The End Is Near! But That’s Just the Beginning: A view under the Retrospectroscope.

If hindsight were 20/20, there would be no need for Practice Pearls in 2020.

The Practice Pearls lessons of 2019 put clinician educators in the spotlight. They have the important responsibility of molding future physicians, especially those destined to practice in one of the Primary Care specialties, into not only diagnosticians and caregivers, but also stewards of public health in helping us live longer, smarter and healthier lives. 2019 saw another blow to the already floundering hospital autopsy rate with the handing down of a so-called burden reduction rule put forth by the Centers for Medicare and Medicaid Services (CMS) which in part called for the removal of the requirement for a hospital’s medical staff to attempt to secure autopsies in all cases of unusual deaths and of medical-legal and education interest (1). Not exactly a good thing for clinical resident education. Clinical educators must prepare these doctors-in-training to educate families about the benefits of the autopsy, to take advantage of the expertise of the pathologist in understanding disease processes, to know when and how to report a death to the Medical Examiner or Coroner, and to know how to properly complete a death certificate and why it makes a difference (2,3,4,5). Earlier exposure of these topics to medical students would further bolster the efforts of clinical educators.

Mortality trends in the United States have identified cardiovascular disease, accidental drug overdoses, suicidal injury in adolescents, fall-related injury in the elderly, birth defects, and pregnancy complications as top common causes of death based on cause-specific information listed by the Certifiers of death in the cause-of-death section of the death certificate (6). There is much room for improvement of mortality trends.

The following death certificate was not originally certified by the local Medical Examiner but by a clinician, not so auld lang syne, but in the not- so-distant past of the latter half of 2019:

There’s still work to be done….
Out with the old and in with more, so desperately needed, new pearls of clinical practice wisdom!

1. Omnibus Burden Reduction (Conditions of Participation) Final Rule CMS-3346-F. Available at:
2. “How Trained is the Trainer-Comprehensive Medical Education: The Keystone of Modern Medicine”. Practice Pearls In Death Reporting and Death Certification, March 2019.
3. “Throwing mud at the wall: Sometimes it just doesn’t stick!”. Practice Pearls in Death Reporting and Death Certification, April 2019.
4. “Sch-o-o-o-ol’s-Out-For-the Summer!(But not if you’re a PGY-1 doc.)”. Practice Pearls in Death Reporting and Death Certification, July 2019.
5. “What Say You? Say It Isn’t So! Practice Pearls in Death Reporting and Death Certification”. October2019.
6. “Oh Say I-C-D!”. Practice Pearls in Death Reporting and Death Certification, May 2019.


Clinicians, kick off your New Year’s resolution to stay out of the crosshairs of the Funeral Director and Vital Statistics with a NEW AND IMPROVED copy of:

Special Sale Price available on eBay EXCLUSIVELY through this link:

Sch-o-o-o-ol’s-Out-for-the Summer! (But not if you’re a PGY-1 doc.)

(The following is a slightly refurbished reprise from a previously published oldie but goodie Practice Pearls -from way back in July 2018 entitled: Comprehensive Public Health Education for the Clinical Practitioner: Mission Impossible?)

The school bell has rung and school has been out to the glee of many except for the fresh-faced, eager resident physicians who have recently embarked on a brand new journey, the first post-graduate year, AKA PGY-1. Others have advanced onward to the years that follow as required by their chosen specialty.

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 all health professions abound creating challenges and opportunities for health professional schools to formulate comprehensive curricula within a defined period of time of students’ training (1,2). The clinician-in-training, especially those training in the primary care specialties, 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. Believe it or not, certain aspects of death 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 school 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). Clinical residency training programs should incorporate lectures into the curriculum with evaluation by way of 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 medical 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 in each state 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 all but 2 states in the US (8) .

1. Public Health and Medical Education Bibliography. Available at: .
2. Integrating Public Health in Health Professions Education: A Resource for Students, Educators, and Health Professionals. Available at: .
3. Reportable Diseases, Medline Plus. National Institutes of Health/US National Library of Medicine. Available at: .
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: .
5. Armstrong EJ. Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. Available at: .
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:–Medical-Certifiers/ .
8. Information Systems for Vital Records Stewardship. National Association of Public Health Statistics and Information Systems. (NAPHSIS). Available at: .

