Death Certification
Let’s get it right
!!!!!!
Dr. Ahmed Mohamed Saleh Abdou, FRCPI, FRCPE
Consultant Physician
Head of Infection Control Office
Rashid Hospital, DHA, Dubai
The last service that doctors can offer their
patients is to provide a certificate of death
which is properly completed with a reasonably
accurate diagnosis.
Horner JS, Horner J. Do doctors read forms?J R Soc Med 1998;91(7):371-376
Cause of Death Statement
Part I
A. Immediate Cause “most recent condition”
Due to, or as a consequence of:
B. Intervening Causes “next oldest condition”
Due to, or as a consequence of:
C. Underlying Cause “oldest, original, initiating condition”
Part II. OTHER SIGNIFICANT CONDITIONS:
Conditions contributing to death but not resulting in the underlying
cause of death in Part I
Cause of Death Statement
Part I
A. Immediate Cause “ Intraperitoneal haemorrhage ”
Due to, or as a consequence of:
B. Intervening Cause “ Ruptured secondary deposit in liver ”
Due to, or as a consequence of:
C. Underlying Cause “ Adenocarcinoma of ascending colon ”
Part II. OTHER SIGNIFICANT CONDITIONS:
Conditions contributing to death but not resulting in the underlying
cause of death in Part I “ Non-insulin dépendent diabètes mellitus ”
Vital Statistics - Mortality Database
• The information from the cause of death statement (CODs)
is the basis for the national mortality database
• Local health officials might use mortality statistics ,,, ,,,
• Surveillance of disease prevalence in a society
• Prioritize governmental decisions and actions in regard to
health care
• Proper allocation of funds for research and educational
programs
Decedent’s Family Benefits
• Legal, medical and psychological benefits:
•
•
•
•
Help settle the estates of the deceased.
Claim life insurance or other death benefits.
Receive government benefits.
Pursue any legal actions they might wish to initiate.
• Valuable in developing a family history or “genealogy”
?
Unfortunately ….
the process is flawed
because of a significant data entry error rate,
particularly, in assigning the cause of death
information provided on death certificates is
frequently incomplete and has limitations
Studies have reported that the documentation of
the cause of death in death certificates is very
poor, with error rates ranging from 16% to 40%
Studies have reported that the documentation of
the cause of death in death certificates is very
poor, with error rates ranging from 16% to 40%
which …
questions the validity of information from the
cause-of-death registry for administrative or
scientific purposes.
and hence …
Accuracy of the national mortality statistics.
? ?
The root problem …
general lack of training in death certification
during medical school and postgraduate
training programs.
Few physicians are actually trained in completing
death certificates or on the significance of death
certification,,,
and,,,,
many take little interest in its accuracy because of
no perceived benefit.
Often,,,,
a physician's first encounter with the death
certificate occurs upon his first patient death.
Problems With Proper Completion and
Accuracy of the Cause-of-Death Statement
Ann E. Smith Sehdev, MD; Grover M. Hutchins, MD Arch Intern Med. 2001;161:277-284.
completeness
Hopefully, next tutorial will help you avoid
mistakes and to be complete and accurate
when writing cause-of-death statements
accuracy
Definitions and Guidelines
Physicians without training in death
certificates completion,,,,
may not even understand the correct
definitions of the Death Certification
Terminology
Death Certification Terminology
• Underlying cause of death
• Immediate cause of death
• Intermediate causes of death
• Mechanism of death
• Manner of death
Underlying “Primary” Cause of Death
• The disease or injury however brief or
prolonged that triggered / initiated the
dependent / related sequence of events that
led to death
we can say that ……………………………
• “But for” this or that particular underlying
event, death would not have occurred.
Underlying “Primary” Cause of Death
a competent cause of death is etiologically specific
• various carcinomas,
• atherosclerotic coronary artery disease,
• chronic obstructive pulmonary disease
(emphysema and chronic bronchitis), and
• human immunodeficiency virus infection.
• chronic viral hepatitis
• road traffic accident
Underlying “Primary” Cause of Death
must appear on the lowest completed line
• Coded to one of the International Statistical
Classification of Diseases and Related Health
Problems (ICD-10) categories and then to a
disease-specific cause of death.
