How to issue Medical Certificate of Death by a Registered Medical Practitioner

Death certificates serve two critical functions: providing documentation for legal/administrative purposes and vital statistics for epidemiologic/health policy purposes. To satisfy both of these functions, it is important that death certificates be filled out completely, accurately, and promptly. The high error rate in death certification has been documented in multiple prior studies, as has the effectiveness of educational training interventions at mitigating errors. This guide to death certification is offered with the intent of illustrating some basic principles and common pitfalls in electronic death registration. It is hoped that such education will serve as a means to help achieve greater accuracy and standardization among physician certifiers in Wisconsin and elsewhere.[NCBI]

The death certificate is an important legal document. In addition to providing the decedent’s family with a cause of death, it has critical administrative and epidemiologic applications. Death certificates may be required to settle decedents’ estates and obtain insurance or other pensions/benefits. In many states, death certification is required prior to cremation or burial services. At both the state and national level, mortality data compiled from death certificates is used to track disease trends, set public health policies, and allocate health and research funding. [U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Physicians’ handbook on medical certification of death]

Definitions of the terminology involved in certifying death

Pronouncement of Death	Date and time an individual was found to be legally dead. May be pronounced by a physician, medical examiner, or coroner.
Date and Time of Death	Date and time an individual is thought to have really died: may be actual or estimated by a physician, medical examiner, or coroner.
Cause of Death	Causal chain of events (disease or injury) that directly led to the death.
Immediate Cause of Death	Final event in the causal sequence that occurred closest to the time of death. Filled in as top line diagnosis on death certificate.
Underlying Cause of Death	Initiating event in the causal sequence that occurred most remote from the time of death. Filled in as bottom line diagnosis on death certificate.
Manner of Death	Classification of death based on circumstances surrounding it, i.e. suicide, homicide, accident, natural, or undetermined.
Medical Certifier of Death	Individual completing the medical portion of the death certificate including time, cause, and manner of death.

U.S. Standard Certificate of Death

The registration of deaths is a State function supported by individual State laws and regulations. The original death certificates are filed in the States and stored in accordance with State practice. Each State has a contract with NCHS that allows the Federal Government to use information from the State records to produce national vital statistics. The national data program is called the National Vital Statistics System (NVSS).

To ensure consistency in the NVSS, NCHS provides leadership and coordination in the development of a standard certificate of death for the States to use as a model. The standard certificate is revised periodically to ensure that the data collected relate to current and anticipated needs. In the revision process, stakeholders review and evaluate each item on the standard certificate for its registration, legal, genealogical, statistical, medical, and research value. The associations on the stakeholder panel that recommended the current U.S. Standard Certificate of Death included the American Medical Association, the National Association of Medical Examiners, the College of American Pathologists, and the American Hospital Association.

Most State certificates conform closely in content and arrangement to the standard. Minor modifications are sometimes necessary to comply with State laws or regulations or to meet specific information needs. Having similar forms promotes uniformity of data and comparable national statistics. They also allow the comparison of individual State data with national data and of individual State data with national data and data from other States. Uniformity of death certificates among the States also increases their acceptability as legal records.

Confidentiality of vital records

To encourage appropriate access to vital records, NCHS promotes the development of model vital statistics laws concerning confidentiality. State laws and supporting regulations define which persons have authorized access to vital records. Some States have few restrictions on access to death certificates. However, there are restrictions on access to death certificates in the majority of States. Legal safeguards to the confidentiality of vital records have been strengthened over time in some States.

Physician’s responsibility

The physician’s principal responsibility in death registration is to complete the medical part of the death certificate. In fulfilling the role of the certifier (i.e., person completing the medical part of the death certificate), the physician performs the final act of care to a patient by providing closure with a well-thought-out and complete death certificate that will allow the family to close the person’s affairs. At the same time, the physician performs a service for the larger community.

The physician is to:

+ Be familiar with State and local regulations on medical certifications for deaths without medical attendance or involving external causes that may require the physician to report the case to a medical examiner or coroner.

+ Complete relevant portions of the death certificate.

+ Deliver the signed or electronically authenticated death certificate to the funeral director promptly so that the funeral director can file it with the State or local registrar within the State’s prescribed time period.

