The Final Act of Care: Completing a Death Certificate for Your Patient

By COPIC’s Patient Safety & Risk Management

The accuracy of the death certificate is vital to the patient’s family and public health reporting. It can also have long-term ramifications, including provider defensibility.

About Death Certificates

Laws vary from state to state about who can certify a death certificate. Typically, providers can complete a death certificate in cases that are 1) not reportable to the coroner, or 2) do not require forensic inquiry, per coroner investigation. Though there can be differences state by state in what a certificate requires, most conform to the U.S. Standard Certificate of Death provided by the Centers for Disease Control and Prevention. Most states require a completed death certificate within a certain timeframe.

To ensure accuracy, it’s important to understand the two parts of death certification: cause of death and manner of death.

PART 1: Cause of Death (i.e., WHY they died)

The first step of a death certification requires documentation of the pathophysiologic derangement or disease/injury state that led to the death. This is documentation of the causal chain of events (disease or injury) that directly led to the death and includes both the immediate and underlying cause of death.

The immediate cause of death is the final event in the causal sequence that occurred closest to the time of death. This is typically filled in as the top-line diagnosis on the death certificate.

The underlying cause of death is the initiating event in the causal sequence that occurred most remotely from the time of death. It’s the disease or injury that initiated the physiologic derangement and downward spiral that ultimately resulted in death. This is typically filled in as the bottom line diagnosis on the death certificate.

For example, a patient’s immediate cause of death may be listed as an upper gastrointestinal hemorrhage. The underlying cause of death may be listed as chronic hepatitis C infection. By stating both the immediate and underlying cause of death, the sequence provides an accurate and chronological explanation of the patient’s death.

Specificity Is Key

• Use specific infectious etiologic agents or anatomic locations of lesions. In the previous example, listing “hepatitis C virus” is preferred to “chronic hepatitis.”

• Avoid using abbreviations.

• List the cause not the mechanism.

• Use the “best medical opinion.” The causal chain of events leading to death may not be clear. It’s acceptable to use qualifiers such as “presumed” or “more likely than not.”

• The underlying cause of death will most likely be coded as cause of death and reported as mortality data.

• Do not list mechanistic terminal events, such as cardiac arrest, a systole, or multi-organ system failure. While the heart and lungs stop upon death, the death certificate should focus on the disease or injury that caused them to stop.

  PART 2: Manner of Death (i.e., HOW they died)

  The manner of death section documents how the death came about. For this section, the burden of proof is a “reasonable degree” of medical probability.

  In most states, the following options are offered as a box to check. Please note, some jurisdictions also include the option for “therapeutic complication.”

• Natural (disease or aging process)

• Accident (sudden, unexpected external event)

• Homicide (act of volition by another meant to cause harm or fear)

• Suicide (act of volition self-inflicted and meant to cause harm)

• Undetermined (cause of death unknown or more than one possible manner–non-natural events or injuries, including intoxication causing or contributing to death will result in an “undetermined” death selection)

This section also provides an opportunity to list significant conditions not connected to the causal chain of events listed in Part 1 but may have contributed to the disease state or worsening health of the individual. List any and all factors that may have contributed to the patient’s decline. Should a non-natural event be listed, this should be reported to the coroner.

CDC Guidance on Death Certificates

The Centers for Disease Control and Prevention offer free guidance on the accurate completion of death certificates.

Physicians’ Handbook on Medical Certification of Death: www.cdc.gov/nchs/data/misc/hb_cod.pdf

Possible Solutions to Common Problems in Death Certification: www.cdc.gov/nchs/nvss/writing-cod-statements/death_certification_problems.htm

Instructions for Completing the Cause-of-Death Section of the Death Certificate: www.cdc.gov/nchs/data/dvs/blue_form.pdf

Cause of Death Mobile App: www.cdc.gov/nchs/nvss/mobile-app.htm