Immediate “Direct” Cause of Death
the immediate cause of death is a complication
and sequela of the underlying cause of death,
that directly precedes death
the last event that occurred before death
as specific as possible ,,, Escherichia coli sepsis
should not be a general concept ,,, organ failure
Intermediate “Intervening” Causes of Death
a disease(s), condition(s), or complication(s) that
occurs somewhere in time between the underlying
and immediate causes of death
For death certification, these conditions should be
recorded in logical pathophysiologic sequence
• The time interval between initial insult and
death can be instantaneous as in a massive
spontaneous intracranial hemorrhage.
• Or ………………
• There may be hours, days, weeks, months, or
even years between initial event and death…
- atherosclerosis ,,,,,
- bronchogenic carcinoma,,,, etc.
• The actual underlying cause of death may be
overlooked or ignored if a considerable time
interval, since the initial insult, has passed
For examlpe ,,,,, “a man suffers a trans-abdominal gunshot wound with perforation of the colon.”
After months of treatment, he develops peritonitis, septicemia, disseminated intravascular coagulopathy,
hepatic and renal failure, bronchopneumonia, and adult respiratory distress syndrome, and dies.
the gunshot wound remains to be the underlying cause of death.
Similarly,,,,, if a person dies from complications of quadriplegia ten years after a
diving accident in which he sustained a cervical fracture with contusions of the
spinal cord … …
10 years
the cervical injuries due to the diving accident remain to be the underlying cause of death.
Another example ,,,,,
• .. an individual with massive abdominal injuries
secondary to a motor vehicle accident (MVA) may
require prolonged hospitalization.
• That patient might develop acute peritonitis, sepsis
with seizures, and subsequently expire as a result
of aspiration pneumonia;
• yet, the blunt traumatic injuries due to MVA to the
abdomen are the underlying cause of death.
Aspiration pneumonia
Acute peritonitis, sepsis and seizures
Traumatic abdominal injuries due to MVA
however ,,,
the sequence of events must be dependent &
related
an independent supervening factor that would
not be a reasonable and foreseeable
consequence of the initial disease or injury …
…
…… would alter the cause of death.
For example ,,,,,
If the MVA patient inadvertently received a lethal
dose of medication ,,,,,
,,,,, that error would represent an independent
supervening factor that is not a reasonable and
foreseeable consequence of the traumatic injuries.
lethal dose of xxxxxxxxx
lethal dose of xxxxxxxxx
Traumatic abdominal injuries due to MVA with acute
peritonitis, sepsis, seizures and aspiration pneumonia
lethal dose of xxxxxxxxx
Traumatic abdominal injuries due to MVA with acute
peritonitis, sepsis, seizures and aspiration pneumonia
Mechanism (Mode) Of Death
A physiologic derangement or biochemical disturbance
produced by a cause of death ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
the means by which The cause of death exerts its lethal
effect.
Mechanisms of death are not etiologically specific and
potentially can result from more than one cause ,,,,,,,,,,,
thus are of little value when cited as an underlying
cause of death.
Common Mechanisms of Death









congestive heart failure
pulmonary oedema
cardiac arrhythmias
hypoxaemia
sepsis
exsanguinations
renal failure
hepatic insufficiency
multiorgan failure
Important Message …..
• Mechanism / modes of death lack etiologic specificity and
are unacceptable substitutes for the underlying cause of
death.
• May only be used if qualified by an appropriate cause of
death.
• A mechanism of death should never stand alone on the
death certificate.
Specificity = accurate ICD-10 coding
• Neoplastic diseases: anatomical site ,,, cell type ,,, grade ,,,
primary or secondary ,,, etc.
• Pneumonias: organism responsible ( Strep pnemoniae ,,,
Pneumocystis carinii ,,, etc)
• Septicaemia: causative organism ( Pseudomonas aeuroginosa
,,, mecicillin resistant Staphylococcal aureus ,,, etc.)
• Strokes: type (infarction or haemorrhage) ,,, anatomical site of
the lesion ( right middle cerebral artery ) ,,, etc.
Cardio-respiratory arrest
• Regardless of the cause or the manner of death, the
heart “cardio” eventually stops beating “arrest” and
the lungs “respiratory” cease to breathe “arrest”.
• Cardio-respiratory arrest is a description of being
dead and provides no information whatsoever as to
what underlying injury or disease was responsible
for the individual’s death.