Be in-the-know with Practice Pearls…Because who really wants to get schooled?


For more information on how not to get schooled on reporting and certifying deaths, check out:



Available at: 

Throwing mud at the wall: Sometimes it just doesn’t stick!

The following death certificate did not pass the Vital Statistics “sniff test” and was sent to the local Medical Examiner’s office for review and amendment:

By all appearances, the patient had a number of serious health conditions. But which one killed the patient? The heart disease, the diabetes or perhaps the congestive heart failure? Did the spinal abscess causing cord compression and paralysis stem from a remote injury and therefore this really isn’t a natural death as was checked off in the manner-of-death section? How does that cause congestive heart failure? If somehow the paralysis with heart failure are linked and are the main cause of death, why is it listed in Part II instead of Part I?

By simply listing all of the patient’s major medical conditions, the laundry-list, catch-all approach to certifying this death missed the mark of identifying the one disease entity that triggered a series of interrelated complications that over time ultimately led to the death. Which International Classification of Disease (ICD) code applies in this death? More than one is represented. There can only be one.

Buzzwords like paresis and paralysis are red flags for injury as the possible underling cause. Injury and its complications fall under the domain of the Medical Examiner or Coroner (i.e. they are reportable deaths). Following a medicolegal investigation into the death circumstances, deaths resulting from injury will be classified as accident, homicide, or suicide.

An important question regarding the manner in which the spinal abscess with paresis was acquired remains- Gunshot wound to the spine? Intravenous injection of drugs with a dirty needle? Spinal trauma from a fall or a jump? Complication of spinal surgery…for an injury or a birth defect? Complication of natural disease like diabetes? Trends derived from manner of death classification have far-reaching important public health implications (1) .

1. National Vital Statistics System-Mortality Data. Available at:

More tips on de-mudifying the death certificate can be found in Chapter 8: The Clinician Certifier of Death from Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available at: .


How Trained is the Trainer? Comprehensive Medical Education: The Keystone of Modern Medicine

A major milestone and rite of passage for thousands of medical students is eminent or has recently come to pass. For the last 3 ½ years, they have successfully cleared many major educational hurdles. They have waited anxiously for the day to find out where the next chapter of life will unfold.

That day…is Match Day. After graduation, they will begin a rigorous period of training as residents, and continue the journey on to becoming our future physicians.

Our health and therefore quality of life depends upon competent medical care. How ready will our future doctors really be to care for us, during life and at death? This will depend on the strength of resident training programs, particularly in the primary specialties like internal medicine, family medicine, pediatrics, obstetrics/gynecology geriatrics, and emergency medicine. This will also depend on their educators, their trainers, who carry out the educational goals of the training program for that medical specialty. Trainers will expend enormous time and effort to teach the medical resident about patient care and how to diagnose and treat disease and injury with the goals of prolonging life, increasing the quality of life, and preventing death. Unfortunately, this leaves little opportunity to give in-depth instruction on an important end-of-life patient care duty: proper death reporting and certification. Death is a daily reality and an eventuality, even after the best of clinical efforts. But what we learn from death importantly can and does aid the living.

With the ever-dwindling rate of hospital autopsies created by the veil of better diagnostic tools (better scans, better tests, better and quicker results etc.), the enthusiasm of physicians to become educated on proper death certification also continues to decline, a sentiment that “rubs off” on impressionable trainees 1,2. Despite this, the autopsy remains the gold standard and the quality assurance tool for understanding disease processes and identifying the actual cause of the patient’s death 2.

But just how trained are the trainers? Are they prepared to educate doctors-in-training on how to:

  • educate families about the benefits of the autopsy and obtain consent for one 3 ?
  • utilize the expertise of the hospital pathologist and forensic pathologist to gain understanding of the lethal potential of disease as demonstrated by the autopsy 3 ?
  • locate and apply the legal statutes that mandate reporting certain deaths to the Medical Examiner or Coroner (ME/C) 3 ?
  • locate and apply the legal statutes that mandate the physician-of-record to certify deaths that do not fall under the jurisdiction of the ME/C 3 ?
  • access resources on death reporting and death certification provided by ME/Cs and local and state Vital Statistics agencies?
  • compose an acceptable and defensible cause-death-statement on the death certificate 3 ?
  • execute role as stewards of public health?

