Can cardiorespiratory (cardiac and respiratory) failure be used as a cause of death on a death certificate?

Cardiorespiratory Failure on Death Certificates

Cardiorespiratory failure should not be used as the underlying cause of death on death certificates as it represents a mechanism of death rather than the true underlying cause.

Understanding Death Certificate Terminology

• Death certificates should identify the specific disease or condition that initiated the chain of events leading to death (underlying cause) rather than the terminal event or mechanism of death 1
• Cardiorespiratory failure is considered a mechanism of death - the final common pathway through which many diseases lead to death - not an underlying cause 1
• Using cardiorespiratory failure as the underlying cause provides inadequate information about the true disease process that led to death 2

Proper Classification of Causes of Death

• The underlying cause of death should be the specific disease that initiated the chain of events leading to death (e.g., myocardial infarction, stroke, cancer) 1
• Cardiovascular causes should be specified as acute myocardial infarction, arrhythmia, cardiogenic shock, heart failure, stroke, etc. 1
• Respiratory causes should be specified as pneumonia, COPD, pulmonary embolism, etc. 1
• When multiple diseases are present, the condition that started the chain of events leading to death should be listed as the underlying cause 3

Impact on Mortality Statistics

• Using non-specific terms like cardiorespiratory failure negatively affects the quality of vital statistics and epidemiological research 2
• Studies show that death certificates frequently misclassify causes of death, with concordance rates as low as 48% when compared to autopsy findings 3
• Heart failure (a component of cardiorespiratory failure) is often incorrectly listed as an underlying cause of death, with one study showing it was used in 3.6% of all deaths 2

Factors Associated with Misclassification

• Advanced age increases the odds of non-specific causes being listed (35% increase for each 5-year increment in age) 2
• Deaths occurring in nursing homes (vs. hospitals) have 78% higher odds of listing non-specific causes 2
• Deaths without autopsy have 602% higher odds of listing non-specific causes 2
• Previous hospitalization with heart failure increases the odds of having heart failure listed as the underlying cause by 514% 2

Best Practices for Death Certification

• Identify and document the specific disease that initiated the events leading to death 1, 4
• Provide a logical sequence of events from the underlying cause to the immediate cause 4
• Include relevant contributory conditions that did not directly cause death but contributed to it 1, 4
• When uncertain about the exact cause, use the most specific diagnosis that can be supported by available evidence 3
• For sudden cardiac deaths, document as specifically as possible (e.g., "presumed sudden cardiac death due to coronary artery disease") rather than using "cardiorespiratory failure" 1

Accuracy Concerns

• Studies show coronary heart disease is often overreported on death certificates by 7.9-24.3% overall and up to two-fold in older persons 5
• Sensitivity for detecting specific causes varies widely: high for cancer (80%) but much lower for heart disease (60%) and pneumonia (46%) 3
• The strongest factor for misclassification is the underlying cause of death itself, with certain conditions being more prone to misclassification than others 3

Alternative Approaches When Cause is Uncertain

• When the cause is truly unknown, "death due to unknown or undetermined cause" is preferable to a non-specific mechanism 1
• For sudden unexpected deaths, "sudden cardiac death" with the most likely etiology is more informative than "cardiorespiratory failure" 1
• For deaths following progressive heart failure, "pump failure death" with the underlying cardiac condition is more appropriate 1