Tag, You’re It! The Case of the Phantom Physician.

On a regular basis, medical examiner and coroner officials expend excessive amounts of time searching for someone to certify a hospital death resulting purely from natural chronic disease and that otherwise does not fall under the jurisdiction of the medical examiner or coroner (ME/C). Why? Because the first physician contacted refuses to sign the death certificate or, amazingly, not one physician is available to perform this important end-of-life patient care duty often for a patient with not only multiple diagnostic workups for previous clinical encounters (documented in the medical record) but also some degree of evaluation leading up to the terminal admission which importantly includes any clinical assessment performed by paramedics.

The reasons proffered for refusal to perform this end-of-life patient care duty run the gamut:

  • “I am not obligated to sign the death certificate.”
  • “I am not the patient’s regular physician or primary physician.”
  • “I’m the pronouncing physician not the attending physician.”
  • “I don’t know the patient’s history.”
  • “I have not seen the patient in ‘x’ number of weeks, months, or years.”
  • “The patient’s chronic medical condition has been stable.”
  • “I’m only the cross covering doctor.”
  • “The patient just arrived to the nursing home and I don’t have all the medical records.”
  • “I don’ t know the cause of death.”
  • “If I’m wrong, I might get sued.”

It is apparent that those who are uninformed also believe that the cause of death cannot be determined unless an autopsy performed, certification of a patient’s death has nothing to do with patient care, and when the ME/C refuses to certify a death, their just passing the buck 1 . It is also apparent that the many “messages” that have been sent to the contrary are not being received by all  2,3 . Message not received. For those still in doubt, your state medical board can surely clear that up!

Families who experience delay in receiving the death certificate generally are not privy to all of the steps required to generate a death certificate but will and do suffer many real-life consequences that result when getting one is delayed (See “On the Edge” entry from 10/22/2017).  Thoughts of doubt, suspicion of substandard care, and suspicion that someone’s trying to cover up a medical mistake also may surface.

It is important to remember that the clinician is not required to be 100% correct when listing the cause of death, just greater that 50% certain, or that in all probability, more likely than not, the patient died of ‘x’. It is the clinician’s opinion put forth in good faith and is otherwise legally defensible. This requires review of the patient’s medical history and history of present illness, exercising clinical judgment, and applying one’s knowledge of the lethal potential of many natural disease entities that can present with sudden unexpected death.  A reasonable cause of death can be opined without results from a battery of tests in patients with little or no medical history including patients with recent exertional chest pain presenting in v-fib arrest, shortness of breath in the setting of obesity, peripheral edema with a history of cardiomyopathy, or other tell-tale signs of a rapidly decompensating disease condition, who expire after brief hospitalization. Use of qualifiers such as “presumed” or “probable” are permitted on death certificates to indicate uncertainty (because of lack of clinical evidence) in those instances. A hospital autopsy could be beneficial in attaining a higher degree of certainty of the cause of death and requires consent from the legal next-of-kin 4 . It may be necessary to list “pending” in the cause-of-death section while awaiting results of the hospital autopsy. Once final results are received and reviewed, a supplemental death certificate listing the etiologically specific cause of death reflective of the autopsy findings must promptly follow.



  1. (author not listed)Who Should Sign Death Certificates? Emergency Physicians Monthly. Available at: http://epmonthly.com/blog/who-should-sign-death-certificates/ .
  2. Philips J. 2013. Coroner says office burdened because doctors won’t sign death certificates. The Columbus Dispatch. Available at: http://www.dispatch.com/content/stories/local/2013/02/04/cause-of-death-hard-to-reach.html .
  3. Cina SJ. Death Certification: A Final Service to Your Patient. Available at: http://www.cmsdocs.org/news/death-certification-a-final-service-to-your-patient .
  4. Armstrong E J. 2017. Chapter 5: Hospital versus Forensic Autopsies. In: Essentials of Death Reporting and Death Certification- Practical Applications for the Clinical Practitioner. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408/ref=sr_1_1?ie=UTF8&qid=1488731535&sr=8-1&keywords=death+certification .

Now, for the answers to the last PPQ:

The case was of a 59 year-old female clinically diagnosed with a hypertensive intracerebral hemorrhage with subsequent death and pronouncement within 24 hours of hospitalization. It is based on a true case.

True. This is a reportable death (death within 24 hours of admission).

False. As there was no suspicion of foul play, findings of trauma, history of signs of substance use disorder, or concerns for suicidality, and  further, with a negative urine toxicology screen test, this death did not need a medicolegal death investigation.