Definition Of Death
Complete
&
Persistent
Cessation
Of
Respiration
&
Circulation
“Cardiopulmonary Arrest”
a mechanistic term that is meaningless for purposes
of death certification;
Cardio respiratory arrest is not a cause of death;
it is not etiologically specific.
It is a description of being dead, not a cause of death.
• The cause-of- death statement contains two parts, appropriately
named Part I and Part II.
Part I
A.
Due to, or as a consequence of:
B.
Due to, or as a consequence of:
C.
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions contributing to
death but not resulting in the underlying cause of death in Part I
• Part I is designed so that a sequence of conditions leading to
death may be reported in a cascade order.
• Part II is for reporting conditions that pre-existed or co-existed
and contributed to death, but did not result in the the cause
reported in Part I.
• Part I will be considered first.
• To facilitate coding, ONE CONDITION per line, starting with the
most recent condition on the top line and going backward in
time on progressively lower lines, “Sequential Part I Format”.
Part I
A. Most recent condition (Cardiac tamponade)
Due to, or as a consequence of:
B. Next oldest condition ( Ruptured myocardial infarction)
Due to, or as a consequence of:
C. Oldest (original, initiating) condition (Atherosclerotic
coronary artery disease)
•
•
•
•
Each condition can cause the one on the line above it.
It is not always necessary to use all of the lines in Part I.
Although rarely needed, extra lines may be added.
The top line (A) should always be used.
• The cause-of-death information from each death YOU certify is
coded and becomes part of the mortality data base.
• Doctors are expected to complete the cause of death statement
to the best of their knowledge and belief.
Part I
A. Cardiac tamponade
Due to, or as a consequence of:
B. Myocardial infarction with left ventricular rupture
Due to, or as a consequence of:
C. Atherosclerotic coronary artery disease
• This cause-of-death statement provides complete information,
and is of greater potential use for research, statistics, public
health decision making and policy setting, and law-making.
• It also provides complete information for the family and others
who use the death certificate.
• It may be necessary to use three or more lines in Part I.
Part I
A. Upper gastrointestinal hemorrhage
Due to, or as a consequence of:
B. Ruptured esophageal varices
Due to, or as a consequence of:
C. Cirrhosis of the liver
Due to, or as a consequence of:
D. Chronic alcohol abuse
• In the example, "chronic alcohol abuse" is the underlying
cause of death.
• "Upper gastrointestinal hemorrhage" is the immediate
cause of death.
• Each of the other two conditions is an intermediate cause of
death because it falls somewhere in the sequence between the
underlying and immediate cause of death.
• In this example, floppy mitral valve syndrome is the
underlying cause of death-- the specific condition that started
the downhill course of events that led to death.
Part I
A. Cerebral infarction
Due to, or as a consequence of:
B. Thrombo-embolism to right internal carotid artery
Due to, or as a consequence of:
C. Thrombo-embolism from bacterial endocarditis of
mitral valve
Due to, or as a consequence of:
D. Floppy mitral valve syndrome
• A major goal when writing a cause-of-death statement is to
report an underlying cause of death that is as etiologically
specific as possible based on current medical knowledge.
• To-date, there is no known, reportable cause of floppy mitral
valve syndrome, thus, it is a "competent" underlying cause of
death.
• In this example, "atherosclerotic coronary artery disease"
is the underlying cause of death.
Part I
A. Acute myocardial infarction
Due to, or as a consequence of:
B. Atherosclerotic coronary artery disease
Due to, or as a consequence of:
C.
• "acute myocardial infarction" was the final and fatal
complication of the coronary artery disease and is the
immediate cause of death (the final condition that was a
complication of the underlying cause of death and which
directly culminated in death).
• Note that in this case, only two lines were needed to complete
the cause-of-death statement.
• You can see the value of reporting the atherosclerotic coronary
artery disease as the underlying cause of death because there
are a number of conditions that may cause acute myocardial
infarction.
Part I
A. Acute myocardial infarction
Due to, or as a consequence of:
B. Atherosclerotic coronary artery disease
Due to, or as a consequence of:
C.
• Examples of other possible causes of acute myocardial infarction
include coronary artery vasculitis, coronary artery anomalies,
embolism from other diseases at other sites, trauma, etc.
• If only the acute myocardial infarction were reported, a user of
the cause-of-death statement would not know which underlying
condition existed in the patient.
• ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Part I
A. Acute myocardial infarction
Due to, or as a consequence of:
B. Coronary artery vasculitis
Due to, or as a consequence of:
C.
