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Introduction and History

The World Health Organization (WHO), as part of its mission, develops standards for the collection and
classification of mortality data so that international comparisons may be made. The United States is a signatory
of the WHO and follows its policies, procedures, and regulations. The National Center for Health Statistics
(NCHS) is part of the Centers for Disease Control and Prevention (CDC) and is responsible for the collection
and analysis of mortality data in the United States. NCHS, through cooperative agreements with states, buys
mortality data from the states.
To comply with WHO standards and to promote uniformity among the states, NCHS has developed and
periodically revises the U.S. Standard Certificate of Death. To receive funds from NCHS for its data, each state
must collect and provide death data in a format consistent with the U.S. Standard Certificate of Death, so the
death certificate in each state appears somewhat similar to other states. Approximately 2.6 million deaths occur
per year in the United States, and the NCHS receives information on virtually all of them.
This chapter contains basic principles that can be used to certify deaths (complete the cause of death section
of the death certificate) in a professional manner. These principles are based largely on guidelines published by
the National Center for Health Statistics and the College of American Pathologists. [1, 2, 3]

Epidemiology
Death certificates are a valuable source for state-based and national mortality statistics. The mortality data
published regularly by NCHS are based on information from every death certificate completed in the United
States. These data are used to prioritize funding and programs geared toward prevention of death and
conditions which cause death, and allocation of federal dollars for these purposes is based in part on such
mortality data. Therefore, making death certificate information as complete and accurate as information allows
is important. The most current national mortality data usually is for the calendar year 2 years prior to the current
year.

Definitions
See the list below:

Cause of death - The disease, injury, or combination of conditions that leads to the death of the
individual
Manner of death - A classification of death based on how the cause of death was brought into play,
with the typical options being natural, accident, suicide, homicide, or undetermined
Certifier of death - The physician, medical examiner, or coroner who completes the cause of death
information and signs the death certificate attesting that, to the best of the certifiers knowledge, the death of
the named individual occurred at the date, time, place, and because of the causes as stated on the certificate
Underlying cause of death - The disease or condition that started the sequence of conditions ultimately
resulting in death
Immediate cause of death - The disease or condition that results from the underlying cause and
immediately results in death
Intermediate cause of death - A disease or condition that occurs between the underlying and
immediate cause of death
Other significant condition - A pre-existing or co-existing condition that contributes to death but did not
result in the underlying cause of death (These concepts will be clarified more fully later in this topic.)

Common Misconceptions

Many people view the death certificate as unimportant and just another piece of paper that must be completed
when a death occurs. Nothing is further from the truth. The importance of the death certificate to mortality
statistics and program prioritization has already been discussed. But on the individual case level, the death
certificate is used to settle estate and other matters and may also be used in legal proceedings.
A second misconception is that signing a death certificate may impose liability if the certifier is incorrect in
reporting the cause of death. First, the death certificate is an opinion based on information available at the time
the death certificate is completed. Second, lawsuits against certifiers of death are rare, and, when they do
occur, the certifier is usually upheld. Third, death certificates can be changed (amended) if needed.

Basic Principles
Each state has vital statistics regulations that require completion of a death certificate for each death that
occurs, and those who "certify" deaths include the following:

A physician who cared for the decedent and has knowledge of the patients medical history and cause
of death, typically certifying death only when death results solely from natural causes.
The medical examiner or coroner who investigated the death when death is due to non-natural causes,
is sudden and unexplained (even if apparently from natural causes), is suspicious or unusual, or when no
physician is present who can certify the death or under other special circumstances such as death in custody.
Depending on the jurisdiction or institution, the autopsy pathologist may sign the death certificate in
lieu of the clinician in the hospital setting, or the coroner may rely upon the autopsy pathologist or medical
examiner to provide wording or opinion about the cause and manner of death.
In some specific settings, nurses and other health care professionals may complete the death
certificate for hospice patients, especially if no physician is available.
The death certificate has specific places to indicate the cause of death, manner of death, circumstances of
death (such as dates, places, and how injury occurred [if injured]), and the certifiers name and title.
The cause-of-death statement of the death certificate is reported using part I, in which a sequence of conditions
leading to death may be reported, and part II, in which "Other Significant Conditions" may be reported if they
contributed to death.

