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

Journal of Family Practice, Feb, 2005 by Doug Campos-Outcalt

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, con firmed 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 1 OMITTED]

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).