Death Certification

The Death Certificate

The United States and other countries provide the World Health Organization with information including cause-of-death data for use in international comparisons of death statistics. Through worldwide cooperation and political agreement, there is a uniform approach to death certification and coding of disease. The standard death certificate is revised periodically, but generally not more frequently than every 7 to 10 years, and the need for international acceptance restricts the extent to which the forms are modified. Nevertheless, currently an effort is under way to overhaul the reporting system and develop a computer-based format that will facilitate interactive help and allow electronic filing. The most recent revision of the U.S. Standard Certificate of Death anticipates this eventuality with some changes related to format and confidentiality.

In the United States, cause-of-death information recorded on death certificates is collected through a cooperative system of registration areas that includes the 50 states, New York City, the District of Columbia, Puerto Rico, the Virgin Islands, American Samoa, Guam, and the Trust Territory of the Pacific Islands. In exchange for federal funds, the registration areas must provide the National Center for Health Statistics (NCHS) with cause-of-death information in formats consistent with the U.S. Standard Certificate of Death (see Fig. 14-1 ) and the U.S. Standard Report of Fetal Death ( Figs. 14-2 and 14-3 ) forms. Thus, the NCHS, in addition to collecting and publishing the data, issues recommendations for laws, regulations, and forms related to reporting cause of death.

Most states or jurisdictions require filing of death certificates with the local registration agency within 48 to 72 hours. If additional time is required to determine the cause of death, the certificate may be filed pending further investigation. The time interval before a pending investigation must be completed is subject to the laws of individual jurisdictions. To facilitate coding, state or local registrars may initiate queries to the individual certifying the death. These queries are initiated according to guidelines for death registration and coding published by the NCHS. Queries may lead to significant revision of a death certificate. For example, querying physicians in Oregon regarding submitted death certificates resulted in new underlying-cause-of-death data in nearly 6% of deaths.

The death certifier may amend a death certificate whenever corrected or when more specific information regarding a death or decedent becomes available—for example, after completion of all autopsy studies. In this situation, the original certifier should notify the local registrar, who then initiates the amendment process. Regrettably, amendments are made only infrequently, most likely because interest wanes and this avenue is forgotten.

To complete death certificates correctly, a physician must be familiar with a number of terms. The immediate cause of death is the final disease, injury, or complication directly causing death. It precedes death as a consequence of the underlying cause or causes. In the case of a sudden, traumatic death, the violent act or accident is antecedent to an injury entered, although these two events are often almost simultaneous.

The immediate cause of death does not refer to the mechanism (mode) of death . The mechanism of death is a physiologic derangement or biochemical disturbance that is a complication of the underlying cause of death or a disturbance through which the underlying cause ultimately exerts its lethal effect. Thus the mechanism of death may have more than one possible cause, and “it is not an etiologically specific or criteria-defined disease, injury, or poisoning event.” Defined as such, mechanisms of death include terminal events such as cardiopulmonary arrest; nonspecific physiologic derangements such as vital organ failures; or nonspecific anatomic processes such as infarction, inflammation, or hemorrhage. Except in special circumstances (as discussed in the following section), mechanisms of death are not listed on death certificates.

Intervening cause(s) of death includes other conditions that stem from the underlying cause. They precede and ultimately culminate in the immediate cause of death. On the death certificate, these are listed in pathophysiologic sequence. The U.S. Standard Certificate of Death (see Fig. 14-1 ) provides lines for the inclusion of two intervening causes of death, although more can be added (see later). The underlying (proximate) cause of death is defined for public health and legal purposes as “the disease or injury that initiated the train of events leading to death.” In other words, without an underlying cause, the death would not have happened. Finally, the manner of death , either natural or unnatural (accident, suicide, or homicide), explains how the cause of death arose.

As can be seen in Figure 14-1 , the death certificate also provides a section for listing other significant conditions contributing to death. Although significant conditions may have adversely affected the health of the decedent, they need not be related to the immediate or underlying causes of death. However, these listings should be conditions that hastened death from the underlying cause. Risk factors such as smoking, alcohol, or drug abuse or concurrent diseases such as hypertension, diabetes mellitus, or cancer are often examples of contributing conditions.