As part of a comprehensive curriculum, resident training programs must begin or continue to make routine efforts to increase proficiency in death reporting and death certification and include this as a core competency milestone requirement of graduate medical education in the primary care specialties 4. This is necessary in order to increase the accuracy of the information derived from death certificates such as the leading causes of death, disease patterns, and outcomes of the many types of medical intervention. It cannot be overstated that the cause of death information provided on death certificates directly influences mortality data, disease surveillance and fund allocation for health programs. Traditional lectures, morbidity and mortality conferences, and online courses and tutorials can be used as platforms of instruction throughout the years of clinical training and beyond. Demonstration of competency in death reporting and certification, just like for any medical procedure, should be required, not voluntary.




  1. Wexelman BA, Eden E, and Rose KM. Survey of New York City resident physicians on cause-of-death reporting, 2010. Prev Chronic Dis. 2013;10:E76. Available at: .
  2. Burton EC. The autopsy: a professional responsibility in assuring quality of care. Am J Med Qual. 2002. Mar-Apr; 17(2):56-60.
  3. Armstrong EJ. Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner Chapters 3, 5, 7 and 8. 2017. Available at: .
  4. Accreditation Council for Graduate Medical Education (ACGME) Milestones Guidebook. Available at: .


A valuable resource! Follow the link and get your copy:

Divisive Devices and Curious Cuts, Part II: Adventures In Medical Intervention and Other Eye Foolery.

The type, number, distribution, and pathologic effects of injuries seen at autopsy are clues that assist the forensic pathologist in the determination of the manner in which they were acquired whether by accident or at the hands of another. Accurate determination is of vital medicolegal importance with influence on the reconstruction of the death circumstances and any adjudication that may follow in the future.

Certain devices and types of medical intervention leave “injuries” recognized as those resulting from resuscitative efforts and surgical procedures. Unnecessary modification or distortion of injuries makes interpretation complicated. Context (i.e. medical records and EMS reports), is usually helpful and always needed in deciphering “injuries” caused by therapeutic intervention from other types of injury.

And so…

(Caution! Graphic images follow!)


Classic patterned abrasions from a mechanical chest compression device, not the bottom of someone’s shoe.


Two stab wound-looking injuries next to a thoracotomy incision? On closer examination, turns out that there were two intersecting incisions and ONE bona fide stab wound of the axillary region.


Stab wounds and gunshot wounds may present as convenient ports for tube placement or starting points for incisions. This spells NIGHTMARE for the forensic pathologist. Steering clear of the evidentiary wounds is much more preferred as shown below in which the thoracotomy incision was made (nicely)above and not through the nearby 2 stab wounds.


Fingernail markings resulting from jaw thrust maneuver and intubation attempt as part of resuscitation efforts, NOT strangulation injuries. Not overcalling these as strangulation injuries saves law enforcement a lot of investigative time and effort.


Marks left by suturing can look like stippling abrasions associated with intermediate-range gunshot wounds. Overcalling suture marks as stippling wounds (victim shot within 2-3 feet) could contradict witness statements or other physical evidence that victim was an innocent bystander or otherwise shot from a greater distance. Unsuspecting or uninformed expert consultants who review autopsy photographs in absence of pertinent information risk providing incorrect opinions in regards to the muzzle-to-target distance estimation.

Suturing of gunshot wounds may  confound the determination not only of an approximate muzzle-to-target distance (aka range-of-fire) but also distort characteristics that help identify it as an entrance wound:

It is much more preferred that gunshot wounds of expired patients NOT be sutured or wiped but instead be preserved with bandaging or other wound occluding (but not wound mutilating) material placed and secured over the wound:

And finally, the classic rib spreader laceration ( skin tear) caused by the gear mechanism of the rib spreader device, is virtually always seen in conjunction with thoracotomy incisions so as not to be confused with inflicted injury.




  1. Armstrong E J. 2017. Therapeutic Devices. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner p 27.
  2. Armstrong E J. 2017. Injury Types: A Primer for Clinical Practitioners. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner. pp 82-102.
  3. Harm T and Rajs J. Face and neck injuries due to resuscitation versus throttling. 1983. Forensic Sci Int. 1983;23:109-116.

