What are the steps to complete a death certificate?

How to Complete a Death Certificate

Complete the death certificate by documenting the underlying cause of death (the disease or condition that initiated the chain of events leading to death) in Part I, line (c) or (d), followed by the immediate cause on line (a), with intermediate causes in between, avoiding listing only terminal mechanisms like "cardiac arrest" or "respiratory failure." 1, 2

Understanding the Structure of Death Certification

The death certificate requires you to distinguish between different types of causes:

• Underlying cause of death: The disease or injury that initiated the chain of events leading directly to death 2, 3
• Immediate cause of death: The final disease or condition resulting in death, listed on line (a) of Part I 2, 3
• Intermediate causes: Conditions arising from the underlying cause, listed in sequence between the underlying and immediate causes 2, 3

Critical Pitfall to Avoid

Never list only terminal events or mechanisms as the cause of death. Terms like "respiratory failure," "cardiac arrest," or "cardiopulmonary arrest" are mechanisms of death, not underlying causes, and should not be used alone. 1, 4 Instead, you must identify and document the specific disease or condition that led to these terminal events. 1, 2

For example, if a patient died from pneumonia that caused respiratory failure, list "respiratory failure" on line (a) and "pneumonia" on line (b) or (c), not respiratory failure alone. 2, 3

Step-by-Step Completion Process

Patient Identification Section

• Document complete patient identification including full legal name, medical record number, and date of birth 5
• Record the exact date, time, and location of death 5, 6
• Document who pronounced the patient dead and the time of pronouncement 5

Part I: Cause of Death Chain

Work backwards from death to identify the causal sequence:

• Line (a): Immediate cause - the final condition directly causing death 2, 3
• Line (b): Condition leading to (a) - if applicable 2, 3
• Line (c): Condition leading to (b) - if applicable 2, 3
• Line (d): Underlying cause - the disease or injury that started the chain 2, 3

Use specific, accurate medical terminology rather than vague descriptions. 2, 4 For instance, specify "adenocarcinoma of the lung" rather than just "cancer," and include organism identification for infections when known. 7

Part II: Other Significant Conditions

List other important diseases or conditions that contributed to death but did not directly cause it. 2, 3 These are conditions that may have influenced the outcome but were not part of the direct causal chain in Part I. 2

Administrative and Legal Requirements

Medical Examiner/Coroner Notification

• Identify and notify the medical examiner/coroner regarding all deaths as directed by applicable law 8, 5, 1
• Medical examiners and coroners are the official death certifiers in their jurisdictions, with over 2,000 such jurisdictions in the United States 1

Healthcare Provider Notification

• Promptly notify the patient's primary care provider and appropriate subspecialty providers of the death 8, 5
• Document coordination with the medical home when applicable 8

Documentation of Resuscitation and Medical Interventions

• Document any resuscitation attempts or presence of Do Not Attempt Resuscitation (DNAR) orders 5, 6
• Record removal of medical devices unless an autopsy is planned 5, 6

Autopsy Considerations

• Routinely offer postmortem autopsy to families for all non-medical examiner-coroner cases 8
• Document whether an autopsy was offered and the family's decision 5

Special Circumstances

Physician-Assisted Suicide (Where Legal)

In jurisdictions where physician-assisted suicide is legal, list the underlying terminal illness as the cause of death, not the ingestion of lethal medication, though this requirement raises ethical concerns about accuracy. 1

Brain Death Cases

For brain death determinations, death is declared after confirmation and completion of the second clinical examination and apnea test. 5 The determination should be carried out by experienced clinicians familiar with neurocritical care. 5

Pediatric Deaths in Emergency Departments

Follow specific protocols including written procedures for death certificate completion, often provided as a "death packet" with guidelines. 8 Ensure coordination with the child's medical home and primary care provider. 8

Family Support Documentation

While completing the death certificate, also document:

• Family notification details (who was notified, when, and by whom) 5, 6
• Cultural, religious, or spiritual considerations addressed in after-death care 5, 6
• Organ donation discussions or decisions 5, 6
• Plans for formal condolences and referrals to bereavement services 5, 6

Quality Improvement Considerations

Senior physicians make more errors than junior doctors in death certification, while general practitioners and pathologists make the fewest errors. 7 This suggests that regular exposure to certification and clinical experience improve accuracy, but even experienced practitioners frequently make errors. 7 The most common errors involve inadequate formulation of the underlying cause of death and failure to record relevant specific information such as tumor histology or identified organisms. 7, 9

Educational training interventions have been documented as effective at reducing certification errors. 4 Consider seeking guidance from pathologists or medical examiners when uncertain about proper cause-of-death formulation. 9

Filing Requirements

Complete and file the death certificate promptly and accurately for legal and statistical purposes. 5, 6 Complete all necessary forms for the funeral director. 5, 6 Mortality statistics derived from death certificates are the only continuously collected, population-based disease information available, making accuracy critical for public health surveillance and policy. 2