Clinician Obligation to Complete a Certificate of DeathCategories: Clinical Practice, Ethics and Professionalism Adopted: Mar 2019 | Amended: Jul 2021
North Carolina law requires that when a death does not meet criteria for jurisdiction by the Medical Examiner (N.C. Gen. Stat. § 130A-383) the death certificate shall be completed and signed by the physician, physician assistant, or nurse practitioner (“clinician”) in charge of the patient’s care for the illness or condition which resulted in death. Delaying the completion of a death certificate or refusing to sign a death certificate makes an already difficult time for surviving family members and other loved ones even more so and may result in unnecessary complications with funeral arrangements, estate proceedings, and other legal and personal matters.
The Board recognizes that clinicians may not be comfortable with uncertainty, however, a clinician should not decline to sign a death certificate simply because the exact anatomic or physiologic cause of death is uncertain. Less than 10% of deaths result in an autopsy. Clinicians are not expected or required to establish beyond a doubt the specific cause of death but should exercise their best judgment under the circumstances using available information.*
Review of the patient’s medical history should provide adequate information to state a reasonable or likely cause of death. Examples of acceptable causes of death may include arteriosclerotic cardiovascular disease, hypertension, Alzheimer’s disease, or complications of diabetes mellitus. Furthermore, it is acceptable to use “probable” or “possible” to identify a suspected cause of death. In the end, a clinician’s determination of the cause of death is a medical opinion and is based on the best available medical evidence available at the time the certificate is being signed, which may include the cumulative effects of multiple risk factors or a previously known disease process. Use of standard nomenclature without abbreviations and legible writing is encouraged.
The Board will not pursue disciplinary action against clinicians who complete death certificates in good faith and to the best of their ability in accord with the information available — even if that information is limited. The clinician completing the death certificate is only asked to provide a cause of death “to the best of [his or her] knowledge,” not to a medical certainty (which is not possible in many instances). The Board also recognizes that clinicians may believe, for a variety of reasons, they were not “in charge of the patient’s care for the illness or condition which resulted in death.” This is often because death has occurred weeks or months after the last contact with the patient. The Board encourages clinicians to undertake completion of death certificates for patients (current, recent, or remote) under these circumstances as a professional, ethical, civic, and public health responsibility. Failure or refusal to complete a death certificate, when the licensee clearly has a responsibility to do so, could lead the Board to consider disciplinary action.
Licensees should perform this final aspect of patient care promptly and with consideration for the decedent and his or her loved ones. Questions or concerns by clinicians regarding medical examiner responsibilities in a particular case or for advice on the completion of a death certificate may be discussed in a collegial and professional manner with the county medical examiner or Chief Medical Examiner’s office. Legal requirements regarding completion of a death certificate may be found at N.C. Gen. Stat. § 130A 115. Additional guidance on the proper completion of death certificates is available at in the Physicians’ Handbook on Medical Certification of Death.
*The Board is aware that N.C. Gen. Stat. § 130A 115(c) requires that the practitioner “state the cause of death in definite and precise terms.” (emphasis added) It is the Board’s interpretation of this statute that the terms describing the cause of death must be definite and precise, not that the cause of death be definite, as this would be inconsistent with other language in N.C. Gen. Stat. § 130A 115(c) and, as previously mentioned, is not possible in some instances.