• -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------• -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
• ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Part I
A. Acute myocardial infarction
Due to, or as a consequence of:
B. Coronary artery anomalies
Due to, or as a consequence of:
C.
• -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------• -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
• ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Part I
A. Acute myocardial infarction
Due to, or as a consequence of:
B. Coronary artery embolism
Due to, or as a consequence of:
C.
• -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------• -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
• It may not always be possible to report an immediate cause of
death.
• Consider a 60 year-old man who had widely metastatic, terminal
prostate carcinoma, whose death was expected, and who died
at home. Permission for autopsy could not be obtained.
• It might be necessary to write the cause-of-death statement as:
Part I
A. Metastatic Adenocarcinoma of the prostate
Due to, or as a consequence of:
B.
Due to, or as a consequence of:
C.
• Insufficient information existed to cite an immediate cause-ofdeath such as pneumonia, midbrain metastasis, or some other
cause.
• In cases such as this one, Line A serves as both the underlying
and immediate cause of death, “Single Line Part I Format”.
• It is permissible to express uncertainty or presumption.
• One may qualify the cause-of-death statement with words such
as "probable" or "presumed“.
Part I
A. Presumed cardiac dysrhythmia
Due to, or as a consequence of:
B. Toluene poisoning
Due to, or as a consequence of:
C. Inhalation of spray paint
• In general, one need not use such terms because the cause-ofdeath statement is an opinion based on all available information
and need only meet the test of being "more likely than not“.
• There are situations, however, where the inclusion of such
wording may be helpful to indicate some degree of uncertainty.
• Patients may die of fatal nonspecific complications such as
gastrointestinal hemorrhage.
• In some cases, there may have been insufficient time to fully
evaluate the patient for the underlying disease, or inability to
obtain permission for autopsy.
• In such cases, this approach may be used:
Part I
A. Gastrointestinal hemorrhage
Due to, or as a consequence of:
B. Undetermined natural causes
Due to, or as a consequence of:
C.
• Of course, one should be reasonably certain that only natural
causes were involved and that there is no other reasonably
probable underlying cause of death.
• Using such an approach lets a user of the cause-of-death
statement know that thought was given about the underlying
cause of death and it wasn't just omitted through oversight.
• Using the same scenario as on the previous screen, but adding
that the patient had symptoms and signs strongly pointing to
peptic ulcer disease as the cause of the gastrointestinal
hemorrhage, it would be preferable to write the cause-of-death
statement as:
Part I
A. Gastrointestinal hemorrhage
Due to, or as a consequence of:
B. Probable peptic ulcer disease
Due to, or as a consequence of:
C.
• Medical judgment is required when picking the best alternative
for writing the cause-of-death statement.
• Truthfulness, completeness, and reasonable accuracy should be
the goal
• Convenience and expedience should not play a role when
deciding upon a cause-of-death statement.
• This is an example of a POORLY WRITTEN cause-of-death
statement which, unfortunately, is typical of many death
certificates that are completed by physicians.
Part I
A. Septic shock
Due to, or as a consequence of:
B. Gram-negative sepsis
Due to, or as a consequence of:
C.
• One must immediately ask "Why did this patient have gramnegative sepsis? that's not something that most healthy people
get, and spontaneous occurrence must be extremely rare."
• The truth is that the patient had multiple sclerosis and a chronic
indwelling catheter for a neurogenic bladder, which resulted in
the urinary tract infection.
• An accurate and complete cause-of-death statement is:
Part I
A. Gram-negative pseudomonas sepsis
Due to, or as a consequence of:
B. Urinary bladder infection
Due to, or as a consequence of:
C. Indwelling catheter for neurogenic bladder
Due to, or as a consequence of:
D. Multiple sclerosis
• This example is much more informative and of greater potential
use than the preceding example.
• It tells the specific story and sequence of events that led to this
patient's death.
• So far, each of the examples has involved only a single
underlying disease entity.
• But what if more than one condition (disease or injury) seemed
to have added together to cause death?
Part I
A.
Due to, or as a consequence of:
B.
Due to, or as a consequence of:
C.
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
• " Part II may be used to report conditions that co-existed or
pre-existed and contributed to death but did not result in the
underlying cause of death reported in Part I.
• This case is a classic example of the intended use of Part II.
