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

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, asystole, 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.

ADDITIONAL INFORMATION

•  Unless directed by a coroner, non-forensic pathologists should never sign a death certificate in any manner other than “natural.”
• Deaths that occur as a result of chronic alcohol abuse (pancreatitis, cirrhosis, seizures) typically are classified as natural deaths.
• Record the interval between onset and death as accurately as possible. If the exact duration is not known, list this in general terms such as seconds, days, months, or years.
• Should your opinion of the cause of death change upon the receipt of new information, it is possible to amend a death certificate. A court order may be required, so check with your state for guidance in this area.

Death certificates are critical documentation for legal purposes, and they provide vital information for public health. Recording the cause of death with etiological specificity, plus the chain of causal events leading to the death will assist in accurate completion of a death certificate.

CDC GUIDANCE ON DEATH CERTIFICATES
The Centers for Disease Control and Prevention offer free guidance on the accurate completion of death certificates.

RESOURCES

• Physicians’ Handbook on Medical Certification of Death
• Possible Solutions to Common Problems in Death Certification
• Instructions for Completing the Cause-of-Death Section of the Death Certificate
• Cause of Death Mobile App

ONLINE TRAININGS
Improving Cause-of-Death Reporting: This web-based training offers guidance on how cause-of-death information is used, how to complete death certificates, when to refer a case to a medical examiner or coroner, and where to access additional resources. Receive 0.75 AMA PRA Category 1 Credits for completion. Available for no charge.

ADDITIONAL GUIDANCE
The CDC also offers specific guidance for the following circumstances on its website:

• Covid-19
• Mpox
• Drug overdoses
• Injury and poison
• Disasters
• Sudden Unexpected Infant Death and Sudden Infant Death syndrome

¹  Pritt BS, Hardin NJ, Richmond JA, Shapiro SL. Death certification errors at an academic institution. Arch Pathol Lab Med 2005;129:1476-1479. | Sehdev AE, Hutchins GM. Problems with proper completion and accuracy of the cause-of-death statement. Arch Intern Med. 2001;161:277–284. | Myers KA, Farquhar DR. Improving the accuracy of death certification. CMAJ. 1998;158:1317–1323.