It should be remembered that a medicolegal death investigation entails personnel and resources that exist as a result of appropriation of tax-payers’ money, including yours and mine, the use of which is perpetually under intense scrutiny by the public. News Flash: There are no deep pockets as it pertains to the governments, especially local ones!

Furthermore, several physicians were involved at some point in this patient’s care, any of whom would be eligible to sign the death certificate. But mysteriously, none could be located to do so. Ideally, a proverbial climb up the “chain of command”, even to the level of Chief Medical Officer, could have been rightly done. But alas, Tag, the ME became It!


Make Practice Pearls your New Year’s resolution and tune in again!

Signed, Sealed, Delivered….To A Vital Statistics Near You!

Physicians and funeral directors have something in common…

…and local and state Vital Statistic agencies want that “something” but can only wait for so long.

That something …(surprise)….is the Death Certificate, the legal proof of that final earthly human milestone and so much more!

Funeral Directors have the State mandated responsibility to:

  • obtain identifying and demographic information from the deceased’s next-of-kin,
  • enter it on death certificate (DC) ,
  • notify the certifier of death (i.e. the physician) of the need to enter the medical cause of death on the DC,
  • and file the DC with local and state vital statistics departments or bureaus.

… all in about 5 days if all goes well 1 .

Did you know? The certifier of death is any physician who treated the decedent within 12 months preceding the death or his/her associate physician, the chief medical officer of the institution, or the physician who performed the autopsy ( i.e. the hospital or forensic pathologist) 2 .

Physicians must enter the medical cause of death within 48 hours. If it cannot be entered within the specified time (usually because medical records and test results need reviewing or the autopsy results aren’t back yet), then “Pending test results”, “Pending autopsy results” , or simply “Pending” must be entered on the DC. Once records and results are reviewed, a supplemental DC listing the final cause of death must be promptly done. It is UNACCEPTABLE to list “Unknown” as a cause of death.

Says who?

The State within which you are employed or your medical board 3 .

The medical cause of death can be entered on paper or online via the secure electronic death registration system (EDRS) set up by the majority of States. The creation of this system was by the diligent and coordinated efforts of many including physicians and public health professionals under the National Association for Public Health Statistics and Information Systems (NAPHSIS) 4 . The EDRS facilitates faster access to DCs used in processing of insurance, benefits, and property claims. The EDRS system also makes data more quickly available for important public health and administrative needs including reporting, analysis, and surveillance 5 .



  1. Funeral Directors’ Handbook on Death Registration and Fetal Death Reporting. 2003.US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Available at: https://www.cdc.gov/nchs/data/misc/hb_fun.pdf .
  2. Model State Vital Statistics Act, 2011 Revision. Available at: http://www.fgs.org/rpac/wp-content/uploads/2010/02/Model-State-Vital-Statistics-Act-2011.pdf .
  3. State Medical Board of Ohio Policy Statement: Regarding the Signing of Death Certificates by the Attending Physician. https://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/vs/2016/Stakeholder/Signing-Death-Certificates-FAQ.pdf?la=en
  4. NAPHSIS. Electronic Death Registration System. https://www.naphsis.org/systems .
  5. Armstrong EJ. Chapter 8: The Clinician Certifier of Death. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Publisher E J Armstrong MD. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

Due to a concern for PPQ Withdrawal Syndrome (AKA PPQWS), a quizlet has been prescribed for you below! It is strongly recommended for clinician certifiers and is PRN. It has no harmful adverse effects and should be shared freely with fellow clinical colleagues:

  1. Case scenario: A 59 year-old female is found unresponsive at home. She has a history of uncontrolled hypertension, COPD, aortic dissection, and non-compliance with her prescribed medication regimen. She is conveyed via EMS to the local hospital whereupon clinical evaluation with imaging reveals an intracerebral and intraventricular hemorrhage consistent with a hypertensive stroke. Foul play and trauma is ruled out and there is no history of substance use disorder or concerns for suicidal tendencies. She is treated by expires and is pronounced deceased within 24 hours of admission. She has a primary care physician and several physicians were involved in her diagnostic clinical work-up during the terminal admission.

True or False: This is a death that is reportable to the Medical Examiner or Coroner (ME/C)?

True or False: This is a case that needs a medicolegal death investigation (i.e. this is an ME/C’s case)?


Stay tuned for the solution to this brain-teaser and the next installment of Practice Pearls!