FAST FACT AND CONCEPT #155: Completing a Death Certificate

Authors: Nikkisha Prentice and Robert Arnold, MD

Physicians are responsible for providing proper documentation of death. This Fast Fact reviews key steps in the completion of a death certificate.

Importance of Proper Completion Death certificate information is a permanent record of death. It is usually necessary for burial and settlement of the deceased’s estate. Written documentation of the cause of death, in addition to direct communication, may provide family members with closure and peace of mind. Death certificates are also used to 1) evaluate the general health of the population, 2) assess the prevalence of medical problems among specific groups, 3) identify areas where medical research may have the greatest impact, and 4) apportion health services, grants, and other resources to common illnesses.

Basic Guidelines

• State laws provide guidelines for who can complete a death certificate. Certification and completion of death certificates is usually the primary responsibility of the physician. However, in some states, death may be certified by the attending physician or attending Advanced Practice nurse.

• Verify the correct spelling of names.

• Personally sign the death certificate; stamps and faxes are unacceptable.

• Complete all required items. If necessary, write “unknown” or “pending further study.”

• Common Errors

• Do not delay completion of the certificate. Some states have specific time periods and civil and/or criminal penalties for non-completion. Moreover, funeral homes will typically not proceed with burial without the death certificate.

• Do not use abbreviations.

• Spell out the month; do not use numbers.

• Use 24 hour clock rather than 12:00 midnight.

• Do not alter the document, erase any parts or use white-out.

• Avoid cursive writing; print clearly, or type, using black ink.

Causality of Death This section of the certificate often consists of two parts. The first part asks for a sequential chain of events that led to death, and the time interval between onset of a condition and death. The most immediate cause of death is stated on line a and the underlying causes follow on lines b, and so on. In assessing the approximate interval between onset and time of death, terms such as “unknown” or “approximately” may be used and general terms such as “minutes,” “hours,” and “days” are acceptable. The second part asks about other significant conditions that contributed to death, but that did not result in the underlying cause stated previously.

NOTE: It is important not to write the mechanism of death (i.e. cardiac arrest, respiratory arrest) as the cause of death. The mechanism of death is the physiologic derangement or biochemical disturbance by which the cause of death exerts its lethal effect. For accurate public health records, the cause of death (COPD) is more helpful than the mechanism of death (respiratory failure). When there is doubt as to the cause of death, it is acceptable to enter “unknown” or “pending further study.” In some states, a condition may also be listed as “probable.” As additional medical information, such as an autopsy report, becomes available, the certifying physician should immediately report amendments to the state vital records office or local registrar.

NOTE: Death certificates are governed by state statutes; variations exist in reporting requirements and specific terminology. Listed below are common terms and definitions that are generally interchangeable between states.

Immediate (or Principle) Cause = Final complication resulting in death.

Intermediate (or Antecedent or Underlying) Cause = Disease or condition causing the immediate cause of death.

Underlying (or Contributory) Cause = The condition present before and leading to the intermediate or immediate cause of death.

References:

1. Campos-Outcalt D. Cause-of-death certification: Not as easy as it seems. The Journal of Family Practice 2005. 54(2): 134-138
2. Herring ME. The Death Certificate. AAHPM Bulleting (reprinted with permission of the Camden Medical Society) Winter 2005; 8-9.
3. Lakkireddy DR , Gowda MS, Murray CW, Basarakodu KR, Vacek JL. Death Certificate Completion: How well are physicians trained and are cardiovascular causes overstated? American Journal of Medicine 2004; 117: 492-498.
4. Magrane BP, Gilliland MG, King DE. Certification of death by family physicians. Am Fam Physician 1997;56:1433-8.
5. Myers KA, Farquhar DE. Improving the accuracy of death certification. CMAJ 1998;158:1317-23.
6. Nowels D. Curbside Consultation: Completing and Signing the Death Certificate. American Family Physician 2004; 70(9): 1873.
7. Physicians’ Handbook on Certification of Death. Department of Health and Human Resources, Centers for Disease Control and Prevention, National Center for Health Statistics, April 2003, DHHS Publication No. (PHS) 2003-1108.

Copyright/Referencing Information: Users are free to d ownload and distribute Fast Facts for educational purposes only. Citation for referencing: Prentice N and Arnold R. Fast Fact and Concept #155; Completing a Death Certificate. May 2006. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

State laws often provide guidelines for certification of medical information. Certification and completion of death certificates is usually the primary responsibility of the physician. However, in some states, death may be certified by the attending physician or attending Advanced Practice Registered Nurse (APRN). In the absence of these individuals, or with the approval of the attending physician or APRN, certification may be completed and signed by an associate physician or APRN, registered nurse, a physician assistant, chief medical officer of the institution or pathologist if the state law provides this option. The medical examiner or coroner investigates certain types of deaths and completes the cause of death for these specific cases. Since laws vary for each state, it is best to reference instructions regarding who may be an acceptable certifier.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Systems based practice

Keyword(s): Ethics, law, policy, health systems