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Death Certification: A Final Service to Your Patient

Chief medical examiner discusses a vexing problem

By Stephen J. Cina, MD

It is never easy to lose a patient. Although the patient may have risk factors for sudden death, such as hypertension, hyperlipidemia, obesity, and diabetes mellitus, the moment of death is most often unexpected. Despite the sudden nature of some natural deaths, most often they do not fall under the jurisdiction of the Medical Examiner or Coroner if there are no suspicious circumstances and the patient is “attended” by a physician. There is a misperception that attendance implies physical presence when, in fact, a physician may be considered attending to a patient if the person is being seen in the office or home by that physician or designee or if the patient is refilling prescriptions written by a physician.

It is clear in the Illinois Vital Records Act that physicians are responsible for signing death certificates within 48 hours of their patient’s death unless the case falls under Medical Examiner or Coroner jurisdiction. Violation of this law is a misdemeanor and may be a reportable offense to the disciplinary board; more important, failing to provide this final service to the patient is a breach of duty to the patient and to the surviving family.

Clinicians cite a variety of reasons for failing to sign death certificates following the demise of their patients due to natural causes. One fear revolves around possible litigation surrounding an incorrect death certificate. I personally have not seen a clinician sued over a wrong cause of death, but I have encountered many families (and funeral home staff) who were upset with physicians for failing to sign death certificates and delaying funerals or cremation.

Another cause of concern centers on physicians needing to be “right.” Many of us are generally Type A personalities with some obsessive-compulsive features. With respect to death certification, the standard is not a “reasonable degree of medical certainty”; rather, it is more likely than not (requiring a 51% chance of being correct). Most patients who die suddenly and have a history of cardiovascular disease risk factors will die of a cardiac dysrhythmia, acute myocardial infarction, cerebrovascular accident, or aortic dissection or aneurysm rupture. If that is the case, arteriosclerotic cardiovascular disease (ASCVD) or hypertensive cardiovascular disease (HCVD) covers the most likely scenarios. It is also permissible to preface the above causes of death with the word “probable.” Last, clinicians sometimes feel uneasy when a patient dies and they were doing well during their last visit. Unfortunately, cardiovascular disease results in sudden death that we often can’t predict.

When clinicians do not sign death certificates on their patients, the Medical Examiner or Coroner is not bound to do so. In fact, our office will not accept jurisdiction over cases if the sole reason to do so is clinician discomfort with death certification. In the event that we do choose to examine the body for some reason, there will be no autopsy and we will be making an educated guess as to the cause of death based on the circumstances of death and whatever medical history is provided by the family, funeral home, or clinician. Clearly, the decedent’s physician is in a better position to certify death in these cases.

The back side of the death certificate lists causes of death that require further qualification (e.g., cardiac arrest is a symptomsof death, not a cause of death). The Medical Examiner’s Office is happy to provide advice to clinicians on how best to certify the deaths of their patients and its office is staffed 24/7 to do so). In most cases, unless the patient has died due to trauma or its sequelae, drugs, or under suspicious circumstances and is over 50 years of age, it is likely most proper for the clinician to sign the death certificate. When in doubt, call our office. Our staff is also happy to lecture on this topic to hospital staff, residents, and medical students.

The following causes of death may be useful and may expedite the dignified final disposition of patients and allow closure for grieving families:

  • Arteriosclerotic cardiovascular disease
  • Hypertensive cardiovascular disease
  • Obesity-related heart disease
  • Complications of diabetes mellitus
  • Sudden cardiac death due to probable myocardial infarction
  • Non-traumatic intracerebral hemorrhage
  • Undetermined natural causes

Finally, remember that “natural” mechanisms of death (e.g., sepsis) fall under the jurisdiction of the Medical Examiner or Coroner if the chain of events that culminated in death (i.e., the underlying cause of death) was a traumatic incident (e.g., sepsis due to pneumonia due to paraplegia due to remote gunshot wound). Similarly, if a traumatic event contributed to death (e.g., hip fracture considered contributory to a patient’s clinical decline), Medical Examiner or Coroner jurisdiction will apply.

Dr. Cina is chief medical examiner of Cook County. For advice on how to best certify the deaths of patients, call 312-666-0200. The office is staffed 24/7.

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