+ Assist the State or local registrar by answering inquiries promptly.

+ Deliver a supplemental report of cause of death to the State vital statistics office when autopsy findings or further investigation reveals the cause of death to be different from what was originally reported.

In some States, hospitals and other institutions are authorized to initiate the preparation of the death certificate when the death occurred in that hospital or institution. In such cases, the attending physician will usually complete the cause-of-death section and sign the certificate at the hospital or other institution. Jurisdictions with electronic registration systems may have other ways to authenticate the certification than by using a signature on paper. In a few States, when the attending physician (physician in charge of the patient’s care for the condition that resulted in death) is not available at the time of death to certify the cause of death, another physician on duty at the hospital or other institution may pronounce the decedent legally dead; and, with the permission of the attending physician, the ‘‘pronouncing physician’’ may authorize release of the body to the funeral director. In such cases, the attending physician will certify the cause of death at a later time.

In all cases, the attending physician is responsible for certifying the cause of death. In most cases, he or she will both pronounce death and certify the cause of death. Only in the instances when the attending physician is unavailable to certify the cause of death at the time of death, and State law provides for a pronouncing physician, will a different physician pronounce death.

If completed properly, the cause of death will communicate the same essential information that a case history would. For example, the following cause-of-death statement is complete:

I a) Septic shock
b) Infected decubitus ulcers
c) Complications of cerebral infarction
d) Cerebral artery atherosclerosis

II Insulin-dependent diabetes mellitus
If not completed properly, information may be missing from the cause-ofdeath section, so someone reading the cause of death would not know why the condition on the lowest used line developed.

For example:

a) Pneumonia
b) Malnutrition
c) ETC

This example does not explain what caused malnutrition. A variety of different circumstances could cause malnutrition, so the statement is incomplete and ambiguous.

In some cases, the physician will be contacted to verify information reported on a death certificate or to provide additional information to clarify what was meant. The original cause-of-death statement may not be wrong from a clinical standpoint, but may not include sufficient information for assigning codes for statistical purposes. Following guidelines in this handbook should minimize the frequency with which a physician will need to spend additional time answering follow-up questions about a patient’s
cause of death. [U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Physicians’ handbook on medical certification of death]

MEDICOLEGAL ISSUES: GUIDELINES TO MEDICAL OFFICERS

Ministry of Health & Family Welfare, Government Of India

Introduction

Medicolegal cases (MLC) are an integral part of medical practice that is frequently encountered by Medical Officers (MO). The occurrence of MLCs is on the increase, both in the Civil as well as in the Armed Forces. Proper handling and accurate documentation of these cases is of prime importance to avoid legal complications and to ensure that the Next of Kin (NOK) receive the entitled benefits.
All medical officers working in hospitals / field medical units / non medical units encounter medicolegal issues which should be handled in accordance with the law of the land and directives issued by service headquarters.
The purpose of this memorandum is to provide general guidelines for Medical Officers of the Armed Forces Medical Services (AFMS) while dealing with commonly encountered situations which fall within the medicolegal domain.
Since law and order is a state subject, there are differences in the legal procedures being followed by different states. Medical Officers should acquaint themselves with medicolegal procedures that are in vogue in the state in which they are serving.

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Case of India

Registering a death is a legal requirement, you need to do this to obtain documents for the funeral director and for dealing with the deceased’s estate.

Medical Certification of Cause of Death (MCCD) in India is carried out under the Government Medical Certification Scheme, which includes training of medical practitioners. Though Medical Certificate of Cause of Death (MCCD), commonly called “Death Certificate”, is the most frequently issued certificate, at least by a government employed medical officer, if not usually by a private practitioner, many of those, issuing it, do not fill up this document of immense medical and legal importance correctly. The reasons may be many, ranging from ignorance to indifference.

Medical Certification of Cause of Death under Civil Registration System has got statutory backing under sections 10(2) and 10(3) of the Registration of Births & Deaths Act, 1969. The Registrar after making the necessary entries in the Register of Birth and Death, forwards the certificates to the Chief Registrar or officer deputed by him, by 10th of every month, subsequent to the month when certificate was issued.

