The Death Certificate

Death certificates are required by law. They are needed for burial permits, life insurance claims, settlement of estates, and claims for survivorship benefits. The death certificate requirement also serves crime detection. The public interest in medical certification of the cause of death reflects the demand for reliable morbidity data that rarely are available in any other way. Death certificates help to locate cases for clinical investigators and aid in follow-up studies. Proper completion of death certificates requires a clear understanding of the organization of these documents and the differences—as defined in Chapter 2 and below—between causes of death, mechanism of death (mode of dying), and manner of death (3).

The determination of the cause of death may be an extremely difficult task. Certain rules and regulations must be observed to secure reasonable and comparable data. The mechanisms causing a death may be so complex that the provisions of the death certificate may be insufficient for adequate documentation, in proper relationship, of the events that led to death. Nevertheless, the law must be satisfied. The physician, the biostatistician, and the judge each may accept as correct a different cause of death and thus, three types of causes of death could be distinguished: scientific, statistical, and legal (4).

The death certificates in the United States are based on the "International Form of Medical Certificate of Cause of Death." The following entries are used:

1. Immediate Cause of Death, defined as the disease, injury of complication that directly led to death. This may be the only entry, for example, if death occurred immediately after a gunshot injury;

2. Due to This entry was provided for the intervening causes of death, defined as conditions that contributed to death and were the result of the underlying cause. An example would be venous thromboses caused by a carcinoma of the pancreas (underlying cause) and leading to massive pulmonary embolism (immediate cause);

3. Dueto This entry is provided for the underlying cause of death, defined as the disease or injury that initiated the train of morbid events resulting in death, or the circumstances or violence that produced the fatal injury (for an example, see #2);

4. Other significant conditions. Diseases and conditions are recorded here that appear important for statistical and other purposes but that do not fit into the chain defined under #1 to #3. An example would be "carcinoma of breast with metastases" in a women who died of multiple injuries in an automobile accident.

It should be noted that the death certificate is not primarily designed for entries describing the mechanism of death, as defined in Chapter 2. Thus, "cardiorespiratory arrest" or "renal failure" represent mechanisms of death. Although terms describing mechanisms of death are found more frequently in death certificates than any other diagnosis, they should not be entered routinely. These diagnoses are acceptable, however, if they are reported together with an etiologically specific underlying cause or if some other criteria are met (5). Generally, the mechanism of death will simply be ignored by the health authorities, as long as it is entered in conjunction with a valid entry, for example, "Cardiac arrest due to rheumatic mitral valvular stenosis."

In contradistinction to the mechanism of death, the death certificate provides space for the manner of death, defined as natural, accident, suicide, and homicide. Deaths as a result of suicide and homicide always are under the jurisdiction of the medical examiner or a comparable official. If a crucial investigation is pending or if the cause of death could not be determined, that also should be noted in this part of the death certificate. The designation "pending" should be used only in very rare situations, as described below under "Delayed Certification."

DEATH CERTIFICATE PROCEDURES Instructions for physicians who must determine and ascribe natural causes of death have been published by the College of American Pathologists (6). The proper use of United States death certificates had been described earlier in a Public Health Service publication (7). Every physician in the United States who is charged with certifying deaths should have the 1994 publication (ref. 6) on hand.

Death Certificates in Medicolegal Cases A United States Standard Certificate of Death is filled out. A form for medical examiners or coroners and a combined form for physicians, medical examiners, or coroners are available. The medical examiner or coroner or equivalent official is charged with filling out and signing the death certificate, or the appropriate section of it, in deaths caused by violence (homicide, suicide, or accident) and in other cases if so defined by state law. Pathologists must be familiar with the appropriate laws in the states where they practice. The correct use of medicolegal death certificates is described in a special publication of the Public Health Service (8).

Proper Completion of Death Certificates U.S. Public Health Service publications (7,8) contain the following general instructions:

• Use the current form designated by the state.

• Type all entries whenever possible. Do not use worn typewriter ribbons. If a typewriter is not used, print legibly in dark, unfading ink. Black ink gives the best copies.

• Complete all items or attach a note explaining any omissions.

• Do not make alterations or erasures.

• All signatures must be written. Rubber stamp or other facsimile signatures are not acceptable.

• Do not submit carbon copies, reproductions, or duplicates for filing. The registrar will accept originals only.

• Avoid abbreviations.

• Spell entries correctly. Verify names that sound the same, but have different spellings (Smith vs Smyth, Gail vs Gayle, Wolf vs Wolfe, etc.)

• Refer problems not covered in specific instructions to the state vital statistics office, or local registrar.

Classification and Terminology Entries should be based on "International Classification of Disease, Clinical Modification 1998" (9). Another valuable source is the American Medical Association's "Physicians' Current Procedural Terminology (cpt 98), Standard Edition" (10).

Delayed Certification Occasionally, the cause of death can be established only after further, and often time-consuming, microbiologic, chemical, or other studies. The legal requirements in such cases vary somewhat throughout the United States, but the statement on the death certificate "Pending further investigations" will be accepted in most if not all places. Local laws, customs, or arrangements determine how long a delay will be acceptable. The following guidelines were recommended by the Public Health Service (8) for delay of a definitive statement as to the cause of death:

• The term "pending" is intended to apply only to cases in which there is a reasonable expectation that an autopsy, other diagnostic procedure, or investigation may significantly change the diagnosis.

• Certification of cause of death should not be deferred merely because "all details" of a case are not available. Thus, for example, if it is clear that a patient died of "carcinoma of the stomach," reporting of the cause should not be deferred while a determination of the histologic type is being carried out. Similarly, if a death is from "influenza," there is no justification for delaying the certification because a virological test is being carried out.

• In cases where death is known to be from an injury, but the circumstances surrounding the death are not yet established, the injury should be reported immediately. The circumstances of the injury should be noted as "deferred," and a supplemental report filed.

• Lastly, the term "pending" is not intended to apply to cases in which the cause of death is in doubt, but for which no further diagnostic procedures can be carried out. In this case, the "probable" cause should be entered on the basis of the facts available and the certification made in accordance with the best judgment of the certifier.

Daylight Saving Time "Daylight Saving Time" has to be recorded on death certificates during the entire period in which daylight saving time is in effect.

WHAT HAPPENS TO THE DEATH CERTIFICATE? After the physician has completed and signed the death certificate, he turns the document over to the funeral director or local registrar. Fig. 17-1 shows the way data of the death certificate are passed on and how they are used.

CERTIFICATION PROBLEMS All problems not answered by the Physicians' Handbook on Medical Certification (7) or the Medical Examiners' and Coroners' Handbook on Death and Fetal Death Registration (8) should be referred to the vital statistics office of the state or to the local registrar. One option is to send the incomplete death certificate with a separate autopsy diagnosis and an explanatory note.

Incorrect certification of cause of death is frequent. Numerous studies have confirmed that educational efforts in this regard have had little effect. This must be considered when studies are evaluated that rely primarily on death certificate diagnoses. Even if an autopsy had been done, the death certificate often fails to reveal the most important diagnosis, for example, when a patient had carcinoma of the ovary with metastases but the death certificate states only "Heart failure due to bronchopneu-monia and recurrent pulmonary embolism."

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