• Assume that the patient had a clinical course strongly pointing
to coronary atherosclerosis with acute myocardial infarction.
Part I
A. Acute myocardial infarction
Due to, or as a consequence of:
B. Atherosclerotic coronary artery disease
Due to, or as a consequence of:
C.
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
-------------------------------------------
• However, the patient also had hypertension which was thought
to have been partially responsible for cardiomegaly which
increased cardiac oxygen demand and facilitated the adverse
effects of the coronary artery disease.
• This case is a classic example of the intended use of Part II.
• Assume that the patient had a clinical course strongly pointing
to coronary atherosclerosis with acute myocardial infarction.
Part I
A. Acute myocardial infarction
Due to, or as a consequence of:
B. Atherosclerotic coronary artery disease
Due to, or as a consequence of:
C.
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
Essential hypertension
• The hypertension co-existed and contributed to death, but did
not cause the underlying cause of death in Part I.
• Hypertension, then, is correctly reported in Part II as an other
significant condition..
• Part II can also be used another way.
• Consider a patient with AIDS who dies with complications
including pneumocystis carinii pneumonia and disseminated
mycobacterium avium complex
• clinically, the pneumocystis pneumonia seemed the most
significant in causing terminal pulmonary problems:
Part I
A. Pneumocystis carinii pneumonia
Due to, or as a consequence of:
B. Acquired immune deficiency syndrome
Due to, or as a consequence of:
C. Human immunodeficiency virus infection
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause of
death in Part I
-----------------------------------------------------• The most important condition should be cited in Part I and the
lesser important one(s) should be cited in Part II.
• This example fits nicely with the intended use of Part II.
• The disseminated mycobacterium infection did contribute to
death.
• Although it resulted from the underlying cause of death
reported in Part I, it did not result in death directly.
Part I
A. Pneumocystis carinii pneumonia
Due to, or as a consequence of:
B. Acquired immune deficiency syndrome
Due to, or as a consequence of:
C. Human immunodeficiency virus infection
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause of
death in Part I
Disseminated mycobacterium avium infection
• More than one condition may be reported in Part II, and it is
often necessary to do so.
• A third way to use Part II is for reporting risk factors.
• For example, the cause-of-death statement for a man who was
a heavy cigarette smoker and who died of Klebsiella pneumonia
as a complication of emphysema may be written as:
Part I
A. Community-acquired Klebsiella pneumonia
Due to, or as a consequence of:
B. Emphysema
Due to, or as a consequence of:
C.
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
Cigarette smoking
• One might argue that whether the cigarette smoking has caused
the emphysema?. In a specific case, however, it may be difficult
to know that a cause-and-effect relation existed.
• The same method of reporting risk factors may be used for
other risk factors (such as diabetes mellitus, obesity, alcohol
intoxication, intravenous drug abuse, etc.) that existed in the
patient and is relevant to the cause-of-death sequence reported
in Part I.
Part I
A. Cerebral toxoplasmosis
Due to, or as a consequence of:
B. Acquired immune deficiency syndrome
Due to, or as a consequence of:
C. Human immunodeficiency virus infection
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
Intravenous drug abuse
• It is not necessary to include the words "risk factor," but doing
so does clarify the nature of the reported condition.
Onset - to - Death time interval
• Part I also contains space on each line to indicate the
interval between the onset of each condition cited and
death.
• It should be apparent that the intervals should get longer (or
at least not get shorter) as one reads from top to bottom.
• The interval since diagnosis should NOT be stated if a
condition is known to have existed for a longer period of
time.
Onset - to - Death time interval
• These intervals are stated as accurately as possible.
• Intervals may also be approximate and generic intervals
such as "seconds," "minutes," "hours," "days," "weeks,"
"months," "years," and "decades" are acceptable.
•
“unknown" is also acceptable if such is the case.
Manner Of Death
• The manner of death is a description of the circumstances
surrounding death, how the cause of death arose, or
circumstances in which the cause of death transpired
• The manner of death is classified as natural when death is
due solely to disease, and unnatural when death is caused
or contributed to by injury or poisoning.
• There are generally considered to be five manners of death:
natural, accident, suicide, homicide, and undetermined
N.B. Some jurisdictions include another category, therapeutic complication
Natural Death
A natural death is any death that is exclusively (100%) the direct
result of the progression of a natural, medically recognized
disease process.