Under Section 23(3) of the RBD Act, any Medical Practitioner who neglects or refuses to issue a certificate under section 10(3) and any person who neglects or refuses to deliver such certificate shall be punishable with fine. Doctor issues Medical Certificate of Death and the Registrar issues Death Certificate / Certificate of Death.

Medical Practitioner can issue the Certificate of cause of death. Issuing MCCD, is done immediately after deciding the person is dead, by the same doctor who has declared the person dead, provided that the doctor is certain about of the cause of death and if it is a natural death. There should be no delay, for any reason, in issuing the medical certificate of cause of death, once the doctor is sure of the cause of death. The doctor should not sign medical certificate of cause of death in advance (i.e. before the individual has died) or without viewing and examining the dead body personally. In some establishments the Death Certificate is to be counter-signed by the Medical Superintendent (legally not required), who should do it only after personal examination of the body. The death report should reach the registrar within 14 days of the occurrence of death.

No fee is to be charged for issuing the certificate.
The doctor must have attended to the deceased in the last seven days preceding death.
In case it is an Unnatural death, body should be handed over to the police, who
holds an inquest and sends the body for Postmortem examination.
Death Report (Form 4) along with Form 8 / 8 A Medical Certificate of cause of
Death for hospital inpatients (Form 8) and for non institutional deaths (Form 8 A) to the registrar of local area.

MEDICAL CERTIFICATE OF CAUSE OF DEATH (INDIA)

Certified that (Name) ………………………………………………………………………………….…..

Rank ……………………… No …………………………….Unit / Ship ………………………………..

Died / was Killed / was Killed in Action on …………………………at ………………………………hrs.

Disease or Condition directly leading to * Death ……………………………………………………………..

………………………………………………………………………………………………………………..

Due to (or as a consequence of ) ……………………………………………………………………………..

……………………………………………………………………………………………………………….

** Antecedent Cause of Death of (Morbid condition or any, giving rise to the above, stating the underlined conditions last) due to (or as a consequence of)

a) ………………………………………………………………………………………………

b) ………………………………………………………………………………………………

Other significant conditions if any contributing to the death but not related to the disease or conditions causing it
Signature of M.O
Place Rank & Name in full

Date Designation

This does not mean the mode of dying for example Heart failure, asthenia etc. It means the disease, injury or complication which causes the death

** Parts (a) &(b) are not to be completed if the disease or condition directly leading to the death describes completely the train of events.

Note:

(A) this form is designed to elicit the information which will facilitate the selection of underlying cause of the death when two or more causes are jointly recorded

(B) See Paragaraph 77 Chapter II of regulations for Medical Service of the Army in India

Medical certificate for cause of non-institutional death

The purposes of death certification in UK

A medical certificate of cause of death (MCCD) enables the deceased’s family to register the death. This provides a permanent legal record of the fact of death and enables the family to arrange disposal of the body, and to settle the deceased’s estate.

A doctor who attended the deceased during their last illness has a legal responsibility to complete a MCCD and arrange for the transmission (electronic recommended) of it to the relevant registrar as soon as possible to enable the registration to take place this duty may be discharged through another doctor who may complete an MCCD in an emergency period. Deaths are required by law to be registered within 5 days of their occurrence unless there is to be a coroner’s post mortem or an inquest.

After registering the death, the family is provided with a certified copy of the register entry (“death certificate”), which includes an exact copy of the cause of death information that you give. This provides them with an explanation of how and why their
relative died. It also gives them a permanent record of information about their family medical history, which may be important for their own health and that of future generations. For all of these reasons it is extremely important that you provide clear, accurate and complete information about the diseases or conditions that caused your patient’s death in a timely manner.

If the deceased has been seen before death by a doctor but not the certifying doctor,
as well as signing the MCCD they should include the name of that doctor on the MCCD.

If no doctor has attended the deceased within 28 days of death (including video/visual consultation) or the deceased was not seen after death by a doctor, the MCCD can still be completed. However, the registrar will be obliged to refer the death to the coroner before it can be registered. In these circumstances, the coroner may instruct the registrar to accept the certifying doctor’s MCCD for registration.

The MCCD is set out in two parts, in accordance with World Health Organisation (WHO) recommendations in the International Statistical Classification of Diseases and Related Health Problems (ICD).