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Medical certification of cause of death

The certifier

The medical knowledge and skills of those responsible for certification critically affect the quality of COD data. Certifiers need to understand the health importance of accurate death certification and COD data, and to receive appropriate training in certification. They also need to be aware of the legal and ethical considerations that may affect the quality of COD certification, and of ways of addressing them.

Training in medical certification should cover four areas:

  • Understanding the sequence of events leading to death and correctly identifying the UCOD
  • Completing the death certificate correctly
  • Understanding the social, legal and ethical issues that certification may entail
  • Appreciation of the health value of cause of death statistics.

Although lack of knowledge and skills often underlie poor certification practices, some common errors arise from more mundane causes such as:

  • Documenting multiple causes per line in the Part 1 
  • Not reporting the time interval from onset to death 
  • Leaving blank lines within the sequence/chain of events 
  • Use of abbreviations used in certifying the COD 
  • Illegible handwriting 
  • Incorrect/clinically improbable sequence of events leading to death 
  • Ill-defined condition(s) entered as the UCOD.

In many countries, physicians do not have adequate opportunities to learn about death certification as part of their medical curriculum and training. Hospitals may lack equipment that may be needed to correctly determine the COD, and medical records may be poorly completed and thus inadequate for informing the decision of the physician responsible for certifying the COD. All these factors will impede reliable and accurate certification of COD by physicians.

A post-mortem examination is sometimes needed to determine the COD and is often a legal requirement in cases of unexpected deaths. However, it is not always feasible and/or practical to conduct such an examination. Therefore, death certification by physicians, based on extensive clinical records of the patients during contact with health services, is considered to be the ‘gold standard’ for producing COD data. 

In countries where a high proportion of people die outside hospitals or other health facilities, the COD is not certified by a physician but by a lay person such as a police officer, village chief, registrar or other person without medical training. COD data certified by nonmedically trained individuals do not generate reliable and accurate mortality statistics. Many such deaths are attributed to ill-defined and nonspecific causes, such as ‘old age’, ‘fever’, ‘heart failure’ and ‘stopped breathing’. Such diagnoses are of no value to disease control and prevention programs. 

Read more

Azim A et al. (2014). Impact of an educational intervention on errors in death certification: An observational study from the intensive care unit of a tertiary care teaching hospital. Journal of Anaesthesiology Clinical Pharmacology.

Burger EH et al. (2015). Medical certification of death in South Africa – moving forward. South African Medical Journal.

Foreman KJ (2016). Improving the usefulness of US mortality data: new methods for reclassification of underlying causes of death. Population Health Metrics.

Maharjan L et al. (2015). Errors in cause-of-death statement on death certificates in intensive care unit of Kathmandu, Nepal. BMC Health Services Research.

Handbook for doctors on cause of death certification thumbnail
Handbook for doctors on cause of death certification

These are generic guidelines about how to certify the cause of death, written for physicians and medical students, particularly in developing countries.

Download resource (1.32MB)
More Info

Author: University of Melbourne

Publication date: September 2019 (update)

Resource type: CRVS technical guide

Related resources: Medical certification of cause of death: Quick reference guide

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