‘Til Death Do Us Part.

Clinical education focuses on the optimization of diagnosis, treatment, disease prevention, and quality of life for the patient. Establishment and maintenance of the physician-patient relationship is also an integral part of the clinical learning experience. Despite the best of all efforts, there are limitations in medical interventions aimed at saving lives and ultimately, the physician-patient relationship must dissolve.

The clinical care team must complete a number of complex tasks for the infrequent occurrence of an impending or unexpected, traumatic or natural hospital death in accordance with established hospital policy 1. These include clinical procedures with adherence to any advanced care directives, pronouncement of death, notifying family, providing family with the means for bereavement, notifying the organ/tissue procurement organization, providing education and obtaining consent from the family regarding a hospital autopsy where applicable, and fulfillment of legal requirements in homicidal deaths. Homicidal deaths will require notification of law enforcement, reporting the death to the Medical Examiner/Coroner (ME/C), and securing any evidence inclusive of the deceased’s body 2. While some variability exists, state law mandates the reporting of deaths that are sudden, unexpected or unnatural to the ME/C.

Fundamentally, clinicians must know not only when and how to report a death, but why. Understanding the “why” facilitates the whole process of reporting. The insufficiency of consistent, periodic education on this topic has fueled uncertainty, lack of knowledge, and lack of understanding 2 regarding:

  • state laws that mandate reporting and by whom 2,3
  • specific types of reportable deaths 2,3
  • specifics on how to report a death 2
  • the public health importance of reporting deaths 2
  • physician responsibilities for in-home patient deaths 4
  • the requirements and the role of the ME/C 2,3

Consistent and periodic education with assessment is necessary, as early as third or fourth year of medical school or at least starting early in the first year of residency. Various learning platforms such as textbook-based lectures, morbidity mortality review conferences, and online courses and tutorials can be utilized to ensure reinforcement and retention of knowledge throughout the years of clinical training and provide continuing medical education following training.



  1. O’Malley P, Barata I, Snow S, et. al. Death of a child in the emergency department. Pediatrics. 2014;134:e313-e330.
  2. Armstrong EJ. Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
  3. Charles A, Cross W, Griffiths D. What do clinicians understand about deaths reportable to the coroner? J Forensic Leg Med. 2017;51:76-80.
  4. Yang M, McNabney MK. Physicians’ responsibilities for deaths occurring at home. J Am Geriatr Soc. 2017;65(3):648-652.


Stay tuned for more Practice Pearls!


Comprehensive Public Health Education for the Clinical Practitioner: Mission Impossible?

Medical education provided to those destined for clinical practice emphasizes development of clinical skills for the diagnosis, treatment, and prevention of disease in the living. Public health-oriented topics including disease prevention, epidemiology, and systems-based practice are also part of the spectra of medical education. Resources for integrating public health education into the health professions abound creating challenges for health professional schools to formulate comprehensive curricula within a defined period of time of students’ training 1,2. The clinician-in-training must also be taught the importance of mandated reporting of certain diseases and circumstances that may place the health or well-being of the patient or the immediate public in jeopardy. Mandatory reporting includes documentation of vital events and circumstances such as birth, abuse and neglect, impaired driving, work-related injury and communicable and other diseases 3. It is vitally important to the surveillance of public health and safety. The overall focus of public health education is on the living. Importantly, aspects of death can actually aid the living.

The proper medical certification of death continues to be an important public health topic inadequately covered or lacking altogether in medical education. This is especially true for physicians, starting in medical school, where early introduction has been shown to be beneficial 4. Erroneous cause-of-death information has direct bearing on health statistics and resource allocation. Early introduction on the topic of death certification with periodic instruction and evaluation throughout and beyond medical training is needed to ensure that the most accurate cause-of-death information is entered on death certificates. For physicians-in-training especially, didactic teaching based on reference texts and e-learning tutorial platforms can be introduced into medical curricula starting after a foundation in anatomy, physiology, pharmacology, pathology has been established and with the start of clinical rotations in the 3rd year 5. Hospitals should incorporate lectures into clinical residency training programs with evaluation via in-service examinations as effectiveness of this level of integration has been shown to be beneficial 6. Hospitals and medical societies should continue to provide lectures and tutorials for their clinical practitioners which can be counted as continuing educational credit 7.

Physician medical examiners and coroners are proficient in death certification and can be an invaluable educational resource for medical educators. Vital statistics professionals are an added important educational resource for instruction especially in the technical aspects of death certificate completion including access to the electronic death registration system active in the majority of jurisdictions in the United States.



  1. Public Health and Medical Education Bibliography. Available at: https://www.aamc.org/download/258062/data/publichealthbibliography.pdf .
  2. Integrating Public Health in Health Professions Education: A Resource for Students, Educators, and Health Professionals. Available at: https://www.cdc.gov/learning/local/pdf/ph-education-resource-list.pdf .
  3. Reportable Diseases, Medline Plus. National Institutes of Health/US National Library of Medicine. Available at: https://medlineplus.gov/ency/article/001929.htm .
  4. Degani AT, Patel RM, Smith BE, and Grimsley E. The effect of student training on accuracy of completion of death certificates. Med Educ Online. 2009;14:17. Available at: http://www.med-ed-online.org .
  5. Armstrong EJ. 2017. 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 .
  6. Henry CH, Greene CM, Koppaka R. Integrating public health-oriented e-learning into graduate medical education. Am J Public Health. 2012;102:s353-s356.
  7. Massachusetts Medical Society. Cause of Death Training for Medical Certifiers. Available at: http://www.massmed.org/Continuing-Education-and-Events/Online-CME/Courses/Cause-of-Death-Training-for-Medical-Certifiers/Cause-of-Death-Training-for–Medical-Certifiers/ .

Be in-the-know and stay tuned for the next installment of Practice Pearls!