CLINICAL COMMENTARY


The Afterlife of Death Certificates


Erie Vann Boorman III, M. D.

Physicians are often accused of playing god. Since we physicians are making
decisions based on inadequate information most of the day, we are far from
infallible. But there is one circumstance when we have the final say: in designating
the cause of death. The first time I was asked as a physician \"what did he
died from?\", it came to me that he died from whatever I designated. Society
recognizes this status as the Oracle for deter-mining the cause of death. But
choosing a meaningful cause of death is problematic. In the beginning (of my
being a physician) I often put as the cause \"cardiac arrest\". Although this
is a bona fide cause of death, the special status reserved for it means that
the cause of death occurred suddenly and was primarily cardiac. However, this
cause of death obfuscates what led up to death in most cases. From the survivors
point of view cardiac arrest provides no useful information regarding future
risk. From an epidemiologic point of view this cause of death provides no information
of value regarding the effectiveness of medical care. Finally, from a practitioners
point of view there is no information contained in this diagnosis that might
help the practitioner to manage a similar case in the future. The opposite
of \"sudden death\" is death due to \"old age.\" Many times patients have answered \"Mom?
She died of old age!\" What a surprise for me to find talking to morticians
that this is a bona fide cause of death. 1 Causes of death range from the sudden
and dramatic to the prolonged and senescent. 2

When I began my career in medicine
30 years ago I naively thought to myself that filling out the death certificate
was going to be easy. After all, for the first several years the immediate
cause of death was always \"cardiac arrest\", \"cardio pulmonary arrest\", or \"pulmonary
arrest\". Imagine my chagrin when a \"mere\" mortician said, \"You can\'t say that.
They all die of that.\" And clearly I had mistaken the fact of death or the
time of death for the underlying cause of death. To say \"cardiac arrest\" was
most of the time a tautology, since death is often defined as the heart stopping.
And as you know, most tautologies provide no new information. What amazes me
is that only one mortician and no coroners ever questioned this diag-nosis.
Clearly, the reason is that this particular diagnosis of death does have a
place. But the term should be reserved for those settings of unexpected sudden
death or, if expected, the outcome of another condi-tion such as a myocardial
infarction or a pulmonary embolism, for example. The death certificate should
attempt to have accurate and meaningful cause-of-death statements. 3

Important
issues about the death certificate can be summed up by considering murder (for
example poisoning), suicide, accidental death, iatrogenic cause, euthanasia,
aggressive pain management for terminal disease producing expected hypoventilation
but not the cause of death directly. Hospice care requires narcotics and sedatives
which often hasten death by short amounts of time. This use of narcotics and
sedatives is almost never mentioned as causing the death. The use of drugs
to alleviate suffering is now well accepted provided it is not done as euthanasia.
Fortunately, in three decades of doctoring, I am not aware of a single iatrogenic
or accidental death that was ever omitted as causing or contributing to death
on the death certificate. I recall cases where specific instructions to family
members not to exceed certain doses of sensitive and narcotic drugs because
of the danger of hastening the expected death probably actually provided instructions
to relieve suffering a bit earlier than expected. But I am not aware of any
cases where such instructions were listed as contributing to the cause of death-since
the death was expected and imminent. I am aware of a case of an unfounded rumor
of poison contributing to death but this suspicion was quashed before making
it to its final resting place on the death certificate.

In the practical day-to-day
practice of medicine, avoidance of interaction with the coroner is sought-after
because it delays release of the body to the patient\'s families and rouses
unnecessary suspicions in family members. I recall such a case where ARDS (acute
respiratory distress syndrome) was the actual cause of death. However, the
coroner was dissatisfied. Unbeknownst to me, \"trauma\", \"aspiration,\" drowning\",
and so on represent possible underlying causes and could have had possible
important legal consequences. The coroner simply wished for more information.
The family unfortunately was trauma-tized by the delay and became unnecessarily
suspi-cious about what might have transpired during the hospital stay because
the coroner had told them a death certificate could not be issued without further
facts.

My most curious case involving a death certificate was not about the
cause of death for the patient but was about determining who the patient was.
After my patient died from advanced liver failure from metastatic bowel cancer,
the body was released to a prominent local mortuary. I received a frantic phone
call from the widow many days later telling me that the bodies had been mixed
up. I was designated to determine if this new body was the right body or not.
I must say that the body -laid out, on the slab, embalmed, gray and cold -had
faint resemblance to the real person I had cared for. During the last weeks
of his life he had been on a respirator, sedated, but animated. Possibly I
knew more about his disease than about his actual appearance. I do believe
that I made a proper identification though.

