Death certificates

Monday, September 01, 2014 12:42 PM

Physician guidelines for death certificate completion

by Leon Kelly, MD, Deputy Chief Medical Examiner El Paso County Coroner’s Office

In Colorado, death certificates can be completed only by physicians or coroners. Despite the fact that every single patient we care for will eventually require a death certificate, almost no time is spent during medical school or post-graduate training teaching physicians how to complete this task. For many of us, completing the death certificate will be the final act in the care of our patient.

The caring physician will be asked to complete a death certificate on cases not reportable to the coroner or cases where the coroner has performed an investigation and deemed it not to require a forensic autopsy. Ideally, the clinician who has the most first-hand knowledge of the patient will be available, but statute allows for any physician with facts concerning the decedent’s health and the circumstances of the death to complete the death certificate. This may be a practice partner, sub-specialist or the chief medical officer of the facility.

The burden of proof for the information on the death certificate is “a reasonable degree of medical probability” or, in other words, “more likely than not.” In many cases, it will be impossible to know why a person has died, but our understanding of pathophysiology and pure common sense will allow us to reasonably surmise the underlying disease state or states that led to death. For cases where one can reasonably conclude a cause of death but medical investigation was limited or incomplete the term “probable” is appropriate.

Cause of death statement
The cause of death – defined as the pathophysiologic derangement or disease/injury state that led to death – is recorded in part one of the death certificate. There may be an identifiable “immediate cause of death,” which is the final disease process that ends life. But perhaps more importantly, there may also be an “underlying cause of death” – the disease or injury states that initiated the physiologic derangement and downward spiral that ultimately resulted in death. The goal is to be as etiologically specific as to both the immediate and underlying causes of death. The statements can be recorded as a single disease state on the first line or a series of disease states with the most immediate on the first line and the preceding disease states below it. The underlying disease state will be listed last, as it is the derangement that began the process. This is known as the “but for” principle, as in “but for this event all subsequent chain of events would not have occurred and the individual would not have died at the time and place they did.” In most cases the underlying cause of death will determine the manner.

Mechanistic terminal events add little value to the cause of death statement. These include cardiac arrest, asystole, cardiopulmonary arrest, multi-organ system failure and hyperkalemia. These events have a multitude of underlying causes and give no hint as to the etiology of the cause of death.

Manner of death
If the cause of death is the “why” are they dead (e.g. gunshot wound), then the manner of death is the “how” are they dead (e.g. suicide). The manner is a checkbox that informs the reader of the circumstances surrounding the death and consists of natural (disease or aging process), accident (sudden, unexpected external event), homicide (volitional act by another meant to cause harm or fear), suicide (volitional self-inflicted act meant to cause harm), or undetermined (unknown cause of death or more than one possible manner). Any non-natural event or injury including drug intoxication causing or contributing to death will result in a non-natural manner selection. Non-forensic pathologists should never sign a death certificate with any manner other than “natural” unless instructed to do so by the coroner.

Part two of the death certificate references other significant conditions that may have contributed to the disease state or caused worsening of the health of the individual while not directly in the chain of events listed in Part 1. It’s important to list any and all factors that you feel may have hastened the decline of the patient. Any non-natural events placed in Part 2 should result in a non-natural manner determination and should be reported to the coroner.

The “interval between onset and death” is to be recorded as accurately as possible, but if an exact duration is unknown this can be listed in a general terms such as seconds, days or years.

Key elements to death certificate completion

The death certificate is a critical public health tool with a value limited to the clarity and completeness of the information recorded on it. Here is a summary of key elements:

• Record the cause of death as etiologically specific as possible.
• Use a sequential description of the chain of physiological disturbances.
• Be as descriptive as possible.
• Do not report mechanistic terminal events.
• Do not use abbreviations.
• Have a low threshold for the inclusion of non-natural events.
• Call your coroner if considering a non-natural event causing or contributing to death.