Background     Physicians are responsible for providing proper documentation of death. This Fast Fact reviews key steps in the completion of a death certificate.  

Importance of Proper Completion    Death certificate information is a permanent record of death. It is usually necessary for burial and settlement of the deceased’s estate. Documentation of the cause of death, in addition to direct communication, may provide family members with closure and peace of mind. Death certificates are also used to 1) evaluate the general health of the population, 2) assess the prevalence of medical problems among specific groups, 3) triage medical research needs, and 4) apportion health services, grants, and other resources to common illnesses. 

Basic Guidelines    Death certificates are governed by state statutes; variations exist in who can complete a death certificate and how they should be filled out. Certification and completion of death certificates is usually the primary responsibility of the attending physician.  However, in some states, death may be certified by the attending advanced practice nurse.

• Verify the correct spelling of names.
• Personally sign the death certificate; stamps are unacceptable.
• Complete all required items.  If necessary, write “unknown” or “pending further study.”
• Common Errors
  • Do not delay completion of the certificate. Some states have specific time periods and civil and/or criminal penalties for non-completion.  Moreover, funeral homes will typically not proceed with burial without the death certificate.
  • Do not use abbreviations.
  • Some state forms require you spell out the month.
  • Use 24 hour clock rather than 12:00 midnight.
  • Some state forms do not allow alteration of the document; avoid erasing or using white-out.
  • Avoid cursive writing; print clearly or type using black ink.

Causality of Death    This section of the certificate often consists of two parts.  The first part asks for a sequential chain of events that led to death and the time interval between onset of a condition and death.  The most immediate cause of death is stated on line a and the underlying causes follow on lines b, and so on. In assessing the approximate interval between onset and time of death, terms such as “unknown” or “approximately” may be used and general terms such as “minutes,” “hours,” and “days” are acceptable.  The second part asks about other significant conditions that contributed to death, but that did not result in the underlying cause stated previously.

Mechanism vs. Cause of Death    It is important not to write the mechanism of death (i.e. cardiac arrest, respiratory arrest) as the cause of death.  The mechanism of death is the physiologic derangement or biochemical disturbance by which the cause of death exerts its lethal effect. For accurate public health records, the cause of death (e.g. chronic obstructive pulmonary disease) is more helpful than the mechanism of death (e.g. respiratory failure).  When there is doubt as to the cause of death, it is acceptable to enter “unknown” or “pending further study.”  In some states, a condition may also be listed as “probable.”  As additional medical information, such as an autopsy report, becomes available, the certifying physician should report amendments to the state vital records office or local registrar.

Note:   Listed below are common terms and definitions that are generally interchangeable between states.  The table presents some examples.

• Immediate (or Principle) Cause = Final complication resulting in death.
• Intermediate (or Antecedent or Underlying) Cause = Disease or condition causing the immediate cause of death.
• Underlying (or Contributory) Cause = The condition present before and leading to the intermediate or immediate cause of death.

References

1. Campos-Outcalt D.  Cause-of-death certification: Not as easy as it seems.  J Fam Practice. 2005. 54(2):134-138
2. Herring ME.  The Death Certificate.  AAHPM Bulletin (reprinted with permission of the Camden Medical Society). Winter 2005; 8-9.
3. Lakkireddy DR, Gowda MS, Murray CW, Basarakodu KR, Vacek JL.  Death Certificate Completion: How well are physicians trained and are cardiovascular causes overstated? Am J Med.  2004; 117:492-498.
4. Magrane BP, Gilliland MG, King DE. Certification of death by family physicians. Am Fam Physician. 1997; 56:1433-8.
5. Myers KA, Farquhar DE. Improving the accuracy of death certification. CMAJ. 1998; 158:1317-23.
6. Nowels D. Curbside consultation: completing and signing the Death Certificate. Am Fam  Physician. 2004; 70(9):1873.
7. Physicians’ Handbook on Certification of Death.  Department of Health and Human Resources, Centers for Disease Control and Prevention, National Center for Health Statistics; April 2003. DHHS Publication No. (PHS) 2003-1108.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in May 2006.  Version copy-edited in April 2009; then again July 2015.