Although the format of death certificates allows a physician to record a series of diseases leading to death, it may be difficult for the death certifier to list the immediate cause of death or to determine the underlying cause of death when two or more parallel processes contribute equally to death. For example, multiple factors often cause the death of a patient with a chronic illness or an elderly individual suffering from several degenerative diseases. Similarly, the forensic pathologist is often faced with cases in which multiple intoxications or multiple traumatic injuries led to death.

The analysis of mortality statistics based on a single underlying cause of death also has a number of shortcomings. Chief among these is that data tabulated from underlying cause of death necessarily exclude the effects of other conditions present at the time of death. Compared with multiple-cause-of-death analysis, data based on a single underlying cause of death lead to underrepresentation of diseases and conditions such as diabetes, dementia, hypertension, nosocomial infections, and injury among elderly people. Conventional cause-elimination life tables based on a single underlying cause of death may also overestimate the gains in life expectancy that might be expected from eradication of a given disease. Thus, a number of epidemiologists favor a multiple-cause approach for death certification. In fact, the NCHS has presented summary data with multiple-cause statistics. Although not yet a replacement for traditional underlying-cause-of-death data, multiple-cause data do provide information pertaining to disease associations, injuries leading to death, and diseases that are often associated with death even though they might not be the underlying cause. However, refinements in the methods of certifying and coding deaths are necessary before multiple-cause-of-death analysis can be used to full advantage.

Completing a Death Certificate

The physician completing a death certificate must adhere to a few specific rules. Death certificates must be typed or printed in black ink only. One should not use any abbreviations but should also avoid excess verbiage. A rational determination of what led to the individual's death should be made on the basis of the data at hand. One should consider the circumstances surrounding the death, the decedent's clinical symptoms and pertinent medical history, laboratory and radiologic studies, surgical pathologic and cytologic examinations, and, of course, the findings at autopsy when formulating death certificates. The pathologist should avoid reporting mechanisms of death, and in describing the cause of death, he or she should use only the applicable terms contained in the appropriate version of the International Classification of Diseases . When listing an infection, one should include the site and the causal organism. With neoplasms, the histopathologic type, the anatomic site, and whether the neoplasm is primary or metastatic should be included. One should record time intervals—minutes, hours, days, months, or years—whenever possible, and state the time interval as unknown only when the time of onset is entirely unknown and a reasonable estimate cannot be made.

There must always be an entry on the line for the immediate cause of death, “Part I, line a.” The immediate cause of death may be a single underlying disease process if only one condition was present at death. To satisfy these conditions, a single condition listed as both the immediate and the underlying cause of death must have directly caused death or led to death through mechanisms that were complex, poorly understood, or both ( Box 14-1 ).

The death certificate provides space (“Part I, lines b to d”) for listing up to three conditions in a pathophysiologic sequence that led to the immediate cause of death ( Box 14-2 ). The initiating condition (i.e., the underlying cause of death) is listed last. If there are more than three stages in the sequence leading to death, additional lines may be added. For purposes of death certification, the length of time between the underlying cause of death and the immediate cause of death may be short or long, but in either case there must be a continuous etiologic or pathologic relationship between them. Medical interventions such as operations or treatments should not be listed in this section of the death certificate unless they were directly related to the train of morbid events (see later).

As explained previously, mechanisms of death include nonspecific anatomic processes, terminal events, and nonspecific physiologic derangements ( Box 14-3 ). Non­specific anatomic processes are complications of the underlying cause of death resulting in an anatomic abnormality that has more than one possible cause. Terminal events are the fatal (without medical intervention) and final complications of the underlying cause of death. Nonspecific physiologic derangements are complications of the underlying cause of death not defined as a terminal event or nonspecific anatomic process. Box 14-4 lists three principles for the use of mechanisms of death as immediate or intermediate causes of death, but it should be noted that listing of a mechanism is almost always accompanied by an etiologically specific entity. Box 14-5 contains several examples of mechanisms of death as immediate and intermediate causes of death.