Divisive Devices and Curious Cuts, Part I: Think Zebras when you hear hoof beats!

Forensic pathologists are regularly called upon to identify and characterize injuries. The accuracy of doing so can have a direct effect on the direction of an investigation conducted by law enforcement in cases where foul play is suspected to be involved in the death. Accurate interpretation of injuries can also have effects on the adjudication process down the line.

Determination of the cause of marks left by medical intervention can be extra challenging without the proper context 1,2,3.

The following images illustrate common quandaries in forensic pathology practice. (Warning! Graphic images follow!):



Stomped?                                                                           Stabbed twice?


Strangled?                                                       Intermediate range gunshot wound?




  1. Armstrong E J. 2017. Therapeutic Devices. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner p 27.
  2. Armstrong E J. 2017. Injury Types: A Primer for Clinical Practitioners. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner. pp 82-102.
  3. Harm T and Rajs J. Face and neck injuries due to resuscitation versus throttling. 1983. Forensic Sci Int. 1983;23:109-116.

Chemical Warfare on the Mind and Body.

Think about it. Could the current epidemic of drug deaths represent a kind of chemical warfare, where the weapon is the drug and the mechanism is the addiction? A veritable army consisting of 63,632 persons in the US died from drug overdose in 2016 1. Recently, half of the country has seen a significant increase in the rate of overdose deaths, largely driven by opioids (especially heroin, fentanyl and other synthetic opioids) but more recently with a new twist-a resurgence of drug deaths that include stimulants, particularly cocaine and methamphetamine (2, 3, and Fig. 1).


Fig. 1: Statistically significant drug overdose death rate increase from 2015-2016, US states Available at:

The causalities are in the prime of their life, able-bodied men and women in their 20’s to 40’s, and come from not just the demographic you think, but from all demographic and socioeconomic strata. Heroin addicts over the age of 55 years who have “managed” their addiction over the preceding decades with their usual supply of heroin, have been getting caught in the crossfire of the opioid epidemic, unknowingly consuming and dying from more potent heroin, heroin mixed with fentanyl, pure fentanyl, or fentanyl-like substances 4.

Is it intentional? Could there be a grand insidious scheme to do away with a population? The thought is disconcerting. Clever “marketing” easily lures those looking for the quick fix, the magic pill, the feeling of belonging, or a better way to cope with the stresses of life. On the other hand, addiction drives demand and demand drives the big profits made by clandestine drug labs 5. Clandestinely manufactured drugs (synthetic drugs) invade from within and outside a country’s borders by land, by sea, by air, underground, and by mail via online transactions 6,7,8. They are being made increasingly more potent and therefore potentially more deadly, and always a step or two ahead of the regulatory laws in places that have them.

Forensic toxicology laboratories struggle to keep up with the barrage of new “products” but must since the detection of each new drug is what keeps the wheels of justice turning, which is what the public expects and demands. In order to optimize patient care and the prevent deaths, hospital labs must also “keep up with the times” in regards to their ability to detect novel synthetic drugs 9.

Jails, hospitals, foodbanks, crisis hotlines, and other social safety nets are being taxed to their limits by those battling addiction or by their dependents left financially and emotionally bereft after the battle has been lost through death 10.

A country continues to loose individuals who would otherwise be contributing members of society through their intellectual and/or physical abilities 11. Anecdotes of the difficulties with finding drug-free workers should be warnings to be heeded and defining the scope of the actual toll on the workforce and the economy will require continued and vigilant study 12, 13.

Through periodic statistical reports and public media alerts regarding drug trends, Medical Examiners and Coroners (ME/C) are part of the army helping to fight the chemical war. Uniformity amongst ME/C offices in reporting specific drugs on death certificates is imperative 14, 15. Through diagnosis, treatment, prevention, and proper reporting of drug-related deaths, clinicians too play a vital role as combatants in the fight to save lives 16.



