillance is through monitoring causes of death as reported on death certificates.
Death certificates are registered for every death occurring in the United States, which helps provide a complete picture of mortality trends and data nationwide. The death certificate includes essential information about the deceased and the cause(s) and circumstance(s) of death. Appropriate completion of death certificates yields accurate and reliable data for
use in epidemiologic analyses and public health reporting.1 In addition, death certificates are vital for settling estates, closing bank accounts, determining insurance and pension benefits, and providing evidence for court, if needed.
In California, all deaths must be registered on “the prescribed certificate forms” according to Health and Safety Code 102100. California’s Uniform Determination of Death Act states the following:
An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.2
But, as important as the death certificate document is, many physicians are not aware of their duties or responsibilities when called upon to certify the death of a patient, in part due to the lack of prior training in medical school or residency training programs and/or the infrequency of opportunities to certify a patient death. Because of this lack of experience, certifying death can be an unfamiliar process.
The problem is further exacerbated because physicians are concerned about their liability associated with completing a death certificate if they had very limited engagement with the patient, or if they had not seen the patient in an exceptionally long time. Physicians may not be aware of the patient’s most recent health status, or if the patient’s condition had changed significantly since their last encounter. As a result, physicians can be uncomfortable completing the death certificate because they are apprehensive about providing the wrong cause of death, which may have negative implications down the road and impact other parties and circumstances.
Certifying a death is also time consuming and demanding. California Health and Safety Code specifies that the doctor who last attended to the deceased person must sign the death certificate within 15 hours, stating the date, time, and cause of death. The coroner or funeral home expects a quick turnaround, as delays can cause problems with disposition of the deceased’s body, preparation for burial or cremation, etc.
Most physicians, excluding those in some medical specialties, will at some point in their careers complete a death certificate. Given this likelihood, it is important to keep in mind the guidelines and risk management strategies when called upon to certify a death as the physician of record, even if you may have engaged with the patient on a very limited basis or have not seen the patient in some time.
Typically, the funeral home director initiates the death registration process by gathering personal and demographic information about the deceased. A coroner will complete the medical section of the certificate if the death was unexpected, unexplained, or resulting from an injury, suspected poisoning, or a public health threat. In most cases, an attending physician is responsible for determining cause of death.
Consider the following when asked to complete a death certificate as an attending physician or physician of record:
Complete the death certificate as requested. In many cases, you may have no reservations about asserting the primary and underlying causes of death based on your familiarity and recent or ongoing engagement with the patient.
If you have reservations about accurately indicating the cause of death, review the deceased’s medical record and try to obtain additional information from the funeral director, the deceased’s family, or a coroner or medical examiner (in the event the request comes from a coroner).
Determine if there is another physician who may be more qualified to complete the death certificate, depending on individual patient factors.
In cases where a definite determination of death cannot be made, but the cause of death is suspected or likely (e.g., the circumstances are compelling within a reasonable degree of certainty), it is acceptable to report the cause of death as “probable” or “presumed.” In these instances, certifiers should use their best clinical judgment in determining cause of death. This has often been a problem when COVID-19 was the probable or presumed cause of death with patients who had other complications or comorbidities.
Resist the temptation to refuse to complete a death certificate. Other parties are depending on the completion of the death certificate before important and timely decisions and arrangements can be made regarding the deceased and the disposition of their remains.
In conclusion, the CDC Physician’s Handbook on Medical Certification of Death addresses common problems in death certification and provides a sound approach to completing death certificates:
The certifier should think through the causes (of death) about which he/she is confident, and what possible etiologies could have resulted in these conditions. The certifier should select the causes that are suspected to have been involved and use words such as ‘‘probable’’ or ‘‘presumed’’ to indicate that the description provided is not completely certain. If the initiating condition reported on the death certificate could have arisen from a preexisting condition, but the certifier cannot determine the etiology, he/she should state that the etiology is unknown, undetermined, or unspecified, so it is clear that the certifier did not have enough information to provide even a qualified etiology. Reporting a cause of death as unknown should be a last resort.3
Brad Dunkin is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to BDunkin@CAPphysicians.com
Additional Resources:
Death Autopsies and Anatomical Gifts (Chapter 14), California Hospital Association Consent Manual 2019
Determination and Pronouncement of Death and Death Certificates, California Physicians Legal Handbook, Document #3402, January 2022
Death Certification: A Final Service to Your Patient, Chicago Medicine, 2014
Creating an Accurate Cause of Death Statement on a Death Certificate, LA County Department of Public Health, Volume 5, Number 5, May 2014
Completing and Signing the Death Certificate, American Family Physician, 2004. American Academy of Family Physicians
Death Certificates: Let’s Get it Right, American Family Physician, 2005, American Academy of Family Physicians
Instructions for Completing the Cause-of-Death Section of the Death Certificate, US Department of Health and Human Services, 2004
References:
1Guidance for Certifying Deaths Due to Coronavirus Disease 2019 (Covid-19), US Department of Health and Human Services, Report #3, April 2020
2California Health and Safety Code Section 7180
3Physician’s Handbook on Medical Certification of Death, Centers for Disease Control 2003 https://www.cdc.gov/nchs/data/misc/hb_cod.pdf