Case Scenario

Recently, one of my patients with severe asthma died at her home. I had not seen her in a month or two and learned of her death only when a representative from the coroner’s office arrived at my door with a death certificate in hand. He insisted that I sign it even though I told him I would not be comfortable doing so. It is my educated guess that the patient died from complications of asthma, which had been the cause of numerous hospitalizations and intubations, and had been worsening steadily up until the time I last saw her in my office. However, I had not seen her recently and thought that I was being pressured into completing and signing the death certificate even though I had inadequate knowledge. What are the rules in such cases? What are the most common pitfalls in signing death certificates?

Commentary

This scenario is becoming less common in primary care practice because the most common place of death (in nearly 80 percent of cases) in the United States has changed from the patient’s home to a hospital or long-term care facility.¹ This shift in death location means that family physicians often are not the ones asked to certify the cause of unsupervised deaths.

Lack of training in death certification and infrequency in certifying death can cause uncertainty and anxiety about how and when to complete death certificates. The implications of this uncertainty can be multifaceted because death certificates are the primary source of information that is used for a variety of purposes. For example, death certificates provide information used by policy makers to set public health goals and determine priorities in funding health care and research. More acutely, death certificates are used to help settle the estates of the deceased, and insurance companies use them to assist in determining issues related to beneficiaries. Delays in the certification of death can delay burial or cremation. Death certification, when handled properly, can help family members achieve peace of mind after the death of a loved one.

The situation described in this scenario is a bit unusual because typically it is the attending physician, who has the most complete understanding of the likely cause of death, who should serve as the certifying physician. When the attending physician is unavailable but a colleague who is familiar with the situation is available, the colleague may complete the death certificate. The cause-of-death section of the standard death certificate is designed specifically to elicit the opinion of the certifying physician, based on the preponderance of evidence, as to the most likely cause of death.² Based on the physician’s statements and report of the patient’s course of illness, this physician attests that he or she has formed such an opinion. It is generally recognized that death certificate opinions are probability statements and that opinions may vary among physicians.

If the person in this scenario was the last physician to see the patient alive, and there were no concerns that the patient died of unnatural causes, it is reasonable for this physician to certify the cause of death, especially because of the longstanding physician-patient relationship.

When the cause of death is uncertain, it may be necessary to use qualifying terms on the certificate, such as “probable” or “presumed” cause of death. If a physician has concerns about how or even whether to complete the death certificate, it may be useful to contact the appropriate coroner’s office and discuss the situation with the coroner or medical examiner. In my practice, I have found coroners’ offices to be most helpful in this regard.

The coroner’s office should be contacted when there is concern that a death resulted from other than natural causes, regardless of the time interval between the illness or injury and the death. Circumstances that should be reported to the medical examiner include possible homicide or suicide, accident or trauma, sudden infant death syndrome (SIDS), suspicious circumstances, and occupational causes.

With regard to unattended deaths, as in this scenario, the coroner’s office usually becomes involved shortly after the death is discovered, and this office determines whether the circumstances leading to the death require additional investigation. When coroners believe that additional investigation is necessary, they assign the cause and manner of death. Because that did not happen in this circumstance, it might be reasonable to conclude that the coroner thought the attending physician was in the best position to identify the probable cause of death.

The standard death certificate, which is used with modifications in all U.S. states, was revised in 2003.³ The medical portion of the death certificate includes date and time of death and death pronouncement; a question about referral to the coroner; the cause of death section; a section about injuries; and the certifier’s section, with signature.

There is a difference between the cause of death and the mechanism of death (Table 1).⁴ Part I of the cause of death section allows for a description of the sequence of events leading to death, with the most immediate cause of death on line “a” and the underlying causes on lines “b,” “c,” and “d.” The certifying physician is not required to complete all lines of part I. Part I also requires the certifier to list the time interval involved in the immediate and underlying causes of death. Declarations of time intervals are expected to be estimations.

Part II of the cause of death section is the place to report all other significant diseases, injuries, or conditions that contributed to the patient’s death but that did not result in the underlying cause of death listed in part I. This section also might include another, less significant, sequence of causes related to the death, including, for example, the decedent’s use of tobacco.²

When injuries or accidents contribute to the sequence leading to death, even if temporally remote, they must be included in the cause of death section, with additional information reported (e.g., date, time, and place of injury, and a description of how it occurred). All deaths resulting from injury must be reported to the medical examiner or coroner, who decides whether to assume jurisdiction and certify the cause of death, or allow the attending physician to certify.²

In the case scenario presented here, an appropriate way to complete the cause of death section using only the given information might be to list “complications of asthma” as the immediate cause of death (on line “a”), and to insert the word “years” in the space indicated for the time from identification to death. If the patient smoked, that fact should be listed in part II as a contributing condition. The patient’s age and comorbid diseases were not mentioned in this scenario, but if the patient was elderly and had coronary disease, it might be reasonable to list “complications of coronary artery disease” (on line “a”) and “asthma” as another significant disease in part II. Because the death certificate has many potential uses, the certifying physician should be sure that he or she can explain the content and the rationale for what is written in the death certificate to the family.

In addition to improper completion of death certificates, delays in completing and processing death certificates are problematic and result from system issues^4–7 (Table 2).⁵ These documents must be signed by physician certifiers, hospitals, funeral directors and, sometimes, coroners. Shortage of staff has been cited as one cause of delay in the completion and release of death certificates by state governments.⁸ In addition, a significant percentage of certificates submitted include inaccurate information and require revision. Illegibility creates difficulty and sometimes contributes to the inaccuracy of information.⁸

Efforts to improve the utility, accuracy, and timeliness of death certification have led a coalition of federal agencies and professional organizations representing funeral directors, physicians, medical examiners, hospitals, and vital records officials to develop an Electronic Death Registration (EDR) system,⁹ which is currently being tested in several states. The revision of the Standard Death Certificate in 2003 was a key step toward development of an EDR that will allow certifiers to access and complete the required documents electronically and from a variety of locations. The EDR will provide physicians with real-time help in completing many items in the death certificate.

Until EDR becomes commonplace, family physicians will continue to complete paper death certificates. Fortunately, several resources are available to assist them, including online tutorials, continuing medical education, and a downloadable handbook.^10–12

The responsibilities of the family physician do not end with the death of a patient. Through careful and accurate completion of death certificates, the family physician can help to ensure that the far-reaching consequences of the patient’s death are as they should be.¹³

DAVID NOWELS, M.D., M.P.H., Associate professor of family medicine, University of Colorado Health Sciences Center, Denver, and senior medical director, Hospice of Metro Denver