  1. US drug overdose deaths continue to rise; increase fueled by synthetic opioids. Press release: March 29, 2018. Centers for Disease Control and Prevention. Available at: .
  2. Drug overdose death data. Centers for Disease Control and Prevention. Available at: .
  3. New surge of meth, cocaine mixed with powerful opioid pushes Ohio’s drug overdose death toll higher. April 2, 2018. Akron Beacon Journal/ Available at: .
  4. Opioid overdose deaths by age group. Available at:,%22sort%22:%22asc%22%7D .
  5. Understanding Clandestine Synthetic Drugs. Available at: .
  6. Buxton J Bingham T. The Rise and Challenge of the Dark Net Drug Markets. Global Drug Policy Observatory Policy Brief. Jan 2015. Available at: .
  7. Over and Under. USA Today. Available at: .
  8. Fighting the Opioid Scourge. Department of Homeland Security-US Customs and Border Protection. Available at: .
  9. Tufel G. Continuing the Battle Against Drugs of Abuse. Clinical Lab Products. June 25, 2015. Available at: .
  10. Karsala M. The opioid epidemic and its impact on the health care system. The Hospitalist. October 24, 2017. Available at: .
  11. Valentic S. Workplace Drug Overdoses is Driving Need for Action. EHS Today. August 13. 2018. Available at: .
  12. Schwartz ND. Economy Needs Workers, but Drug Tests Take a Toll. New York Times, July 24, 2017. Available at: .
  13. Aliprantis D and Chen A. The Opioid Epidemic and the Labor Market. Economic Commentary. Sept. 29, 2017. Available at: .
  14. Slavova S, O’brien D, Creppage K, et. al. Drug Overdose Deaths-Let’s Get Specific. Public Health Report. July-Aug. 2015. Vol. 130. Available at: .
  15. Harper J. Omission on Death Certificates Lead to Undercounting of Opioid Overdoses. National Public Radio. Shots Health News Series. March 22, 2018. Available at: .
  16. Szalavitz M. Opioid Overdose: Emergency Treatment Is Crucial, but It’s Not Enough. Scientific American. May 13, 2016. Available at: .

Body of Evidence Part III: Just Brown Baggin’ It.

There seems to be some lingering confusion among some hospital medical personnel and those involved with the recovery of human tissue and organs on the proper way to preserve potential evidence on the hands of patients who have died in the hospital as a result suspected foul play or outright homicidal violence. Recently, tissue procurement technicians placed plastic bags on the hands of a decedent who was destined to be transported to the local medical examiner’s office due to death circumstances highly suspicious for foul play.

Plastic bags, latex or nitrile gloves should NEVER be placed hands of a decedent that is a Medical Examiner’s or Coroner’s case. Because of their impermeability, unlike paper, they will contain condensation produced by the body’s heat prior to cooling. This condensation can promote the growth of bacteria and mold that can interfere with or preclude the recovery of foreign materials, i.e. the perpetrator’s DNA or the gunshot residue from the shooter’s gun.

PAPER not plastic please! A paper bag placed over each hand secured at the wrist by a rubber band is modus operandi! Better, forensically speaking (as well as more environmentally friendly).

Sometimes visuals are better memory aids:


YES!                                                                 NO!


NO!                                                     MAYBE.


(Only those of you who grew up in the 70’s watching the Gong Show will understand the last one.)


Your memory aide and ticket to more CME credits available at: .


A Manner of Fact.

How a death happened can be just as important as what caused the death. Yes, manner matters.

Take another look at the cause-of-death statement presented in the last installment of Practice Pearls. It was taken from an actual death certificate:

Part I.




A.                  Pneumonia-Aspiration poss.


Approximate interval: Onset to death


1 day

Due to (or as a consequence of):


B.                  Dysphagia


6 months

Due to (or as a consequence of):


C.                   Quadriplegia


3 years

Due to (or as a consequence of):


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



While aspiration pneumonia could result from dysphagia which in turn could be caused by quadriplegia, the question that should linger in the certifier’s mind is: What is the cause of the quadriplegia? Cervical spinal cord damage by Multiple Sclerosis? Epidural abscess complicating cervical disc surgery? A fall with fracture of the cervical spine and injury to the spinal cord? Or perforating injury to the cervical spinal cord from a remote gunshot wound? The manner of death for each of the four scenarios is very different: Natural vs Therapeutic Complication vs. Accident vs. Homicide. If the death circumstances are or might be accidental, homicidal, therapy-associated 1 or anything not associated with pure natural disease, the death must be reported to the ME/C. If you are a clinician certifier and list ‘quadriplegia’ or other non-specific terms as the underlying cause of death (the lowest line in Part I), expect to be notified by your friendly local Vital Stats professional (or your patient’s funeral home)!

