Corresponding Author: Erin G. Brooks, MD; Department of Pathology and Laboratory Medicine; University of Wisconsin Hospital and Clinics; L5/149 Wisconsin Institutes for Medical Research; 1111 Highland Avenue; Madison, WI 53705; Tel: (608)265-0884; Email: ude.csiw@skoorbge
Received 2015 Feb 13; Revised 2015 Apr 23; Accepted 2015 Apr 27. Copyright © 2015 Marshfield ClinicDeath certificates serve the critical functions of providing documentation for legal/administrative purposes and vital statistics for epidemiologic/health policy purposes. In order to satisfy these functions, it is important that death certificates be filled out completely, accurately, and promptly. The high error rate in death certification has been documented in multiple prior studies, as has the effectiveness of educational training interventions at mitigating errors. The following guide to death certification is intended to illustrate some basic principles and common pitfalls in electronic death registration with the goal of improving death certification accuracy.
Keywords: Death certification, Electronic death registration, Death record, Cause of death, Manner of death
The death certificate is an important legal document. In addition to providing the decedent’s family with a cause of death, it has critical administrative and epidemiologic applications. Death certificates may be required to settle decedents’ estates and obtain insurance or other pensions/benefits. In many states, death certification is required prior to cremation or burial services. At both the state and national level, mortality data compiled from death certificates is used to track disease trends, set public health policies, and allocate health and research funding. 1 , 2 For these reasons, it is important that death certificates be filled out completely, accurately, and promptly.
In most states, there is a specified time within which the death certificate must be filed. For instance, in the State of Wisconsin, physicians are required to complete and return the medical certification portion of the death certificate within a maximum of 6 days of the date of death pronouncement, 3 and it is considered a Class I felony to “willfully and knowingly” supply false information on a death certificate. 4 Despite the importance of accurate death certification, errors are common. Studies at various academic institutions have found errors in cause and/or manner of death certification to occur in approximately 33% to 41% of cases, 5 – 7 with disproportionate overrepresentation of cardiovascular causes of death. 8 , 9 Among the reasons most commonly cited for major errors in certification are physician inexperience (eg, resident physicians) and lack of appropriate death certification training. When brief educational interventions such as didactic seminars or distribution of printed guidelines are made, error rates have been shown to decrease markedly. 7 , 9 For instance, in one study of 200 resident physicians asked to complete a cause-of-death statement from a sample hospital death case, only 15.5% correctly identified the cause of death. Following either a workshop or review of printed guidelines, 84.5% could correctly identify the cause of death. 9 The following review is intended to educate medical certifiers about basic principles and common pitfalls of electronic death registry and certification in order to improve accuracy. While some of the principles discussed herein apply to perinatal deaths, the general topic of perinatal (ie, fetal and infant) death certification has very different practical considerations and challenges that are beyond the scope of the current review.
While there may be some minor variability between states, most death certificates conform in content and structure to the US Standard Certificate of Death ( figure 1 ). 1 There are three main categories of information contained on the standard death certificate: demographics/statistics (eg, name, social security number, race, occupation), method/place of bodily disposition (eg, funeral home, burial vs. cremation, cemetery site), and death information (eg, date and time, cause, manner). 1 , 2 Only certain individuals are qualified to officially pronounce death. For instance, in the state of Wisconsin, death can be pronounced by a physician, hospice nurse, medical examiner/coroner (ME/C), or deputy ME/C. 10 While in some states medical examiners are required to be medical doctors, in Wisconsin this is not necessarily so. The term ‘pronouncement’ refers to the date and time when the individual was found to be legally dead and, particularly in ME/C cases, may not always correspond to the time death is actually suspected to have occurred. For instance, an individual expiring alone in a secured residence may not actually be discovered and pronounced dead until days afterward ( table 1 ).