Part I
Part I usually consists of 3 or 4 lines on which a sequence of conditions may be reported, including the
underlying cause of death, the immediate cause of death, and any intermediate cause(s) of death, as follows:

The "Underlying Cause of Death" is the condition (disease or injury) that started the downhill course of
events leading to death (such as atherosclerotic coronary artery disease).
The "Immediate Cause of Death" is the condition that was last to occur, immediately resulted in the
death, and was the result of the underlying cause of death (such as cardiac tamponade).
An "Intermediate Cause of Death" is a condition that was caused by the underlying cause of death and
resulted in the immediate cause of death or another intermediary cause of death (such as ruptured
myocardial infarct).
Thus, the cause-of-death statement using the conditions above would read:
Cardiac Tamponade

due to: Ruptured Myocardial Infarct


due to: Atherosclerotic Coronary Artery Disease

Part II
Part II is used to report one or more conditions that contributed to death, but did not result in the underlying
cause of death reported in part I, these being referred to as "Other Significant Conditions." "Other Significant
Conditions" in part II usually consist of coexisting, comorbid conditions or additional complications of the
underlying cause of death that were less important than those reported in part I.
Thus, if the person described in the above example also had hypertension with left ventricular hypertrophy
(which could increase oxygen demand and exacerbate the atherosclerotic heart disease), the cause-of-death
statement could be written as follows:

Part I
Cardiac Tamponade
due to: Ruptured Myocardial Infarct
due to: Atherosclerotic Coronary Artery Disease

Part II (Other Significant Conditions): Hypertension with cardiac hypertrophy


In general, only one condition should be reported per line in part I, but reporting more than one condition in part
II is acceptable. Examples of other cause-of-death statements are provided at the end of this section.
Another item on the death certificate is the manner of death. The typical options for manner of death are as
follows:

Natural: Death results solely from disease and/or the aging process and no external cause (injury or
poisoning) contributed to death.
Accident: An unintentional death results from an injury and/or poisoning, such deaths typically being
unforeseen and not predictable as to time and place of occurrence.
Homicide: This is due to the volitional act of another person that is meant to cause injury, harm, fear, or
death or as a result of the wanton disregard for human life.
Suicide: This is due to a self-inflicted act that was meant to do harm or cause ones own death.
Undetermined (or "Could not be Determined"): Insufficient information exists to classify the manner of
death into one of the other categories.
For each death, the manner of death must be specified. In some states, the manner of death is written in text
form; in other states, a checkbox system is used. Familiarity with the death certificate form used in your state is
important.

Mechanisms of death
Mechanisms of death may be loosely defined to include terminal events and nonspecific processes.

Terminal events
Terminal events are final common pathways of death and include such things as cardiopulmonary arrest,
asystole, ventricular fibrillation, respiratory arrest, and electromechanical dissociation. In general, terminal
events should not be reported on the death certificate because they are so common and nonspecific that they
are essentially useless for mortality statistical purposes.

Nonspecific processes
Nonspecific Processes (NPs) consist of anatomic or physiologic abnormalities and include such things as
pneumonia, cirrhosis, hyperkalemia, and many other conditions, each of which has multiple possible underlying
causes and may be reported on the death certificate using the guidelines below.
NPs may be reported on the death certificate if they contributed to death. Preferably, these should be reported
as an immediate or intermediate cause of death rather than an underlying cause of death. Reporting of a NP
helps to clarify how the underlying cause resulted in death in the present patient compared with other possible
options. In rare instances, reporting a NP alone may be necessary, but only if a reasonably certain underlying
cause of death cannot be identified know that this should be done only when absolutely necessary.

Cause-of-death statement
The cause-of-death statement for deaths due to external causes can be constructed in a way analogous to
those involving natural causes, but instead reporting the nonspecific process that caused death, the bodily
trauma that caused the nonspecific process, and the injury event that caused the bodily trauma. In a case of
cardiac tamponade that occurred from a penetrating injury of the heart because of a stab wound to the thorax,
the cause of death statement could be reported as follows:
Cardiac tamponade
due to: Penetrating wound of heart
due to: Stab wound of thorax
When death is due to non-natural causes, the certifier must also complete additional items that explain the
circumstances of death. The date and time of injury may be reported as actual, approximate, date and time
found dead, or unknown. The "place of injury" is the type of place where the injury occurred (or where body
was found), using generic terms such as "interstate highway," "fast-food restaurant," etc. The "location of injury"
is the street name, number, zip, city, and county where the injury occurred (or body was found). "Injury at work"
is a Yes or No answer indicating if the fatal injury occurred while the decedent was on the jobusually in the
setting of an employee/employer relationship.
"How injury occurred" is a concise statement of how the fatal injury occurred, using generic terms, such as
"Driving small car, lost control, struck tree." A place exists to indicate whether an autopsy was performed and
whether the autopsy findings were considered when the death certificate was completed. The autopsy question
should be answered "Yes" even if only a partial (or limited) autopsy was performed, and the nature of the
limited autopsy can be reported as shown in the example at the end of this chapter. Space exists to report the
duration of each condition reported in part I of the cause-of-death statement but whether this is required
depends on policy in the involved jurisdiction.

