April 8 2020
Q: Are there any rules for determining and reporting the cause of death?
A: Absolutely. We use the US Standard Certificate of Death . Recording births, marriages, divorces and deaths is important from legal, administrative, financial, and medical standpoints.
Q: Why do you want to discuss reporting, when we must be focused on helping to contain epidemic and people affected?
A: I would like to focus on medical aspects of cause-of-death reporting in the light of yesterday’s admission by Dr. Fauci and Dr. Birx that any death with the virus is recorded as death from the virus. My biggest concern is that we distort the reality by blankly assigning one specific cause of death to thousands of people.
This already led to a panic/hysteria both amongst politicians and population, unnecessary mobilization of resources, waste of resources, and will lead to re-distribution of funding away from other public health and medical issues such as “opioid epidemic”, “vaping epidemic”, suicide prevention, accident prevention, maternal and infant mortality, and “diseases of civilization”: cerebral, peripheral, and coronary artery disease, hypertension, and diabetes, not mentioning cancer and other dread diseases.
Q: Why such well known doctors would mischaracterize mortality causes during COVID-19 epidemic?
A: My hypotheses are
Either esteemed doctors are not fully aware of the death reporting rules and their importance; or
They are negligent without malicious intent; or
The (least likely) negligence is with a malicious intent, such as
Self-serving in order to support one’s theories and views in order to obtain recognition and funding for one’s research;
Following one’s supervisor orders for supervisor’s benefit.
Q: What information is contained in the US Standard Certificate of Death?
A: The first 30 items on the death certificate contain demographic and legal information in order to identify who died and how the body will be disposed. The latter is usually given to next in kin to decide.
The government steps in when there is a reportable infectious disease with two goals in mind:
correctly identify the disease and take measures for it's prophylaxis, and
to dispose the body in a way protecting others from the risk of contracting communicable disease from a dead. This could be a “body bag”, zinc coffin, or cremation.
Q: When medical examiner/coroner gets involved?
A: The medical examiner/coroner investigates deaths that are unexpected, unexplained, or if an injury or poisoning was involved.
The 31st item on death certificate inquires if MEDICAL EXAMINER (ME) of CORONER was contacted. If “Yes” is checked, completion of the certificate may be terminated and the case may be referred to the ME or Coroner.
Dr. Why: this means that ME or Coroner have the final say in determining the cause of death. Truly: “the coroner is the best diagnostician!”.
Q: What is the correct order for recording cause of death?
A: The 32nd item of the certificate deals with CAUSE OF DEATH itself. It has four lines: 32 a-d and can be amended further. The cause-of-death section consists of two parts:
Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on line (a) and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line.
Part II is for reporting all other significant diseases, conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I.
Q: How shall physician determine the cause-of-death? Is there a manual for this?
A: Yes, it is titled Death Edit Specifications for the 2003 Revision of the U.S. Standard Certificate of Death.
The cause-of-death information should be physician’s best medical opinion. A condition can be listed as “probable” even if it has not been definitively diagnosed.
It provides important personal information about the decedent and about the circumstances and cause of death. Information on cause of death is important to the family to bring closure, peace-of-mind, and to document the exact cause of death.
Cause of death is used for medical and epidemiological research on disease etiology and evaluating the effectiveness of diagnostic and therapeutic techniques. It is a measure of health status at local, state, national, and international levels.
Q: What are the rules for determining cause of death?
A: There are several important rules to follow when considering cause of death (Dr. Why: not a complete list):
Each condition in Part I should cause the condition above it;
Provide the best estimate of the interval between the presumed onset of each condition and death;
The terminal event (e.g., cardiac arrest or respiratory arrest) should not be used. One should report the causes of the terminal event (e.g., cardiac arrest due to coronary artery atherosclerosis or cardiac arrest due to blunt impact to chest);
If an organ system failure such as congestive heart failure, hepatic failure, renal failure, or respiratory failure is listed as a cause of death, always report its etiology on the line(s) beneath it (e.g., renal failure due to Type I diabetes mellitus);
A complete sequence should be reported in Part I that explains why the patient died. Always report the fatal injury (e.g., stab wound of chest), the trauma (e.g., transection of subclavian vein), and impairment of function (e.g., air embolism);
In Part II, report all diseases or conditions contributing to death that were not reported in the chain of events in Part I and that did not result in the underlying cause of death;
If two or more possible sequences resulted in death, or if two conditions seem to have added together, report in Part I the one that, in your opinion, most directly caused death. Report in Part II the other conditions or diseases;
The sequence may be an etiological or pathological sequence as well as a sequence in which an earlier condition is believed to have prepared the way for a subsequent cause by damage to tissues or impairment of function.
