"How many of you have ever written a death certificate?" I was giving a continuing medical education lecture to my clinician colleagues. I figured I'd start with the basics. Most of the hands in the room went up. "How many of you, even if you have never written a death certificate, have had to interact with the coroner or medical examiner when they called you about one of your patients who had died?" Now all the hands were up. "How many of you have ever had any training about how to write a death certificate?" Not one hand. I can't say I was surprised. Back when I was in medical school, this topic was not covered. I learned it on the job, as a forensic pathology fellow. In the twenty years since, I've seen a lot of death certificates written by clinicians. You can tell when they're winging it. I had seen their certification errors cause complications for the coroner's office, the families of the deceased, and their own colleagues. My patient died. Now what? DO declare death. Seriously. Check for a heartbeat and breathing. Use an EKG to confirm that there is no longer electrical activity. It is really bad form to mess this up; it scares the bejeezus of the morgue techs when the allegedly dead person starts to move, and you're opening up a can of lawsuits against yourself and your hospital. DO write the death certificate if the death is due to natural disease. Doctors sometimes get hung up on what to write when the patient has multiple medical problems. Use the most serious disease the patient had as the cause of death. Add the phrase "complications of" if there are lots of things wrong that all stem from that etiologically significant condition. If they also have other medical conditions that exacerbated their disease, put those under "other significant conditions contributing to death." Familiarize yourself with the CDC handbook on medical death certification, and you will never worry about this again. DO report the death to the medical examiner or coroner if the death was due to any accident or injury, even if you think the injury contributed just a little bit. If an injury, poisoning, or trauma causes your patient to decline and not return to baseline then you must report the case to the medical examiner, even if that incident happened years ago. The medical examiner may want to pursue an investigation to determine whether the death might actually be classified as an accident, suicide, or a homicide. DO play nice with the coroner or medical examiner staff. These people may not have your medical training, but they do know more than you do about death certificates. They can guide you in what the Department of Health will accept or reject. When a death certificate is rejected, the coroner has to investigate and re-write it, or they have to get you to fix it, causing funeral delays and fees for your patient's family. DO explain the death to the patient's family. I can't begin to tell you how many family members complain that I, the forensic pathologist, am the "first doctor who explained things to me." Take the time to talk to the family about your patient's final hours, and don't assume that they automatically understand precisely why their loved one died, even if they have been sitting by the sickbed for weeks. DO follow up on the autopsy findings. Consider inviting the autopsy pathologist to M&M conference to examine whether anything was missed that might affect your management of other patients. DO call risk management if the death was due to a medical error, or if the family was particularly angry or litigious. The lawyers at risk management are there to protect you. They would rather be notified of a problematic situation by you than be blindsided by a subpoena when you have already rotated off service. DON'T write "cardiorespiratory arrest," or any other vague condition that could have arisen from multiple causes, on the death certificate. The cause of death needs to be a disease -- not a mechanism or physiologic abnormality. For example, "sepsis" is not a sufficient cause of death. It doesn't tell me the source of the systemic infection, or how the patient became fatally ill. "Sepsis due to complications of diabetes mellitus" works. So does "septic complications of immunodeficiency due to chemotherapy for bladder cancer." Both are detailed, specific, and will pass muster. Heed these do's and that one big don't. If you need help, call your friendly neighborhood coroner or medical examiner. We are experts at death certification and we can guide you on how to properly navigate these important legal responsibilities. Judy Melinek, MD, is a forensic pathologist and CEO of PathologyExpert Inc. Her New York Times bestselling memoir, co-authored with her husband, writer T.J. Mitchell, is Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner. They've also embarked on a medical-examiner detective novel series with First Cut, now available from Hanover Square Press. Source