Never, ever, under any circumstances,
sign a blank death certificate. I can recall a dozen instances where the funeral
parlor requested that I sign a blank certificate \"to make it easier\". Signing
a blank death certificate is fraught with danger. Any person\'s name can be
filled in. Any cause of death can be inserted. In addition, any time of death
can be inserted. The time of death may have important implications for inheri-tance
(for example which spouse preceded the other in death can determine which spouse
would be the next in line to inherit. The time of death may also have implications
in taxation. Hence, leaving a blank for the time of death is also a potential
mistake.

There may be many vested interests in what the cause of death is.
For instance, federal or state monies may be parceled out based on the number
of deaths of a certain type each year. For example, infant mortality may
help to determine federal to state reimbursement levels. Other funds may similarly
be affected: tuber-culosis rates, breast cancer rates, HIV deaths, alcohol
related deaths, tobacco related deaths, and so on. The involved funds may
be private rather than public in the sense that litigation may be related to
the number of accidental deaths or tobacco related deaths, for instance. Finally,
individual hospitals or individual physicians have a vested interest in outcome
statis-tics. 4 Hospitals with high death rates for certain conditions, for
example death rates for acute myocar-dial infarction, may find themselves
explaining why their statistics are significantly worse than a similar
institution across the street. The same idea goes for physicians such as thoracic
surgeons, neurosurgeons, cardiologists to select a few high risk groups, whose
future income depends on securing patients by their reputation for good care.

There are often valid research reasons to track causes of death. 5,6 Arecent
example comes to mind: the now-apparent correlation between estrogen replace-ment
therapy and an increase in both cardiac deaths and breast cancer deaths. How
these deaths are reported may affect whether links can be found or not. Another
easy example is the importance of tracking whether statin drugs have a salubrious
effect on the number of cardiac deaths, strokes, or similar conditions such
as congestive heart failure. Accurate causes of death help certify conclusions
about such drugs. Clinical trials of new anticancer chemotherapeutic drugs
clearly depend on accurate data about causes of death as well.

The most troublesome
case is the case where several competing diseases vie for the cause of death.
7 For example in the case to be presented below, the number of candidates for
the cause of death include: congestive heart failure, diabetes mellitus, hyperten-sive
cardiovascular disease, vasculitis, adult respira-tory distress syndrome, and
septic shock. Depending on which of these is chosen as the proximal cause of
death or the contributing cause of death could influ-ence important health
statistics. In a complicated case where many of these potential causes of death
inter-twine it may not be possible to unravel the cause of death. Even in cases
where an autopsy occurs, more than one cause of death may be likely. 8,9,10
Apparently, death certificates have the best agreement with autopsy findings
when there is a neoplastic disease responsible. Surprisingly the lowest corre-spondence
is for chest diseases. For cardiovascular disease about two-thirds of death
certificates are correct. For coronary artery disease concordance is about
three-fourths. For cerebrovascular disease the stated cause is correct almost
80% of the time. 11 According to one study, the discordance was highest for
death certificates filled in by the family physi-cian. 7 Clearly, however,
a specialist who fills in the death certificate has already been supplied with
a patient of his subspecialty who is most likely quite ill
from a disease within that specialty. In figuring out rates of concordance
or discordance one must be aware of the top 10 leading causes of death: diseases
of the heart; malignant neoplasms; cerebrovascular disease; chronic lower respiratory
diseases; accidents; diabetes mellitus; influenza and pneumonia; Alzheimer\'s
disease; nephritis, nephrotic syndrome and nephrosis; and septicemia. These
causes appar-ently account for about 80% of all deaths in the United States.
12 Concordance would be more likely to occur if the cause of death or an underlying
cause of death included at least one of these top prospects. Nevertheless,
in one study only 55% of death certifi-cates met minimally accepted standards.
13

The patient was a 77 year-old Holocaust survivor. Over the previous 15 years
he was afflicted with the following significant diseases: hypertensive cardio-vascular
disease, renal insufficiency from DM, congestive heart failure of the diastolic
type, coronary artery disease with prior myocardial infarction, diabetes mellitus
type 2, severe peripheral vascular disease involving the carotid arteries,
the ileal femoral and popliteal arteries producing severe ischemia of the left
foot and leg but responding eventually to revascularization, chronic anemia
of renal insuffi-ciency, and COPD. He had a major post-traumatic stress disorder
caused by his time in the Nazi death camps where he was beaten in such a way
that a cardiac contusion probably produced an anterior myocardial infarction,
which contributed to his heart failure many years later.

