Practice Alert

Cause-of-death certification: Not as easy as it seems

Author and Disclosure Information


The most challenging part

Item 32, the Cause of Death, is the most difficult item to complete accurately. It consists of two parts. Part I is a sequential list of conditions leading to the immediate cause of death and the time interval between their onset and the death. Part II is a list of other conditions contributing to the death but not directly causing death. Thinking about the death as a sequence of events and reconstructing this sequence helps classify correctly the various illnesses and conditions the decedent might have had.

Immediate cause of death. Part I, line a, is for the immediate cause of death (see Table 1). This should be a disease, complication, or injury that directly caused the death. A common error is to list a mechanism of death (for example, cardiac arrest) rather than a disease (myocardial infarction).

Specific terms are better than vague ones. For instance,“cerebral infarction” is better than “stroke.” “Escherichia coli sepsis” is better than just “sepsis.”

When cancer is the cause of death, list the primary site, cell type, cancer grade, and specific organ or lobe affected.

Avoid terms without medical meaning, such as old age or senescence.

If additional information is expected from an autopsy, it is acceptable to list the cause of death as pending. But an update to certificate will be required once the additional information is obtained. It is also acceptable to list a cause as unknown. This will not automatically forward the case to the medical examiner.

Intermediate/underlying causes. Lines b, c, and d are for intermediate and underlying causes. Each condition listed should cause the one above it. You should be able to proceed logically from the underlying cause through each intermediate cause by saying the phrase “due to” or “as a consequence of,” moving from the lower line up through line b. There may be several intermediate causes. For example, a death may be due to a pulmonary embolus, as a consequence of hip surgery, resulting from a injury from a fall, resulting from a cerebral infarction. The underlying cause is the cerebral infarction.

Marking time intervals. To the right of lines a through d is space to write the time interval between the condition listed (immediate, intermediate, or underlying cause of death) and the time of death. The more precise the time the better. But it is understood that times must occasionally be estimated, and terms such as “approximately” are acceptable. If the time cannot be estimated, insert the phrase “unknown duration.” Something should be listed on this line next to the immediate, intermediate, and underlying conditions listed. No lines should be left blank.

Other illnesses. Part II is where to list other significant illnesses or conditions that may have contributed to the death but were not the direct causes of it. More than one condition may be listed. Many patients have multiple conditions and there may be uncertainty as to direct and contributing causes of the death. The physician is only expected to make the best judgment possible as to the most likely causes and sequences. Coders referring to international standards and rules will use the information to make a final classification of the underlying cause.

Specific errors to avoid

Table 2 includes some points to remember to avoid making errors when filling out the death certificate medical information. By following these rules, studying the cases provided in the Physicians’ Handbook on Medical Certification and Death, and systematically thinking about the sequence of events that caused the death, physicians can improve on their accuracy when performing the important and under appreciated role of accurately certifying the medical cause of death.

Important points to remember when completing medical information on a death certificate

Do not use abbreviations.
Do not use numbers for months; spell out the month.
Use a 24-hour clock (1600, not 4 P.M.).
Do not alter the document or erase any part of it.
Print legibly using black ink.
Complete all required items, do not leave them blank. If necessary, write “unknown.”
Do not delay completing the certification. The burial or other disposition of the remains depends on the correct completion of the certificate and its acceptance by the state or local registrar.
Do not complete the medical information if another physician has more knowledge of the circumstances, unless they are unavailable.

Useful resources

The Physicians’ Handbook on Medical Certification of Death, published by the Centers for Disease Control, National Center for Health Statistics, is available at It contains instructions on how to complete a death certificate and a series of useful examples that take about a half hour to review.

Next Article: