Medical Examiners' and Coroners' Handbook on Death ..., Lecture notes of Statistics

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Preface

This handbook contains instructions for medical examiners and coroners on the registration of deaths and the reporting of fetal deaths. It was prepared by the Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics (NCHS). These instructions pertain to the 2003 revisions of the U.S. Stan dard Certificate of Death and the U.S. Standard Report of Fetal Death and the 1992 revision of the Model State Vital Statistics Act and Regulations. This handbook is intended to serve as a model that can be adapted by any vital statistics registration area.

Other handbooks and references on preparing and registering vital records are mentioned at the end of the section on ‘‘Medical Certification of Death’’ and are listed in the references. For most of these resources, the State vital statistics office or NCHS will be able to provide as many copies as requested.

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Acknowledgments

This publication was prepared by staff from the Division of Vital Statistics led by Donna L. Hoyert, Ph.D., and Arialdi M. Minino, M.P.H. Martha L. Munson, M.S., provided content for fetal death items. Robert N. Anderson, Ph.D., also contributed to this handbook. Mary Anne Freedman, M.A., the Director of the Division of Vital Statistics while this publication was being prepared, reviewed and commented on the contents. Expert medical re- view and comments were provided by Randy Hanzlick, M.D.; Gregory G. Davis, M.D.; and Lillian R. Blackmon, M.D.

This handbook was edited by Kathy Sedgwick, typeset by Jacqueline M. Davis, and the graphics produced by Jarmila G. Ogburn of the Publica tions Branch, Division of Data Services.

Questions about mortality and cause-of-death issues may be directed to staff in the Mortality Statistics Branch, whereas questions about fetal death issues may be directed to Joyce A. Martin, M.P.H., or other staff in the Reproductive Statistics Branch of the Division of Vital Statistics, the Centers for Disease Control and Prevention’s National Center for Health Statistics, Hyattsville, MD 20782.

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• Introduction Acknowledgments v
  • Purpose
  • Importance of Death Registration and Fetal Death Reporting
  • U.S. Standard Certificates and Reports
  • Confidentiality of Vital Records
  • Responsibility of Medical Examiner or Coroner
    • Death Registration
    • Fetal Death Reporting
• General Instructions for Completing Certificates and Reports
• Medical Certification of Death
  • Certifying the Cause of Death
  • Cause of Death
  • Changes to Cause of Death
  • Instructions
    • Part I of the Cause-of-death section - Line (a) Immediate Cause - Lines (b), (c), and (d) Due to (or as a Consequence of) - Approximate Interval Between Onset and Death
      • Conditions) Part II of the Cause-of-Death section (Other Significant
  • Other Items for Medical Certification
    • Autopsy
    • Circumstances of Injury or Violence
  • Special Problems for the Medical-Legal Officer - Items Precision of Knowledge Required to Complete Death Certificate
    • Trauma as a Cause of Death - Natural - Accident - Suicide - Homicide
      • Could not be Determined
      • Pending Investigation
    • Determining a Suicide
    • When Cause Cannot be Determined
    • Deferred ‘‘Pending Investigation’’
  • Certifier Section
  • Examples of Medical Certification
  • Common Problems in Death Certification
  • Additional Resources
• Completing Other Items on the Death Certificate
  • About the Decedent (Items 1–19, 51–55)
  • Parents (Items 11 and 12)
  • Informant (Items 13a–c)
  • Place of Death (Items 14)
  • Facility (Items 15–17)
  • About the Disposition (Items 18–23)
  • Pronouncement (Items 24 and 25)
  • Pronouncing Physician (Items 26–28)
  • Date of Death (Item 29)
  • Time of Death (Item 30)
  • Medical Examiner or Coroner Contacted (Item 31)
  • Cause of Death (Item 32)
  • Autopsy (Items 33 and 34)
  • Tobacco Use Contribute to Death (Item 35)
  • If Female, Pregnancy Status (Item 36)
  • Manner of Death (Item 37)
  • Accident or Injury (Items 38–44)
  • Certifier (Items 45–49)
  • Decedent’s Education (Item 51)
  • Decedent of Hispanic Origin (Item 52)
  • Race (Item 53)
  • Occupation and Industry of Decedent (Items 54 and 55)
• Completing the Cause of Fetal Death
  • Cause of Fetal Death
  • Supplemental Report of Cause of Fetal Death
  • Other Items for Medical Certification
  • Examples of Reporting Cause of Fetal Death
  • Common Problems in Fetal Death Certification
• Completing the Report of Fetal Death
  • FACILITY WORKSHEET
    • CAUSE OF FETAL DEATH
  • PATIENT WORKSHEET
• References
• A. The U.S. Standard Certificate of Death Appendixes
• B. Decedent’s Educational Level Selection Card
• C. Race and Hispanic Origin Category Selection Cards
• D. The U.S. Standard Report of Fetal Death
• E. Definitions of Live Birth and Fetal Death
• F. Facility Worksheet for the Report of Fetal Death
• G. Patient’s Worksheet for the Report of Fetal Death
• H. The Vital Statistics Registration System in the United States

