Think you know how to fill out a death certificate? It’s often not as easy as it seems. Try the following cases.

Case 1

A 68-year-old woman is admitted to the ICU because of acute chest pain. She has a history of type 2 diabetes, hypertension, obesity, and angina. Over the next 24 hours an acute myocardial infarction is confirmed. Heart failure develops but improves with medical management. The patient then experiences a pulmonary embolus, confirmed by ventilation-perfusion lung scan and blood gases; over the next 2 hours she becomes unresponsive and dies.

Question: What should be written on the death certificate as the immediate and underlying cause of death? Answer: pulmonary embolus due to acute myocardial infarction due to atherosclerotic heart disease.

Question: What should be listed as conditions contributing to death but not directly causing death? Answer: type 2 diabetes, obesity, hypertension, and congestive heart failure.

Case 2

A 78-year-old woman has left hemiparesis from a stroke 2 years earlier. She has been unable to care for herself and has lived in a nursing home. She has had an indwelling urinary catheter for the past 6 months. Because of fever, increased leukocyte count, and pyuria, she is admitted to the hospital and started on 2 antibiotics. Two days later, the blood culture result is positive for Pseudomonas aeruginosa resistant to the antibiotics being administered. Despite a change of antibiotics, hypotension ensues and the patient dies on hospital day 4.

Question: What should be written on the death certificate as the immediate and underlying cause of death? Answer: P aeruginosa sepsis, due to a urinary tract infection due to an indwelling catheter, due to left hemiparesis, due to an old cerebral infarction.

Question: What should be listed as conditions that contributed to the death but that did not directly cause the death? Answer: nothing.

If you were correct on both cases, congratulations. If you were not, this article offers basic advice that will help you provide accurate medical information on death certificates.

Death certificates are important official records used for personal, legal, and public health purposes, yet they are frequently filled out inaccurately. Physicians are responsible for determining the cause and manner of death, yet they are seldom formally trained for this responsibility in medical school or residency. The result is frequent and avoidable errors.

Who is responsible for what?

Registration of deaths is a state responsibility. The National Center for Health Statistics compiles data from all states to produce national vital statistics, and most states use death certificate forms that conform to a recommended national standard. Though funeral directors are responsible for filing the certificate with the state, physicians are responsible for completing the medical portion of the certificate.

With the medical information provided, trained coders classify the cause of death using standardized methodology.

Medical examiners or coroners are responsible for investigating and certifying the cause of any death that is unexpected, unexplained, or resulting from injury, poisoning, or a public health threat.

Physicians are additionally responsible for answering inquiries from the registrar (these inquiries can be reduced by accurately and completely filling in the medical information) and submitting a supplemental report when autopsy findings or other information indicates a cause of death different from that originally reported.

How to complete the medical portion of the death certificate

The Figure is a standard certificate of death. It may vary slightly state to state. Physicians are responsible for items 24 through 49. If the state requires a pronouncing physician (Table 1), the pronouncing and certifying physicians may be different, in which case the pronouncing physician completes items 24 through 31 and the certifying physician items 32 through 49. If the pronouncing physician is also the certifying physician, items 26 through 28 need not be completed. If the death is referred to the coroner or medical examiner, they complete items 24, 25, 29, 30, and 32 through 49.

FIGURE
US standard death certificate

TABLE 1
Definitions

Immediate cause of death:The final disease or injury causing the death.
Intermediate cause of death: A disease or condition that preceded and caused the immediate cause of death.
Underlying cause of death: A disease or condition present before, and leading to, the intermediate or immediate cause of death. It can be present for years before the death.
Manner of death: The circumstances leading to death—accident, homicide, suicide, unknown or undetermined, and natural causes.
Medical examiner: A physician, acting in an official capacity within a particular jurisdiction, charged with the investigation and examination of persons dying suddenly, unexpectedly, or violently, or whose death resulted from, or presents, a potential public health hazard. The medical examiner is not always required to be a specialist in death investigation or pathology. Most systems employing physicians as part time medical examiners encourage them to obtain training for medical examiners such as that offered by the National Association of Medical Examiners.
Coroner: A coroner is a public official, appointed or elected, in a particular geographic jurisdiction, whose official duty is to make inquiry into deaths in certain categories. In some jurisdictions, the coroner is a physician, but in many localities, the coroner is not required to be a physician nor be trained in medicine.
Pronouncing physician: The one who determines the decedent is legally dead. Not all states require a death to be pronounced by a physician.
Certifying physician: The one who certifies the cause of death.

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.

TABLE 2
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 www.cdc.gov/nchs/data/misc/hb_cod.pdf. It contains instructions on how to complete a death certificate and a series of useful examples that take about a half hour to review.

Correspondence
12229 S. Chinook, Phoenix, AZ 85044. E-mail: dougco@u.arizona.edu.

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