If an injury (or poisoning ) of any sort causes or contributes to
death,
- no matter how trivial the contribution,
- no matter how long after the injury death occurred,
the manner of death cannot be natural.
Natural Death
Cancer
Chronic Hepatitis B infection
Systemic lupus erythematosus
Chronic obstructive pulmonary disease
Atherosclerotic coronary artery disease
The foreseeable and expected complications of these
diseases would also be classified as natural
Unnatural Death
Any death that is not the direct and complete result of a natural,
medically recognized disease.
Death where an outside intervening influence,
- either directly or indirectly is contributory to the individual’s
demise, or
- accelerates and exacerbates an underlying disease process to
such a degree as to cause death.
Natural Death Vs Unnatural Death
Fulminant hepatitis due to acute hepatitis B infection
would be classified as natural
Fulminant hepatitis due to acetaminophen overdose
(homicide, suicide or accident) would be classified as
unnatural
Natural Death Vs Unnatural Death
Acute bacterial bronchopneumonia may be the direct
cause of death following:
 aspiration following an epileptic fit
 homicidal stab to the chest
 suicidal drug overdose with subsequent coma and
aspiration
 blunt traumatic chest injuries in a motor vehicle accident
What would change in each instance, is the manner of
death
Principles … “Cause of Death Statement”
• Make every effort to report an etiologically specific
underlying cause of death.
• Try to use a Sequential Part I Format, if possible.
• Err on the side of reporting too much rather than too little.
• DO NOT report mechanistic terminal events such as:
cardiopulmonary arrest
Asystole
ventricular fibrillation
electromechanical dissociation
• DO NOT report symptoms or signs.
• DO NOT report a condition if its existence in the patient is
obvious based on another reported condition.
• DO NOT oversimplify.
• DO NOT use abbreviations.
Scenario ,,,
A chronic alcoholic
• developed cirrhosis, jaundice, ascites, portal-systemic
shunt, caput medusae, hyperammonemia, asterixis,
hepatic encephalopathy,
• and then … …
• respiratory arrest followed by cardiac arrest and death
These conditions are to be listed in approximate sequence
from most recent to the oldest …. and ……
the conditions to remain for writing the cause-of death
statement are determined by applying the Principles…
Rationale …
• Cardiac arrest and respiratory arrest are mechanistic
terminal events.
• Asterixis, caput medusae, ascites, and jaundice in this
case were either symptoms or signs.
• Hyperammonemia is just one component of a complex
process, and to cite it would be oversimplification.
• Portal-systemic shunt was eliminated because its existence
seemed apparent based on the other reported conditions,
although it could have been retained to err on the side of
reporting too much rather than too little.
• Cirrhosis and hepatic encephalopathy remain, are major
conditions in the sequence that led to death, and enable the
use of a Sequential Part I format.
• Chronic alcohol abuse was retained because it was the
underlying cause of death.
• Now, the cause-of-death statement is easily written as
shown on the following screen.
• By using the Principles, the following cause-of-death statement
may be written:
Part I
A. Hepatic encephalopathy
Due to, or as a consequence of:
B. Cirrhosis of the liver
Due to, or as a consequence of:
C. Chronic alcohol abuse
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
• The cause-of-death statement tells a complete story about how
this patient died compared to how someone else may have died
of the same underlying cause of death.
• In other words, not all patients with hepatic encephalopathy
have cirrhosis, and not all patients with cirrhosis acquired it
from chronic alcohol abuse.
Scenario ,,, ,,,
A 72 year old woman
• had a 20 year history of type II diabetes mellitus for which
insulin had been required for about 3 years.
• 5 years previously she had a stroke (cerebral infarction) ,,
left her bed-ridden and dependent on long-term care.
• work up revealed; carotid bruits and marked occlusion of
the carotid arteries by atherosclerosis.
later, she developed decubiti which became infected with
proteus mirabilis, leading to septic shock and death
• By using the Principles, the following cause-of-death statement
may be written:
Part I
A. Proteus mirabilis infection of decubitus ulcers
Due to, or as a consequence of:
B. Remote cerebral infarction
Due to, or as a consequence of:
C. Carotid artery atherosclerosis
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
Type II Diabetes mellitus
• Diabetes was listed in Part II because it is a risk factor for
atherosclerosis, and it was also felt to predispose the patient for
soft tissue infection.
• In this example, diabetes mellitus is the underlying cause of
death.
