Nothing is certain but death (…and paperwork)

The next part is cumbersome but an equally critical component of the death process entrusted to JMOs – the paperwork. Whilst the forms may vary in appearance and organization, generally, the process is the same and involves:

1. A determination of whether the death is reportable to the coroner (usually a checklist),

2. A cremation certificate (filled in pre-emptively should the family wish the body to be cremated) and

3. A death certificate

Finally, a medical discharge summary should still be completed by the JMO (or left to the treating team if certified after-hours).

Do I report this to the coroner?

Before proceeding with any paperwork, the JMO should decide whether the death is reportable to the coroner. This is because if the death is reportable, the JMO should NOT fill in the death certificate. The circumstances under which a death becomes subject to a coronial enquiry varies in the fine print from state to state. In NSW this is spelled out in the Coroner’s Act 2009. Some of the common and better-remembered criteria include a violent or unnatural death; a sudden death for which the cause is unknown; death under suspicious circumstances; death whilst in or temporarily absent from a mental health facility. JMOs are not expected to remember all of the criteria which is why most hospitals now have a checklist on hand containing the criteria.

If the JMO suspects a death may be reportable to the coroner they should notify the consultant or senior registrar looking after the patient. Following this, the next step is usually to contact the local police station and inform them of the coroner’s case. The police will attend a hospital (or a scene of death) on behalf of the coroner to obtain details about the deceased and gather information about the death from healthcare staff, family, friends and other witnesses. At this point, the patient and surroundings are treated as a crime scene and it would be pertinent to remind the nursing staff that all drips, nasogastric tubes, catheters, cannulas should be left in situ and untouched pending police inspection. Instead of completing the death certificate, there is usually an alternate form for cases reported to the coroner.

In most cases, the death is not reportable to the coroner, and the JMO can proceed to complete the death certificate.

Death certificates – What’s the point?

We all know that the death certificate is a legal document required by the family to obtain permission for funeral arrangements and for other legal matters including the will. However, what most JMOs do not know is that the main purpose behind writing the cause of death is epidemiological in nature.

When a death certificate is completed, the cause of death is then coded according to an international disease classification. The codes are then added up to form our national mortality statistics which are used by policymakers as the basis for determining national and global priorities to improve health. Furthermore, all countries, including Australia, are required to report their national mortality data to the World Health Organization which is used to inform global health initiatives. Indeed most death certificates, including our own, look similar across the world because they follow an international template set by the WHO.

By appreciating the above, you should now understand that the face of our future healthcare services is shaped by the quality of information provided on the death certificate. I also found that this knowledge made filling out the death certificate easier as shown below.

Filling out a death certificate

Disease or condition leading directly to death

As mentioned above, death certificates follow an international template and this consists of two main parts. Part I requires JMOs to document the diseases or conditions directly leading to the death which are written in a logical sequence ending in the underlying cause of death. The most important clue to filling out this section is that the mortality statistics are based on the underlying cause of death – this is the disease process or injury that initiated the sequence of events leading to the death i.e. the disease written in the bottom line.

One example, taken from the University of Queensland’s Handbook for Doctors on cause-of-death certification, asks you to imagine a person dying from a cerebral haemorrhage following a motor vehicle accident. In this case, the MVA is the underlying cause of death. Although the surgeon is concerned about cerebral haemorrhage, the public health focus would be to prevent deaths due to motor vehicle accidents.

If there is only one cause of death, it should be entered on the first line (1a).

Other significant conditions

The second part requires doctors to note other significant conditions that may have contributed to the death but are not directly related to the death. Often this second part is referring to disease that may have reduced the patient’s physiological reserve and prevented them from overcoming or recovering from disease e.g. Diabetes, hypertension, ischaemic heart disease, dementia, chronic obstructive lung disease, previous malignancy.

