Call of Duty.

On a regular basis, Medical Examiner and Coroner (ME/C) offices encounter or are notified of physicians who refuse to sign death certificates in deaths in which the ME/C has declined jurisdiction.

Contrary to the belief of many in clinical practice and hospital risk management professionals, the ME/C is not obligated to complete and sign death certificates on individuals whose death circumstances do not fall under the jurisdiction of the ME/C. The laws of each state mandate that authorized clinical practitioners determine the cause of death with completion of the death certificate in deaths resulting from purely natural disease. While such deaths may be sudden and unexpected, they can be explained based on one’s medical knowledge of the lethal potential of many natural diseases.

The laws of each state mandate that ME/Cs determine the cause and manner of death and complete death certificates in cases of sudden, unexpected, unexplained, and unnatural death. While many of these deaths are ultimately determined to be natural deaths, this determination is made after it is evident that other unnatural causes have been ruled out. The important public health function of the Medical Examiner or Coroner is to identify and investigate non-natural deaths, especially those known or suspected to have resulted from overdose and homicidal violence.

Refusal to sign death certificates is not without consequence and can result in disciplinary action executed by one’s state medical board inclusive of actions that affect one’s medical license (1,2,3,4,5,6,7).  Furthermore, death certification is a professional duty and a final courtesy to the patient!



Time now for a PPQ!

The following cause-of-death statement is from an actual death certificate recently completed and signed by a local physician. It was flagged by the Vital Statistics bureau and sent to the local Medical Examiner for review. Several errors are evident. Can you identify them? Should this death instead have been reported to the ME by the physician?

Part I.




A. Septic shock, suspect right lower extremity wound bacteremia, acute diastolic CHF


Approximate interval: Onset to death



Due to (or as a consequence of):

B. Severe pulmonary hypertension

Due to (or as a consequence of):

C. Severe aortic stenosis

Due to (or as a consequence of):

D. Acute kidney injury

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I
Manner of Death




This mystery will be unraveled in the next Practice Pearls, so tuned!


Click on the link below and take a look inside!

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