What is the primary cause of death to be recorded on the death certificate for an elderly patient with ischemic heart disease who underwent coronary artery bypass grafting and subsequently developed a surgical site infection leading to septicemia and multiorgan failure?

Primary Cause of Death Documentation

Septicemia should be documented as the primary cause of death on this patient's death certificate. 1, 2

Rationale for Death Certificate Completion

The primary cause of death represents the disease or condition that initiated the chain of events directly leading to death, not the underlying chronic condition that predisposed the patient to complications. 1, 3 In this case:

• The causal chain progressed from surgical site infection → septicemia → multiorgan failure → death 1, 2
• The American College of Cardiology/American Heart Association guidelines explicitly recommend attributing death to the specific proximate cause rather than distant underlying conditions 1, 2
• Septicemia directly caused the multiorgan failure that killed the patient, making it the primary cause despite the cardiac history 1

Proper Death Certificate Structure

Part I (immediate cause and antecedent conditions):

• Line A: Multiorgan failure
• Line B: Septicemia
• Line C: Surgical site infection post-CABG 2

Part II (other significant conditions):

• Ischemic heart disease 2

This structure reflects that ischemic heart disease was a contributing factor but not part of the direct causal chain leading to death. 1, 3

Clinical Context Supporting This Determination

Post-operative sepsis carries exceptionally high mortality in cardiac surgery patients:

• Mortality rates of 32-46% when progressing to multiorgan failure 1, 4
• Septicemia-related deaths in post-CABG patients have 16-fold higher mortality compared to those without sepsis 1
• In severe sepsis with multiorgan failure, death occurs in 88% of patients with 4 or more organ failures 4

The progression from infection to septicemia to multiorgan failure represents a clear, uninterrupted causal chain that supersedes the underlying cardiac disease in determining the primary cause of death. 1, 2, 5

Common Pitfall to Avoid

Do not list ischemic heart disease or CABG as the primary cause of death. While the patient's cardiac disease necessitated surgery and created vulnerability to complications, it did not directly cause death—the infectious process did. 1, 2, 3 The World Health Organization defines cause of death as the disease or injury that initiates the chain of events leading to death, which in this case was the surgical site infection and subsequent septicemia. 3