Importance of death registration and fetal death reporting

The death certificate is a permanent record of the fact of death, and depending on the State of death, may be needed to get a burial permit. The information in the record is considered as prima facie evidence of the fact of death that can be introduced in court as evidence. State law specifies the required time for completing and filing the death certificate.

The death certificate provides important personal information about the decedent and about the circumstances and cause of death. This informa tion has many uses related to the settlement of the estate and provides family members’ closure, peace of mind, and documentation of the cause of death.

The death certificate is the source for State and national mortality statis tics (figures 1–3) and is used to determine which medical conditions re ceive research and development funding, to set public health goals, and to measure health status at local, State, national, and international levels. The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) publishes summary mortality data in the Na tional Vital Statistics Report publication ‘‘Deaths: Final data’’ and on the Internet at http://www.cdc.gov/nchs (under vital statistics, mortality).

These mortality data are valuable to physicians indirectly by influencing funding that supports medical and health research (which may alter clini cal practice) and directly as a research tool. Research topics include iden tifying disease etiology, evaluating diagnostic and therapeutic techniques, examining medical or mental health problems that may be found among specific groups of people (2), and indicating areas in which medical re- search can have the greatest impact on reducing mortality.

Analyses typically focus on a single condition reported on the death cer tificate, but some analyses do consider all conditions mentioned. Such analyses are important in studying certain diseases and conditions and in investigating relationships between conditions reported on the same death certificate (for example, types of fatal injuries and automobile crashes or types of infections and HIV).

Because statistical data derived from death certificates can be no more accurate than the information provided on the certificate, it is very impor tant that all persons concerned with the registration of deaths strive not only for complete registration, but also for accuracy and promptness in reporting these events. Furthermore, the potential usefulness of detailed specific information is greater than more general information.

Figure 1. Deaths by age

Figure 2. Deaths by cause

To ensure consistency in the NVSS, NCHS provides leadership and coor dination 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 stan dard certificate for its registration, legal, genealogical, statistical, medical, and research value. The associations on the stakeholder panel that recom mended the current U.S. Standard Certificate of Death included the Ameri can Medical Association, the National Association of Medical Examiners, the College of American Pathologists, and the American Hospital Associa tion (3). For the U.S. Standard Report of Fetal Death, the associations included the American Academy of Pediatrics, American College of Obste tricians and Gynecologists, Association of State and Territorial Health Officers (Maternal and Child Health Affiliate), American Medical Associa tion, and American College of Nurse Midwives (3).

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 statis tics. They also allow the comparison 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 (1). State laws and supporting regulations define which persons have autho rized 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.

The fetal death report is designed primarily to collect information for statistical and research purposes. In many States these records are not maintained in the official files of the State health department. Most States never issue certified copies of these records; the other States issue certified copies very rarely.

Responsibility of the medical examiner or coroner

Death registration

The principal responsibility of the medical examiner or coroner in death registration is to complete the medical part of the death certificate. Before

delivering the death certificate to the funeral director, he or she may add some personal items for proper identification such as name, residence, race, and sex. Under certain circumstances and in some jurisdictions, he or she may provide all the information, medical and personal, required on the certificate.

The funeral director, or other person in charge of interment, will otherwise complete those parts of the death certificate that call for personal informa tion about the decedent. He or she is also responsible for filing the certifi cate with the registrar where the death occurred. Each State prescribes the time within which the death certificate must be filed with the registrar.

In general, the duties of the medical examiner or coroner are to:

• 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.

When the cause of death cannot be determined within the statutory time limit, a death certificate should be filed with the notation that the report of cause of death is ‘‘deferred pending further investigation.’’ A permit to authorize disposal or removal of the body may then be obtained.

If there are other reasons for a delay in completing the medical portion of the certificate, the registrar should be given written notice of the reason for the delay.