Remember that in most jurisdictions, if the manner of death is other than natural, the death certificate should be
completed by or at the direction of the medical examiner or coroner.
The cause of death and death certificate are not written in stone and can be changed (amended) if needed. In
general, the time between an injury and death does not impact on the manner of death if the immediate cause
of death resulted from the injury (eg, a man who dies 10 years after being shot by another person, and was
quadriplegic with recurrent sepsis which ultimately caused death, would still be classified as homicide). The
"but-for" paradigm can be used in most cases to determine manner of death (eg, "but-for the gunshot wound 10
years ago, the person would not have died at the time he did and of the causes stated"). In general, if an injury
or poisoning caused, contributed, or hastened death, preference is given to the non-natural manner of death.
Rarely, a condition that is separate and distinct from the presumed underlying event "breaks the chain" and
serves as an intervening cause of death (such as someone in the hospital because of a traffic accident but is
then euthanized by a "mercy killer.")
Some jurisdictions have special categories for manner of death (such as Oregon, having an "Other" category
for physician-assisted suicides, or "Unclassified" in some states for recreational drug use deaths, or
"Complications of Therapy" in some jurisdictions for deaths involving adverse outcomes of treatment).
Whether or not to include statements such as "Collision of motor vehicles" in part I (in addition to other more
specific causes) is a matter of space and personal preference, although for lay readers of the death certificate
this method may be helpful.
Some states are involved in projects that will enable the electronic certification and registration of death
(internet based) instead of using paper copies. [4] The principles are generally the same as described in this
chapter.
Strictly adhering to guidelines for cause-of-death statements is not always possible, and some cases require
atypical approaches.
Classification of manner of death can be quite controversial, but some general truths include the following:

Acute recreational drug use deaths are typically classified as accidents.


Effects of chronic substance or drug use are usually classified as natural.
Autoerotic asphyxial or drug-related deaths are usually classified as accidents.
Russian roulette deaths are usually classified as suicide, but some classify them as accidents.
Deaths resulting from police restraint are usually classified as homicide.
Some deaths during restraint involve significant drug intoxication or underlying disease and may be
classified as other than homicide.
Anaphylaxis to insects, drugs, and other external factors are usually certified as accidents.
Hit and run pedestrian fatalities are usually certified as accidents, but some jurisdictions classify them
as homicide or vehicular homicide.
Deaths that immediately result from fright induced by another or from minor assault are usually
classified as homicide, but the timing is quite important.
Manner of death is frequently dependent on issues that are not evident at autopsy and relevant police,
investigative, and other information are critical to appropriately classifying manner of death.
Many manner of death classifications are straight-forward, or are done as a matter of conventions,
while others are more controversial.
Being familiar with the National Association of Medical Examiners "Guide for Manner of Death
Classification" is important; this guide addresses many issues related to manner of death and provides
guidance for certain types of scenarios. [3]

Death certification examples


The examples below are intended to represent well-written cause-of-death statements and death certifications,
which should be complete and clear enough that the story of the death is apparent without a case history. The
format is similar to the death certificate used in each state.
Table 1. Death Certification, Example 1 (Open Table in a new window)
Interval between onset and death

Part I

A. Hemorrhage of esophageal varices

Hours

Due to, or as a consequence of:

B. Cirrhosis of liver

Years

Due to, or as a consequence of:

C. Chronic alcoholism

Decades

Part II

OTHER SIGNIFICANT CONDITIONS:

Autopsy? (Yes or No)

If yes, were autopsy findings considered in determining cause of death? (Yes or No)

Yes

Yes

Manner of Death

Natural

Injury at Work? (Yes or No)

Date of Injury

Place of Injury

Describe how injury occurred

Hour of Injury

Location

Table 2. Death Certification, Example 2 (Open Table in a new window)


Interval between onset and death

Part I

A. Metastatic small cell carcinoma of lung

Approx 3 years

Due to, or as a consequence of:

B.