Tips and tricks for filling out a death certificate

There are some excellent open-access resources and guides for filling out death certificates with specific details based on types of conditions. Some of these have been included in the references section below. I have chosen a few of the useful tips highlighting common pitfalls in writing out death certificates:

• Avoid non-specific terms such as cardiac failure, respiratory failure or shock whenever possible. At the very least they should never be the underlying diagnosis (i.e. the final line)
• Where sepsis is the underlying cause, always state the organism or write ‘organism unknown’ if truly unknown – e.g. methicillin sensitive staphylococcus aureus septicaemia
• Pneumonias should be differentiated between hypostatic and aspiration and are usually not the underlying diagnosis. For example, dementia may be the underlying cause for a hypostatic pneumonia caused by inactivity
• Pulmonary embolism usually has an inciting factor as the underlying cause. Where a fatal PE results as a post-operative complication, the underlying diagnosis is actually the reason for the operation (e.g. motor vehicle accident resulting in a tibial fracture)
• Avoid ‘old age’ unless there is evidence of a very gradual decline in their ability to function over several months, and even then is usually a contributing factor rather than the primary mode of death
• Don’t forget tobacco smoking as a comorbidity!
• In most states, deaths resulting from a trauma or accident in an elderly patient (greater than 72) which may be attributable to old age (such as a fall) do NOT need to be reported to the coroner.

Case study

Consider the following scenario – a 65-year-old male with a history of hepatitis C presents with severe haematemesis and jaundice. The haematemesis was subsequently found to be due to bleeding oesophageal varices secondary to liver cirrhosis and portal hypertension. He died shortly after his endoscopy. His background medical history included chronic obstructive pulmonary disease, hypertension and smoking.

For the first part, the diseases leading to the cause of death would include the following:

1a. Hypovolaemic shock due to (as a consequence of)

1.b Bleeding oesophageal varices due to (as a consequence of)

1.c Portal hypertension due to liver cirrhosis due to (as a consequence of)

1.d Hepatitis C (underlying cause of death)

As you can see above, the underlying cause of death is hepatitis C (highlighted) and would be the main public health concern. Also notice that if you run out of lines, you can write two conditions on the same line (as in 1.c) as long as you make the logical sequence clear.

The second part, other significant conditions, would include all the comorbidities – COPD, hypertension and nicotine dependence – which theoretically have all reduced this patient’s physiological reserve and ability to survive the primary cause of death.

For more worked examples such as these, from neoplasms to infections and injuries – check out the resources below.

What if I don’t get the exact sequence of events correctly?

One worry that I had as an intern was that reporting the cause of death incorrectly made me legally liable resulting in much time and angst wasted over the exact wording of the death certificate. But this is a common misconception – Death certificates are regarded as medical opinion limited to the information available at the time and as such lawsuits against death certifiers are exceedingly rare and usually rule in favour of the certifier. And in any case, death certificates can be amended if required. So as a rule of thumb – do the best you can to get it right but don’t fret excessively over it. As always, if you aren’t sure, never hesitate to ask a senior colleague (such as the team registrar) for advice.

Can I complete the death certificate if I haven’t seen the patient?

Most state laws concerning the certification of death do not require you to have viewed or examined the body before issuing the death certificate. In fact there is no requirement that you had even been involved in the patient’s care prior to the death. What matters is that you have sufficient information – from the patient’s records and from speaking to other doctors who may have cared for the patient previously – to make a reasoned and informed opinion as to the cause of death.

Go forth and verify

The process of verifying and certifying death rarely features as part of formal medical training and yet is one of the most fundamental and important skills expected of junior medical officers. It should also be regarded as a great privilege – from the swinging of the pen torch to the passing of the stethoscope from sternal edge to sternal edge, junior doctors all across the world perform the same ritual that sees the legal transition of bodies from life to death.

References

1. Broad, J., Gott, M., Hongsoo, K., Chen, H. and Connolly, M. (2013) ‘Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential care settings in 45 populations, using published and available statistics’, International Journal of Public Health, 58, p 257-267
2. Higginson, I., Sarmento, V., Calanzani, I., Benalia, H. and Gomes, B. (2013). ‘Dying at home – is it better? A narrative appraisal of the state of the science’, Palliative Medicine, 27(10), p 918-924
3. Swerissen H., Duckett S.“Dying Well” (2014). Grattan Institute