Clinicians certify only natural deaths. Medical Examiners and Coroner (ME/C) physicians certify ALL manners of death.

For clinicians, accurate cause and manner of death determination flows from clinical diagnoses, clinical terminal events, and knowledge of the lethal potential of disease 2. For physician ME/Cs, this flows from comprehensive medicolegal death investigation, from scene to autopsy.

For both clinicians and ME/Cs, cause and manner of death determinations summarized in the cause-of-death section on the death certificate have important wide-ranging public health ramifications including increasing overall awareness of certain death trends with aims at death prevention or reduction in mortality rates 3-10. Examples include:

  • Deaths associated with medical procedures and devices: reports and bulletins compiled from data provided by online reporting
  • Fall injury deaths: identifying medical risk factors and in-home hazards
  • Traffic accident deaths: identifying road hazards, intervention by law enforcement regarding distracted or impaired driving
  • Opioid deaths: identifying sources of clandestinely manufactured fentanyl analogues, prompting changes in clinician prescribing habits and promoting alternate treatments for acute and chronic pain
  • Accidental drowning deaths: promoting and instituting measures regarding pool safety and safe boating
  • Homicide deaths of intimate partners-prevention through education in conflict resolution, offender intervention, improvement of services for domestic violence victims
  • Child homicide deaths: education of physicians, social workers, law enforcement and other mandated reporters in recognition of signs of abuse and the creation of integrated multi-agency standard operating procedures



  1. Armstrong E J. Chapter 8 Section 8.5: The Clinician Certifier of Death-Peri-procedural and Therapy-Associated Death Certification. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: .
  2. Armstrong E J. Chapter 7: The Lethal Potential of Disease. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: .
  3. MedWatch: The FDA Safety Information and Adverse Event Reporting Program. Available at: .
  4. Fowler KA, Jack SPD, Lyons BH, et. al. Surveillance for Violent Deaths-National Violent Death Reporting System 18 States, 2014. MMWR Surveill Summ. 2018 ;67(SS-2):1-36. Available at: .
  5. Centers for Disease Control and Prevention. Motor Vehicle Safety: Distracted Driving. Available at: .
  6. Centers for Disease Control and Prevention. U.S. Drug Overdose Deaths Continue to Rise; Increase Fueled by Synthetic Opioids. Available at:
  7. Centers for Disease Control and Prevention: Unintentional Drowning-Get the Facts. Available at: .
  8. Centers for Disease Control and Prevention: Child Abuse and Neglect Prevention. Available at: .
  9. National Coalition Against Domestic Violence Fact Sheet. Available at: .
  10. Deaths from Falls Among Persons Aged ≥65 Years –United States, 2007-2016. MMWR 2018:67:509-514. Available at: .


Mind Your Manners. Avoid A Query.

“…but in this world nothing can be said to be certain, except death and taxes”-Benjamin Franklin, 1789.

It is also pretty certain, that a clinician practicing in a primary care specialty will on more than one occasion during his/her career encounter the death of a patient and be called upon to certify the death. Collectively, clinicians certify the majority (about 80 %) of deaths as compared to those certified by medical examiners and coroners (1,2). Those of you who follow the Practice Pearls site regularly know why getting it right matters and the consequences of getting it wrong.

Consider the cause of death statement below taken from an actual death certificate involving a death that  was certified in lieu of reporting to the local Medical Examiner. It was promptly flagged by an astute Vital Statistics professional. Can you identify the reasons why?

Part I.


A.                  Pneumonia-Aspiration poss.

Approximate interval: Onset to death

1 day

Due to (or as a consequence of):

B.                  Dysphagia


6 months

Due to (or as a consequence of):

C.                   Quadriplegia


3 years

Due to (or as a consequence of):


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




  1. Cambridge B and Cina SJ. The accuracy of death certificate completion in a suburban community. Am J Forensic Med Pathol. 2010;31(3):232-35.

2. Armstrong E J. Chapter 8: The Clinician Certifier of Death. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: .