He was admitted to
the hospital and expired more than a month later. He was admitted with respiratory
distress, requiring intubation and intensive care treat-ment. Amyocardial infarction
was determined to have occurred. He required right heart catheterization to
manage fluids and vasopressors to improve cardiac output. He was also given
antibiotics. Weaning from the respirator proved difficult. He had to be re-intu-bated
several times for the same sequence of respira-tory events. Although aspiration
pneumonia seemed to have occurred, contributing to his desperate pulmonary
status his presumed vasculitis may have contributed even more to his nearly
hopeless pulmonary status. He eventually required a gastric tube for feeding
because of aspiration risk. Nevertheless he vomited and aspirated and developed
acute respiratory failure, septic shock, and repeated the same cycle already
noted. Despite intensive efforts the patient became bradycardic and eventually
asystolic and did not respond to code blue protocol. Among the many diseases
present, the leading cause of death was felt to be severe coronary artery disease.

Clearly I have chosen this case for illustrations because there are many
possible ways of filling out the death certificate. For the immediate cause
of death one might choose cardiac arrhythmia because his
rhythm rapidly deteriorated to asystole. However, he was also being treated for
septic shock associated with aspiration pneumonia. Therefore, I think it would
also have been reasonable to list septic shock as the prime event with the cause
being aspiration pneumonia and contributing causes being congestive heart failure,
coronary artery disease, respiratory failure, diabetes mellitus, and vasculitis.
Because of the lack of clarity about his respiratory failure, it is possible
to say that the entire sequence of events was caused by respiratory failure.
The fact that he could not be weaned successfully suggests that the lung contribution
to his death was quite significant. The cause of his lung disorder was never
actually ascer-tained but the vasculitis was suspected. In this case the contribution
of vasculitis would have to be recog-nized more prominently in the death certificate.
Finally, during his final days the possibility of pulmonary embolus as a cause
of death occurred to everyone. Without obtaining an autopsy this possi-bility
could not be proven. If the cause of death was actually coronary artery disease,
then both diabetes and hypertensive cardiovascular disease contributed a prominent
role. During his final rapid deterioration with abrupt bradycardia and loss of
rhythm, it was not possible to pick out the most proximal cause. Autopsy might
or might not have been conclusive. Nevertheless, the choices for the causes of
death were very likely correct. As a footnote to history a contributing factor
of death could be listed as the cardiac contusion inflicted by the Nazis in the
concen-tration camp: one more victim to add to the millions of persecution-related
deaths.

I have had cases so mystifying as an intern that everyone was confused.
After bemoaning my failure to get permission for autopsy, a resident, whose
name long escapes me, said I should have told the family that the cause of
death might be important to their own health later in life. Of course, I had
already used that valid tactic. The resident then suggested, face-tiously, that I must use
the \"gold ball.\" As I had never heard of this technique I ask for an explanation.
His explanation, which I still believe to be facetious, was that the family
should be told that in the last hours a golden ball was used and that it had
to be retrieved by autopsy or the family will be responsible financially. Obviously,
I never used this technique but have often thought of it in perplexing cases.
For example, I had a case of a mysterious pneumonia, beginning as a simple
bronchitis, but progressing rapidly to respira-tory failure. This case occurred
many many years ago and nicely fits the defining criteria for SARS, the most
recent plague on humanity. Various tests including perfusion lung scans suggested
the possi-bility of pulmonary emboli but could never be confirmed. Disastrously,
the patient expired. The cause of death was listed as ARDS but truly the answer
could have been elsewhere. Many years later the possibility of toxic reactions
has also occurred to me. In one such case the son of the patient who died mysteriously
suggested to me the possibility of a toxic reaction. His viewpoint was different
because he was trained as a veterinarian and must have had reasons for his
suspicions. Despite searching for possible toxic substances including medications
administered in the hospital to this perplexing patient, the under-lying cause
could not be identified--even by autopsy. I have read about cases where the
patient dies years later from being in a coma after an assault or after a car
accident, for example, but where the immediate cause of death could have been
a pulmonary embolus or an aspiration pneumonia or sepsis from decubitus ulcers,
but where the autopsy lists homicide as the cause of death-providing evidence
that the State clearly has an ultimate interest in these cases-even when delayed
by years. In death involving veterans, survivor benefits may be at issue. For
example a World War II veteran who sustained shrapnel injury to the leg may
later developed cellulitis and sepsis from sequestered bone or bullet fragments.
If it is not clearly stated that there is a connection between the World War
and the eventual death-even though death came 52 years later, certain benefits
may be lost. And History would not be well served.

Finally, I would like to
comment on revisionist history as it applies to death certificates. In the
early 1980\'s, before AIDS was actually a diagnosis, I had a
case where the underlying cause of illness was stated to be \"tetracycline allergy\".
Medical progress, being inexorable, changes insight into causes of death. I expect
to be surprised as many times in the future as I have been in the past.

REFERENCES

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2. Physician\'s Handbook on Medical Certification of
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Sep. (Reprinted 1995 Jul).

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