Death certificates present final medical complication

Death certificates are vital documents that serve as the primary source of information for families, insurance companies and authorities about a patient's cause of death. The information also helps policymakers set public health goals and research funding priorities.

But signing a death certificate is not always a straightforward process.

Physicians often face uncertainties about an individual's cause of death or how to answer the portions of certificates they are responsible for. Although the basic format has changed little in the last few decades, doctors face difficulties as some states attempt to convert from paper to electronic certificates.

Doctors need to recognize the importance of the documents and be as specific as possible, said Gregory McDonald, DO, chief deputy coroner of Montgomery County in Pennsylvania.

“Their duty doesn't end when the patient dies,” Dr. McDonald said. “A lot of physicians when they're signing a death certificate don't realize that what they put down has some real, long-term ramifications.”

Most doctors are never taught how to fill out the documents, said Randy Hanzlick, MD, chief medical examiner for Fulton County in Georgia and professor of forensic pathology at Emory University School of Medicine in Atlanta.

“Training is a big problem. There are very few medical schools that teach it,” he said. “For many physicians, the first time they see it is when they are doing their internship or residency and one of their patients dies. The nurse hands them a death certificate and says, 'Fill this out.' ”

That was the case for Drew Rosielle, MD, assistant professor of medicine and director of the Hospice and Palliative Medicine Fellowship at the University of Minnesota Medical School. He was given his first death certificate to sign as a young resident and had to ask a colleague what to do.

Physicians who are new to signing death certificates probably will have the document returned if they make a major error or omission, said Dr. Rosielle, a palliative care physician. “I think a lot of physicians learn by having them rejected by the medical examiner,” he said.

The basic information that death certificates require hasn't changed much. Every 10 to 12 years, the Centers for Disease Control and Prevention's National Center for Health Statistics has a committee review the U.S. Standard Certificate of Death, Dr. Hanzlick said. States must follow the standard but may have some variation based on the health concerns in a specific area. The most recent changes to the standard form about 10 years ago included questions about pregnancy and whether tobacco use contributed to a death, he said.

Information on the certificates is reported to the CDC and used in compiling national mortality data. Agencies that fund medical and health-related research then use those statistics to determine their funding priorities, Dr. Hanzlick said.

“It is important that the data be accurate and complete so the money is being put into the right places,” he said.

The critical parts of a death certificate that the physician is responsible for are date and time of death, the time the doctor signed the form and the cause of death, said Robert Wergin, MD, a family physician in Milford, Neb., a town of about 2,000 in the southeastern part of the state.

The standard certificate includes a place to list the primary cause of death. Secondary causes, such as other health conditions that may have accelerated a patient's death, can be listed in a separate section.

As a doctor in a small community, Dr. Wergin said he has the advantage of having long-term relationships with his patients and their families. Although knowing the patients makes it easier to fill out a death certificate, having that personal connection also makes each loss more difficult.

“Most of the patients who I sign death certificates for I know personally,” said Dr. Wergin, who serves on the board of directors of the American Academy of Family Physicians. “I usually know the cause of death because I know their medical history.”

Certainty can be elusive

Although the goal is to be as specific as possible about the cause of death, meeting that goal sometimes can be a challenge, said Charles Cutler, MD, an internist in Norristown, Pa., and chair-elect of the American College of Physician's Board of Regents.

Dr. Cutler has been signing death certificates for about 34 years. If a patient dies in a hospital, it is easier to pinpoint the cause of death. But when he is called by a funeral director to sign the death certificate of a patient who died at home, he may not have seen the patient for weeks or months. It can be particularly difficult in people with Alzheimer's disease, because such patients are unable to describe their symptoms, he said.

Dr. Rosielle faces similar challenges.

“Almost all of my patients who die at home I am not entirely sure of what the disease is that immediately leads to their death,” he said.

It is common for there to be uncertainty about the cause of death, Dr. McDonald said. Physicians sometimes try to resolve the issue by putting a general cause of death, such as cardiopulmonary arrest. Such responses are unacceptable, he said.

“I've never seen a dead person who didn't have cardiopulmonary arrest,” he said.

If physicians are unsure of the cause of death, they first need to determine whether they think it was a natural death. If they are unsure, they should contact the coroner or medical examiner, Dr. McDonald said.

In some states, physicians can use words such as “probable” to qualify a cause of death that they are not completely certain of. That language isn't acceptable in Pennsylvania, Dr. Cutler said. The state requires a specific cause of death to be listed.

“I do worry. From a professional standpoint, I want to get it right, but more draining on my psyche is if the family disagrees with me because of some information that they have that I didn't have access to,” Dr. Cutler said.

In some cases he will talk to family members and make suggestions to gauge their reaction. For example, he might say, “Your father had advanced cancer and a weak heart, but in the end I think it was the heart that did him in. What do you think?” In more than 30 years of signing death certificates, Dr. Cutler said relatives have had questions about the document only a handful of times.

Manner vs. cause

In signing death certificates, physicians need to be aware of the difference between the “manner of death” and “cause of death” entries, Dr. McDonald said. He often sees certificates where physicians have mistakenly filled out the manner of death portion of a certificate.

In most states, the manner of death would be either natural, suicide, homicide, accident or undetermined. In many states, such as Pennsylvania, only a medical examiner or coroner can answer that question on the form. Errors can have serious consequences, Dr. McDonald said.

In one instance, a person died of a seizure, and the physician thought it was a natural death. It turned out that the seizure occurred as a result of injuries from an assault, making it a murder.

“In that case the homicide was almost missed, and a murderer almost went free,” Dr. McDonald said.

For the cause of death, it's important that physicians list a disease and not a mechanism, said Yul Ejnes, MD, immediate past chair of the ACP's Board of Regents. For example, one would list “pneumonia” and not “respiratory arrest,” he said.

Filling out certificates inaccurately can have widespread consequences, said Edward W. Martin, MD, MPH, medical director of Home and Hospice Care of Rhode Island. Many patients have more than one illness, and some causes of death, such as dementia, are grossly underreported, he said.

Providing more clinical information to be as accurate as possible “benefits us all,” Dr. Martin said.

Documents go electronic

Some states have had electronic death certificates for many years, while others are just getting started. The conversion to electronic forms is a complicated process because funeral homes, physicians and others must be able to access the systems, Dr. Hanzlick said.

For example, Georgia is working on implementing electronic death certificates. But there are so many different vendors offering the systems that it is difficult to find one with a proven product.

Having electronic death registration will help increase accuracy because certain checks and balances can be built into the system, Dr. Hanzlick said. For example, if a physician lists the cause of death as cardiac arrest, the system would prompt the doctor to be more specific.

“In a paper copy, there are no checks and balances,” he said.

Dr. Wergin still uses paper forms, but Nebraska is among the states that is converting to electronic records. Dr. Wergin said he initially was looking forward to the conversion, but he has found the new system difficult to use.

“It's not very intuitive,” he said. “It hasn't been as easy as filling out a paper form.”

One significant problem with death certificates is that physicians are not paid for signing them, making some doctors reluctant to fill in the forms, Dr. Hanzlick said. But even when there is uncertainty, physicians should know that changes can be made if new information comes to light later, he said.

“The most important thing is that people who sign these need to realize that it is not written in stone,” Dr. Hanzlick said. “It is just their opinion based on the facts that they have on hand at the time they sign the death certificate.”