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Physician obligation to complete death certificates

Refusals or delays in certifying patient deaths have real consequences
The North Carolina Medical Board frequently receives phone calls and complaints from patients’ families, EMS directors, funeral home personnel and others about refusals and/or unacceptable delays in physician completion of death certificates. Most often these concerns relate to an unattended death from natural causes. Most of these decedents have an established relationship with a physician, but for a variety of reasons, the identified physician is reluctant to
certify the death. For example, the decedent may not have seen the physician for several months, or the physician may have been providing treatment for stable, conditions that posed no apparent immediate threat to the patient’s life (hypertension, diabetes, etc.). Or, the physician may simply feel he or she has no exact idea why the patient died.

Regardless of the reason, delaying the completion of a death certificate or refusing to sign a death certificate creates unnecessary complications with funeral arrangements, estate proceedings, and other legal and personal matters.This makes an already difficult time for surviving family members and other loved ones even more so.

This article will discuss a clinician’s professional obligation to certify deaths in a timely manner. And, while I do not intend for this article to serve as an authoritative guide to completing death certificates, I will also offer some basic guidance on certifying deaths. Finally, I want to allay licensees’ unwarranted concerns about completing and signing death certificates for deaths from natural causes or in cases where the exact cause of death may be unknown but reasonably deduced.

Whose responsibility is it to complete death certificates?
Under North Carolina law, death certificates must be completed by a licensed physician or, thanks to changes that took effect in fall 2011, a physician assistant or nurse practitioner who has been specifically authorized by his or her supervising physician to certify deaths. In situations where a person dies at home and is brought by ambulance to a hospital emergency department, it is common practice for hospital staff to check the person’s medical records to determine if he or she had an established relationship with a primary care doctor or other physician. If so, the hospital will generally ask the decedent’s physician to certify the death. It is the Board’s view that this is a reasonable practice, as physicians or other professionals who have examined and treated a patient in the past are arguably in the best position to make an educated guess about the likely cause of death, even if the patient had not been seen recently.

As noted, PAs and NPs may now lawfully share the responsibility of certifying deaths. Amendments to NCGS 90-18.1 require that PAs and NPs be specifically authorized to complete death certificates by the supervising physician under the terms of their written supervisory arrangement or collaborative practice agreement. As with any other delegated tasks, the supervising physician is ultimately responsible for ensuring that death certificates are properly filled out and filed.

Clinicians may not decline to sign a certificate because they are uncertain of the exact cause of death. Clinicians are merely expected to exercise their best clinical judgment under the circumstances, just as they would in diagnosing treatment for a patient. Deaths should not be referred to the medical examiner's office because a clinician involved in a patient's care is not comfortable attributing a cause of death or believes it is another person’s responsibility to complete the death certificate. Understand that, before the attending physician is contacted about signing the death certificate, an assessment of the circumstances has almost always been made by EMS, law enforcement, or the medical examiner.

If the death falls within the medical examiner’s jurisdiction, it will be referred accordingly. Natural deaths are referred to the medical examiner only in extremely limited circumstances. Refusing to sign a death certificate and forcing the case to be accepted by the medical examiner: 1) Does NOT mean that an autopsy will be done. (It probably will not be.) and 2) Will initiate a chain of events that requires additional time, creates unnecessary expense and hassle for the family, and costs the county about $300.00.

Basics of completing death certificates
It’s important to understand that a death certificate is a legal and not a scientific document. As such, physicians are not required to establish a specific anatomical reason causing the death. If that were the case, postmortem studies (autopsies) would be necessary in all deaths. Obviously, performing autopsies on a routine basis would be unmanageable and beyond the resources of both the medical examiner and hospital-based pathologists.

The requirement for death certification is a statement of the condition most likely responsible for death. Clinicians may be uncertain about the exact cause of death, even if they have been treating the patient for one or more stable chronic conditions. The physician, PA or NP may feel that the death is unexplained and believe the decedent should be referred to the medical examiner to determine a specific anatomical diagnosis. This is NOT the case. The patient’s medical history should provide adequate information to state a reasonable cause of death that meets legal requirements.

It is acceptable to use “probable” to identify a suspected final cause of death. If a specific anatomic cause of death is desired a clinician may request permission for a private autopsy from the family after clearing the death with the medical examiner. Remember, the cause of death is a medical opinion and is based on the preponderance of medical evidence, which includes the cumulative effects of multiple risk factors for particular disease processes. Cause of death is the disease process that sets in motion the chain of events that lead to death. For detailed guidance on completing death certificates, I recommend the U.S. Centers for Disease Control and Prevention booklet, "The Physician’s Handbook of Medical Certification of Death."

Licensees should know that the Board is not interested in pursuing disciplinary action against individuals who complete death certificates in good faith and to the best of their abilities. The chance of facing investigation by the Board, or other adverse legal consequences, related to the completion of a death certificate in good faith is remote and should not deter a physician from performing this duty.

How quickly must death certificates be completed?
State law (NCGS §130A 115) specifies that death certificates must be completed within three days of receipt of the request. Based on the calls and complaints the Board receives, this does not always happen. The Board has received reports of families waiting for several weeks to have a loved one’s body released due to a physician’s unwillingness to certify the death.

The reporting of vital events is an integral part of patient care. The Board requests that licensees (physicians, physician assistants, and nurse practitioners) accept the professional responsibility to complete death certificates for patients (current, recent, and remote) who die of natural causes (manner), regardless of whether the death occurs in or out of the hospital.

Licensees can, and should, perform this final aspect of patient care promptly and with consideration for the decedent and his or her loved ones.