DEATH CERTIFICATES: Certification of Death: Whose Responsibility?

A. Jay Chapman, MD

Many patients with fatal disease follow a predictable course through their illness that ultimately results in their death. Having one’s patient die is always discomforting, but in most of these instances, the physician is prepared for the event. For these cases, there is almost never a question that the patient’s physician is responsible for the certification of death and completing the death certificate (DC).

In addition to providing data for leading causes of death and other public health statistics, DCs most immediately allow arrangements for the disposal of the body. Thus, if the family cannot promptly obtain a valid DC, they will at a minimum be terribly inconvenienced. At the other extreme, families can even be shoved into financial ruin if the DC is delayed for a prolonged period since it is necessary for life insurance claims, pension benefits, settling of estates (wills, trusts, accessing bank accounts, real estate holdings), Medicaid benefits, and even future marriages where proving the death of a previous spouse may be necessary.

Some patients have risk factors for sudden demise, and their death is quite often unexpected to family, friends and physicians. The most common and obvious risk factors are hypertension, obesity, diabetes mellitus, hyperlipidemia and seizure disorders. Despite the unexpected nature of these natural deaths, nearly all are under the purview of the attending physician—not the coroner—if there are no suspicious circumstances. By statute, the attending physician must complete the DC. Physicians may not avoid this responsibility by making a “policy” that is contrary to state law.

One common misconception is that the physician must be in physical attendance at the time of death. A physician is considered to be the attending physician if the patient was being seen by that physician or designee in the physician’s office or the patient’s home, or if the patient was using or refilling prescriptions written by the physician. There are no specified limits as to the time when the patient was last physically seen by the physician.

Patients seen in the emergency room are a different matter. If the emergency physician only performs resuscitative measures and pronounces the patient dead—and the emergency physician was not otherwise seeing the individual as a patient—he or she is only the “pronouncing” physician and is not responsible for completing the DC. The responsibility for death certification still falls to the physician who has been treating or “attending” the patient, provided the death is due to natural means and didn’t occur under valid suspicious circumstances.

In some cases, the emergency physician diagnoses and treats a natural illness unrelated to trauma or suspicious means. If the patient succumbs to that illness, the emergency physician is responsible for signing the DC, regardless of any “policy” established by the hospital or other entity. In these cases, the emergency physician is considered to be the attending physician, no matter how long he or she has been treating the patient.

The Coroner’s Role
California law specifically provides that the coroner has the discretion to determine the extent of inquiry to be made in any given case. The law further provides that if the inquiry determines that the “physician of record” has sufficient knowledge to reasonably state the cause of death, the coroner may require that physician to sign the DC.

The coroner is notified in most cases of sudden and unexpected death. The case is then investigated to the extent that the coroner deems necessary. The attending physician is responsible for completing the DC when the coroner determines that the death was due to natural causes, that there are no suspicious circumstances, that there is a physician of record, and that the death was reasonably due to a condition or conditions for which the deceased had been seen by that physician. The identity of the physician of record is determined most often via history given by family or friends or through medical records or prescriptions possessed by the deceased.

Physicians notified by the coroner’s office of their responsibility to sign the DC sometimes object because they were not present when the patient died. This misconception has been discussed above and is not a valid reason for refusing to sign the DC. The only valid reason for not completing the certificate is that trauma or overdose initiated the process that led to the patient’s demise, or that the attending physician is also deceased.

Some physicians believe that their simple refusal to sign the DC obligates the coroner to assume jurisdiction. In fact, the coroner is under no such obligation. The practical effect of such refusal in many instances is to create a great inconvenience for the patient’s family.

Another reason given for not wanting to complete the DC is that the physician cannot state the exact cause of death. An exact cause of death is not required on the DC. The DC only requires that the cause of death be based upon reasonable medical probability. If the physician feels more comfortable doing so, he or she can qualify the cause of death with a modifier such as “probable.”

Autopsies
Some physicians may believe that their absolute or adamant refusal to sign the DC will result in an autopsy; but that is highly improbable. What is much more likely to happen is the following:

• Taxpayers will incur considerable expense for bringing the body to the morgue, where an autopsy is unlikely to be performed. Instead, the pathologist will only undertake an external examination of the body.
• The family of the deceased will be inconvenienced and may have to pay an increased fee for the funeral home to retrieve the body from the morgue.
• The cause of death will be determined by the pathologist who examines the body.
• The pathologist will determine the most probable cause of death by investigating the circumstances of death and the medical records. These records will be subpoenaed by the coroner and must be provided from the physician’s office or other treatment facility—another inconvenience and expense for the physician or facility.