When the circumstances of death (accident, suicide, or homicide) cannot be determined within the statutory time limit, the cause-of-death section should be completed and the manner of death should be shown as ‘‘pend ing investigation.’’

As soon as the cause of death and circumstances or manner of death are determined, the medical examiner or coroner should file a supplemental report with the registrar or correct or amend the death certificate accord ing to State and local regulations regarding this procedure.

• Return the fetal death report to the person or institution charged by State law with the responsibility for filing the report.

• If the medical-legal officer is required by State law to fill out a report of fetal death when the fetal death occurs outside a hospital or other institution, complete such a report and send it directly to the local or State registrar.

When an abandoned infant or apparent newborn is found dead, a problem may arise as to whether the event should be registered as a fetal death or an infant death (see appendix E for definitions). If the infant is considered to have lived, even for a very short time, following delivery, then the medical examiner or coroner will use the death certificate usually em ployed. He or she must also ensure that the birth of this infant is properly registered. If the infant is considered to be a fetal death or stillborn, then the appropriate fetal death report must be completed.

General Instructions for Completing Certificates and

Reports

Aside from the facts related to medical certification, the medical examiner or coroner may need to obtain some or all of the personal information required on the certificate or report.

In some jurisdictions the medical-legal officer is not required to complete all of the personal items. He or she may complete and sign the medical certification section and add a few identifying items, such as name, age, sex, race, and residence. The certificate or report is then given to the funeral director who completes the remainder of the record.

In other jurisdictions the medical-legal officer customarily completes all the personal items. Under such conditions the medical examiner or coro ner must obtain the information from an informant who has knowledge of the facts.

The informant is usually a member of the family or a friend of the family. The following individuals can be the informant and are listed in order of preference: spouse, a parent, a child of the decedent, another relative, or other person who has knowledge of the facts. At times the medical exam iner or coroner will have to obtain personal information from a physician or a hospital official. In some cases, information will be obtained from the police.

Whatever the source may be, the name, relationship to decedent, and mailing address of the informant must appear on the certificate in the space provided.

It is essential that certificates and reports be prepared as permanent durable records. Completing a death certificate involves the following guide- lines:

• Use the current form designated by the State.

• Complete each item, following the specific instructions for that item.

• Take care to make entry legible. Use a computer printer with high resolution, typewriter with good black ribbon and clean keys, or print legibly using permanent black ink.

Medical Certification of Death

Certifying the cause of death

The medical examiner or coroner’s primary responsibility in death regis tration is to complete the medical part of the death certificate. The medical certification includes:

• Date and time pronounced dead;

• Date and time of death;

• Question on whether the case was referred to the medical examiner or coroner;

• Cause-of-death section including cause of death, manner of death, tobacco use, and pregnancy status items;

• Injury items for cases involving injuries;

• Certifier section with signatures.

The proper completion of this section of the certificate is of utmost impor tance to the efficient working of a medical-legal investigative system.

Cause of death

This section must be completed by the medical examiner or coroner. The cause-of-death section, a facsimile of which is shown on page 12, follows guidelines recommended by the World Health Organization. An important feature is the reported underlying cause of death determined by the medi cal examiner or coroner and defined as (a) the disease or injury that initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence that produced the fatal injury. In addition to the underlying cause of death, this section provides for report ing the entire sequence of events leading to death as well as other condi tions significantly contributing to death (6).

The cause-of-death section is designed to elicit the opinion of the medical certifier. Causes of death on the death certificate represent a medical opinion that might vary among individual medical-legal officers. A properly

completed cause-of-death section provides an etiological explanation of the order, type, and association of events resulting in death. The initial condition that starts the etiological sequence is specific if it does not leave any doubt as to why it developed. For instance, sepsis is not specific because a number of different conditions may have resulted in sepsis, whereas Human immunodeficiency virus infection is specific.

In certifying the cause of death, any disease, abnormality, injury, or poi soning, if believed to have adversely affected the decedent, should be reported. If the use of alcohol and/or other substance, a smoking history, or a recent pregnancy, injury, or surgery was believed to have contributed to death, then this condition should be reported. The conditions present at the time of death may be completely unrelated, arising independently of each other; or they may be causally related to each other, that is, one condition may lead to another which in turn leads to a third condition, and so forth. Death may also result from the combined effect of two or more conditions.

The mechanism of death, such as cardiac or respiratory arrest, should not be reported as it is a statement not specifically related to the disease process, and it merely attests to the fact of death. The mechanism of death therefore provides no additional information on the cause of death.