From the Guidelines
When the cause of death is unknown, the death certificate should list "Undetermined" or "Unknown" as the cause of death, as this approach maintains the integrity of vital statistics while acknowledging the limitations of medical knowledge in certain cases 1. This is in line with the standardized definitions for evaluation of heart failure therapies, which classify deaths due to unknown causes and not clearly cardiovascular or non-cardiovascular as "unknown or undetermined" 1.
Key Considerations
- Medical examiners or certifying physicians may also use terms such as "Pending investigation" if further tests or inquiries are being conducted to determine the cause.
- In some jurisdictions, "Natural causes" might be used when death appears to be from disease but the specific condition cannot be identified.
- The certifier should be as specific as possible with the information available, noting any contributing conditions that may have played a role even if the primary cause remains unclear.
- Death certificates serve important public health and legal purposes, so accuracy is essential even when that means acknowledging uncertainty about the precise cause of death.
Relevant Evidence
The European Journal of Heart Failure study 1 provides guidance on classifying deaths with unknown causes, emphasizing the importance of accuracy and specificity in death certification. While the Circulation study 1 focuses on out-of-hospital ischemic CHD death, it highlights the challenges of determining the cause of death in certain cases, underscoring the need for a standardized approach to death certification. However, the more recent and higher-quality study 1 takes precedence in guiding clinical practice.
Clinical Implications
In clinical practice, accurate and transparent death certification is crucial, not only for legal and public health purposes but also for maintaining trust and integrity in the medical profession 1. By following standardized guidelines and being as specific as possible, healthcare providers can ensure that death certificates accurately reflect the circumstances of death, even when the cause is unknown.
From the Research
Cause of Death on a Death Certificate
When the cause of death is unknown, it can be challenging to determine what to list on a death certificate. According to various studies 2, 3, 4, 5, 6, there are several factors to consider:
- Sudden Unexplained Death (SUD): In cases of SUD, the death certificate may list the cause of death as "unknown" or "sudden unexplained death" 4.
- Autopsy Results: If an autopsy is performed, the results may provide some insight into the cause of death. However, in some cases, the autopsy may not reveal any underlying conditions or abnormalities 2, 6.
- Genetic Testing: Genetic testing, such as molecular autopsy, may be used to help determine the cause of death in cases of SUD 3, 4, 5.
- Clinical and Family History: A detailed clinical and family history can also be helpful in determining the cause of death and identifying potential risk factors for sudden cardiac death 4, 6.
Listing the Cause of Death
When listing the cause of death on a death certificate, it is essential to be accurate and thorough. Some possible options for listing the cause of death in cases of unknown cause include:
- Sudden Unexplained Death: This term can be used when the cause of death is unknown and there is no evidence of any underlying conditions or abnormalities.
- Sudden Cardiac Death: This term can be used when the death is suspected to be related to a cardiac condition, but the exact cause is unknown.
- Undetermined: This term can be used when the cause of death cannot be determined, even after a thorough investigation and autopsy.
It is crucial to note that the specific wording and formatting of the death certificate may vary depending on the jurisdiction and local regulations. Ultimately, the goal is to provide an accurate and informative death certificate that reflects the circumstances surrounding the death.