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.
- (author not listed)Who Should Sign Death Certificates? Emergency Physicians Monthly. Available at: http://epmonthly.com/blog/who-should-sign-death-certificates/ .
- 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 .
- 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 .
- 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!