Death Certification

The process of medical death certification is a challenging and daunting task for most healthcare practitioners and physicians who are tasked with this responsibility. In most instances, in the United States, when a death certificate must be completed, it is the responsibility of the physician to fill it out. In instances where a crime or foul play is suspected, the medical examiner or coroner takes responsibility for filling out the death certificate. Physicians should not be concerned if the manner of death is natural, suicide, homicide, accident, or indeterminable. The burden of determination lies with the medical examiner (ME). In rare instances, for example, the death of a hospice patient, a nurse practitioner may fill out the death certificate if a physician is not available. If the death certificate is not completed or filled out properly, the document is usually rejected by the official public registrar of vital statistics in the jurisdiction the document is completed. The death certificate is a public record that can be accessed by the decedent's family, clinical researchers, lawyers, and insurance companies when there is litigation involved. The death certificate should document the immediate cause of death, which can be an event, clinical condition, or disease process, which is unsuitable for the continuation of life. The mechanism of death is not as important as the event or condition that precipitated the occurrence of death. The physiologic process of respiratory failure or cardiac failure does not explain the event preceding death. For this reason, clinicians are discouraged from using terminologies such as: Cardiac arrest. Respiratory arrest. Cardiopulmonary arrest. Old age. The main purpose of death certification is for governmental agencies to compile vital statistics. This is used as official documentation of deaths and the causes of deaths. The death certificate is not intended to document the history of the present illness or the decedent’s clinical problems but rather to focus on the immediate cause of death. The World Health Organization (WHO) has a mission statement that includes collecting and classification data on mortality. The collection and classification allow researchers to compare data from different countries. The United States is a signatory to this mission statement and follows the WHO's policies, procedures, and regulations. The responsibility of collecting national data in the United States is vested in the hands of the National Center for Health Statistics (NCHS), which is a part of the Centers for Disease Control and Prevention (CDC). The responsibilities of the NCHS include but are not limited to the collection of national data within the United States on the causes of mortality. For the NCHS to meet the WHO standards, the United States standard certificate of death is reviewed by NCHS periodically. Each state is required to comply with the rules and regulations set forth by the NCHS to receive federal funding. In the United States, there are about 2.6 million annual deaths that are reported to the NCHS. Each US state has specific requirements regarding when a death certificate must be filed. In Wisconsin, for example, the medical portion of the death certificate has to be completed within a maximum of 6 days from the time of death. It is considered a class 1 felony to willfully and knowingly falsify information on the death certificate. In about 33% to 41% of cases, errors are made on the death certificate. There is a significant over-representation of cardiovascular diseases as the primary cause of death. The most cited reasons for errors in death certification are: Inexperienced physician (physician in training). Lack of training by attending physicians. Studies suggest that organizing seminars and workshops that teach the process and procedure involved in death certification can greatly improve documentation accuracy. Some health care professionals are wary of signing a death certificate, believing that the signature might impose some legal responsibility on the practitioner. The death certificate is a medical opinion regarding the cause of death based on the available information at the time of death. Lawsuits against health care practitioners for signing a death certificate are extremely rare, and when there is a lawsuit, the certifier of death is usually not held liable. The death certificate can be subject to amendment.