Part I
A. End-stage renal disease
Due to, or as a consequence of:
B. Diabetic nephropathy
Due to, or as a consequence of:
C. Type I diabetes mellitus
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
Ischaemic heart disease
• Always remember to specify whether your patient’s diabetes
was type one, or type two and the complication or sequence
that led to death.
Death Certification Errors
• Death certification errors are common and range
from minor to severe
• We attribute errors to house staff inexperience,
fatigue, time constraints, unfamiliarity with the
deceased, and perceived lack of importance of the
death certificate
Mechanisms of death should not be used in cause-of-death statements
Abbreviations should not be used anywhere in cause-of-death statements
Citing a nonspecific process as the underlying cause of death without qualification, ie,
unspecified etiology
Nonsequential listing of conditions
The underlying cause of death (disease or condition that initiated the morbid train of events
leading to death) is listed in Part II
Hypertension is another significant condition that likely contributed to but did not cause death
The man’s alive Sir, for
he has open’d one eye.
The doctor declar’d him Dead two hours
since & he must remain Dead Sir, so I shall
preceed with the Inquest
A Coroner’s Inquest. London:
( Courtesy of the United States National Library of Medicine
The man’s alive Sir, for
he has open’d one eye.
The doctor declar’d him Dead two hours
since & he must remain Dead Sir, so I shall
preceed with the Inquest
A Coroner’s Inquest. London:
( Courtesy of the United States National Library of Medicine
Death in The Elderly - Principles
• It would be considered unlikely that patients would die of old
age, with no apparent disease or injury, in an acute hospital
• Coexistent medical problems that may have contributed to
death should be sought
• The certifier should not overlook possibilities of: abuse or
neglect ,,, inconspicuous injury ,,, suicide ,,, hypothermia
and hyperthermia
• Dementia should not be overlooked
Death in The Elderly
Generally, old age is not acceptable as a cause of death
Aging is not a disease, and “old age” does not contribute to
vital statistics.
Old age should only be given as the sole cause of death in
very limited circumstances. These are that:
•
•
•
•
You have personally cared for the deceased over a long period (many
months or years)
You have observed a gradual decline in your patient's general health and
functioning
You are not aware of any identifiable disease or injury that contributed to
the death
You are certain that there is no reason that the death should be reported
to the coroner (unnatural)
• By using the Principles, the following cause-of-death statement
may be written:
Part I
A. Subdural haematoma
Due to, or as a consequence of:
B. Blunt force head trauma
Due to, or as a consequence of:
C. Fall
Part II. OTHER SIGNIFICANT CONDITIONS: Conditions
contributing to death but not resulting in the underlying cause
of death in Part I
Senile dementia
• In this case, an injury event (the fall) seems to have been
brought about by natural disease (senile dementia), but death
clearly resulted from trauma.
When no specific condition could be ascribed ,,,,,,,
An option for certification include “undetermined natural causes”
as a last resort choice
The man’s alive Sir, for
he has open’d one eye.
The doctor declar’d him Dead two hours
since & he must remain Dead Sir, so I shall
preceed with the Inquest
A Coroner’s Inquest. London:
( Courtesy of the United States National Library of Medicine
Therapy-Related Death
Therapeutic maneuvers may contribute to death
For example …
a patient with acute myelogenous leukemia is treated
with chemotherapy that leads to neutropenia
While neutropenic, the patient develops invasive
pulmonary aspergillosis and dies
natural course of disease was altered by therapeutic
intervention with a known risk of complication
Therapy-Related Death
The standard of care was followed but the manner of
death was unnatural, therapy-related
Therapy-related death does not equate with, imply, or
assume malpractice or negligence
However …
Neglect or failure of a health care provider to intervene
in a patient’s management when medically necessary
may result in a reportable unnatural death
A Coroner’s Inquest. London:
( Courtesy of the United States National Library of Medicine
Juror (the local barber): The man’s alive Sir, for he has open’d one eye
Coroner: Sir, the doctor declar’d him Dead two hours since & he must
remain Dead Sir, so I shall proceed with the Inquest
A Coroner’s Inquest. London:
( Courtesy of the United States National Library of Medicine
Juror (the local barber): The man’s alive Sir, for he has open’d one eye
Coroner: Sir, the doctor declar’d him Dead two hours since & he must
remain Dead Sir, so I shall proceed with the Inquest