Due to, or as a consequence of:

C.

OTHER SIGNIFICANT CONDITIONS:

Part II

Conditions contributing to death but not resulting in the underlying cause of death in
Part I

Autopsy? (Yes or No)

No

If yes, were autopsy findings considered in determining cause of death? (Yes or No)

Manner of Death

Natural

Injury at Work? (Yes or No)

Date of Injury

Describe how injury occurred

Place of Injury

Table 3. Death Certification, Example 3 (Open Table in a new window)

Hour of Injury

Location

Interval between onset and death

Part I

A. Subarachnoid hemorrhage

Minutes

Due to, or as a consequence of:

B. Ruptured berry aneurysm

Years

Due to, or as a consequence of:

C.

OTHER SIGNIFICANT CONDITIONS:

Part II

Conditions contributing to death but not resulting in the underlying cause of death in
Part I

Autopsy? (Yes or No)

If yes, were autopsy findings considered in determining cause of death? (Yes or No)

Yes

Yes

Manner of Death

Natural

Injury at Work? (Yes or No)

Date of Injury

Describe how injury occurred

Place of Injury

Hour of Injury

Location

Table 4. Death Certification, Example 4 (Open Table in a new window)


Part I

A. Systemic sepsis

Interval between onset and death

Days

Due to, or as a consequence of:

B. Infected decubitus ulcers

Weeks

Due to, or as a consequence of:

C. Senile dementia and bedridden state

Years

OTHER SIGNIFICANT CONDITIONS:

Conditions contributing to death but not resulting in the underlying cause of death in
Part I
Part II

Diabetes mellitus, peripheral vascular disease

Autopsy? (Yes or No)

No

If yes, were autopsy findings considered in determining cause of death? (Yes or No)

Manner of Death

Natural

Injury at Work? (Yes or No)

Date of Injury

Describe how injury occurred

Place of Injury

Table 5. Death Certification, Example 5 (Open Table in a new window)

Hour of Injury

Location

Interval between onset and death

Part I

Minutes

A. Atlanto-occipital dislocation

Due to, or as a consequence of:

B. Blunt force injury of head

Minutes

Due to, or as a consequence of:

C. Motorcycle Accident

Minutes

OTHER SIGNIFICANT CONDITIONS:

Part II

Conditions contributing to death but not resulting in the underlying cause of death in Part I

Autopsy? (Yes or No)

If yes, were autopsy findings considered in determining cause of death? (Yes or No)

Yes

Yes

Manner of Death

Date of
Injury

Accident

Injury at Work? (Yes or


No)

No

Describe how injury occurred

10/11/2009

Hour of Injury

Helmeted motorcycle operator which lost control and struck power


utility pole

Place of Injury

City Street

2150

Location

2 Alice Street, SW, Atlanta, GA


30312

Table 6. Death Certification, Example 6 (Open Table in a new window)


Part I

A. Intrathoracic hemorrhage

Interval between onset and death

Minutes

Due to, or as a consequence of:

B. Dissection of ascending aorta

Hours

Due to, or as a consequence of:

C. Hypertension

Years

OTHER SIGNIFICANT CONDITIONS:

Conditions contributing to death but not resulting in the underlying cause of death in Part I
Part II
Atherosclerotic vascular disease

Autopsy? (Yes or No)

If yes, were autopsy findings considered in determining cause of death? (Yes or No)

Yes

Yes - Limited Autopsy

Manner of Death

Natural

Date of Injury

Injury at Work? (Yes or No)

Place of Injury

Describe how injury occurred

Hour of Injury

Location

Issues Arising in Court


Typically, when a death certificate is introduced in a legal proceeding such as a court trial, the certifier of death
is asked to verify that the certificate is authentic. The witness may be asked to indicate his/her opinion of the
cause and manner of death as indicated on the death certificate. The death certificate, however, is used more
to prove the fact of death (that death actually occurred) rather than serving as proof of the cause and manner of
death.

As mentioned previously, occasional lawsuits arise regarding a cause or manner of death reported on the death
certificate.[5] Usually these have involved suicides. Most often, the opinion of the certifier is upheld.

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