In these cases, the attending physician is in a much better position to provide the medically probable cause of death, thereby eliminating the inconveniences and expenses that are otherwise involved. The coroner’s office does not exist to provide autopsies that should properly be done by hospital or private pathologists.

If the coroner notifies you, as the attending physician, that your patient has died, that the death has been investigated, and that the death is due to natural means, you should have no hesitancy in completing the DC—unless you know of some valid circumstance that the coroner did not investigate. I don’t know of any case in which a physician has been sued for a cause of death stated on the DC.

Another misconception regarding the DC is that it may be signed at your leisure. California law provides that the DC must be signed and made available to the funeral director no later than 15 hours after the time of death.

Bear in mind that if you have been treating a patient for a potentially fatal condition, you have obviously been billing with a code for that condition. It goes without saying that if you are capable of billing for the patient’s condition, you are quite capable of placing that condition on the DC!

Completing the DC
The cause of death is the disease, injury or abnormality that, either alone or in combination, caused the sequence of events that ultimately led to death. The terms initiating, proximate or underlying cause of death may also be used—all with the same meaning. In assigning a cause of death, you should use a simple statement of the underlying cause: the event without which the chain of events leading to death would not have occurred.

The mechanism of death is the process by which an organ or organ system fails when there is fatal disease, injury, abnormality or chemical insult: the pathophysiologic change(s) set in motion by the cause of death. The mechanism of death represents the physiologic or anatomic change that is incompatible with life after the body sustains a lethal event. For instance, a dissecting aneurysm of the aorta may cause a laceration of the aortic wall and produce massive hemopericardium with cardiac tamponade, followed by brain death due to anoxia. Death in this case was due to 1) hypoxic/anoxic encephalopathy due to 2) circulatory failure due to 3) cardiac tamponade due to 4) massive hemopericardium due to 5) aortic wall perforation due to 6) dissecting aneurysm of the aorta. All of the “due to’s” except the sixth are mechanisms of death. The sixth and final due to is the cause of death.

Manner of death must be distinguished from cause of death. The manner of death designations specify how the cause of death came about. The designation can refer to social relationships and personal causation. The customary designations are natural, suicide, accident, homicide, undetermined and pending. A special designation for people dying from military actions is operations of war—with the exception of situations arising in military actions that constitute homicide.

In California only the coroner or medical examiner can certify deaths in which the manner of death is other than natural. Any physician who treats a victim of gunfire, blunt force trauma, poisoning, sharp force injury, or any other kind of violence—or whose death occurred under suspicious circumstances—cannot certify the death and is required to notify the coroner.

Sometimes the underlying cause of death may be overlooked but should properly require that the coroner be notified. A few examples are 1) sepsis due to decubitus ulcers due to paraplegia due to remote gunshot wound to spine; 2) pneumonia complicating acute ethanol or drug toxicity; 3) seizure disorder due to closed head injuries due to remote motor vehicle accident, blow to the head or a fall; 4) anaphylaxis due to bee sting; 5) pulmonary thromboembolism due to deep vein thrombosis due to hip fracture due to unwitnessed fall; 6) pneumonia complicating subdural hematoma due to trauma.

Helpful Hints
When completing death certificates, the most important thing to remember is that the statement of the cause of death most often should not include the mechanism of death, although it is sometimes employed for clarity in a particular situation. When the cause of death is stated, it should be the underlying cause—the culprit that initiated the entire series of events leading to death. Terms such as cardiac arrest, asystole, cardiopulmonary arrest, respiratory arrest, electromechanical dissociation and ventricular fibrillation are all mechanisms of death and cannot be used as the statement of the cause of death.

• Simple statements of cause of death include:
• Arteriosclerotic cardiovascular disease
• Hypertensive cardiovascular disease
• Obesity-related heart disease
• Sequelae of diabetes mellitus
• Non-traumatic intracerebral hemorrhage

In summary, death certificates need to be as accurate as possible, and completing the DC should be accomplished with the least expense and inconvenience to taxpayers and the family. The coroner’s staff, including the pathologist, are always willing to assist in completing the DC. Physicians can call the office at 415-473-6043 at any time with questions or problems that arise.

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Dr. Chapman is a forensic pathologist at the Sonoma County Coroner Unit.

For more information on completing death certificates, consult the CDC’s Physician’s Handbook on Medical Certification of Death at www.cdc.gov/nchs/data/misc/hb_cod.pdf.