The following are examples of properly completed death certificates:
PART I.
IMMEDIATE CAUSE (Final disease or condition resulting in death)
a. Rupture of myocardium - - - - - - - - - - - -> Minutes
Due to (or as a consequence of):
b. Acute myocardial infarction - - - - - - - - - - - -> 6 days
Due to (or as a consequence of):
c. Coronary artery thrombosis - - - - - - - - - - --> 5 years
Due to (or as a consequence of):
d. Atherosclerotic coronary artery disease - - - - ->7 years
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I.
Diabetes, Chronic obstructive pulmonary disease, smoking
The death certificate of the person who died from a heart attack but was found to have COVID-19, shall look like this:
PART I.
IMMEDIATE CAUSE (Final disease or condition resulting in death)
a. Rupture of myocardium - - - - - - - - - - - -> Minutes
Due to (or as a consequence of):
b. Acute myocardial infarction - - - - - - - - - - - -> 6 days
Due to (or as a consequence of):
c. Coronary artery thrombosis - - - - - - - - - - --> 5 years
Due to (or as a consequence of):
d. Atherosclerotic coronary artery disease - - - - ->7 years
PART II.
a. ARDS (Acute Respiratory Distress Syndrome) due to SARS-CoV-2 infection
b. Chronic obstructive pulmonary disease
c. Smoking
d. Diabetes, type 2
Q: Is there a quality assurance mechanism for cause of death reporting?
A: Yes, it is called “Cause-of-death querying” .
The purpose of querying is two-fold:
To obtain information needed to properly code and classify the cause of death, and
To educate the certifier about the proper method of completing medical certifications of death.
Querying is one of the most important ways to improve the quality of cause-of-death data. It must therefore, be viewed as an integral part of any State’s vital statistics activity.
Querying is an essential part of the vital registration process (1-2), so both local registrars and registration personnel in the State health department should be thoroughly knowledgeable of the laws, procedures, and other requirements for death registration, querying, and death certificate amendment.
Normally, cause-of-death queries are directed to the certifier (attending physician, medical examiner, coroner) who originally provided the information in the medical section of the death certificate.
However, if the death occurred in a hospital, it is also possible to obtain additional information from the hospital files to further clarify the cause of death. For legal reasons, no changes or additions should be made on the face of the original record without the approval of the legally designated certifier. If the cause-of-death statement is substantially changed, the certifying physician should be encouraged to file an amended certificate. The procedures for filing amended certificates vary by State.
While querying has an immediate goal of clarifying the cause of death for individual records, it has a broader goal of educating physicians on how to complete a medical certification. On occasion, it may be beneficial for the certifier physician to discuss medical certification of death with a member of the State health department staff before certifying a cause of death.
Q: Who carries out the query?
A: Historically, nosologists have done the querying, but with the advent of automated processing, fewer States have nosologists.
The person who queries records needs to be someone who understands the content and purpose of the querying, which in turn implies an understanding of coding rules and medical causality. It is critical that the person doing the querying have good communication skills as well as an understanding of why the certificate is being queried (e.g., to obtain more information or to correct obvious inadequacies).
Q: What querying is used for?
A: If employed correctly, the query procedure can be a very effective method of acquainting physicians with the proper methods for certifying a cause of death. Unfortunately, most physicians do not receive training on completing death certificates during their formal education; therefore, querying can help provide them with information to enable them to certify a death correctly.
The design and wording of form letters used in querying is very important, not only for obtaining the necessary information for the death being queried, but to convey to the certifier enough information so that he/she can correctly certify future cases of the same or similar types.
Questions in query letters need to be specific enough to indicate what is missing or incorrect and what information is being requested. The more explicit the letter, the better the response that can be expected.
Q: What are the levels of querying?
A: Several levels of querying (levels 1 through 6) are offered: a minimal level of querying (Priority Level 1) is necessary to produce cause-of-death statistics.
It is estimated that Level 1 querying would involve about five percent of a State’s death records. However, higher levels of querying are desirable to ensure specificity and completeness in the physicians’ statements of cause of death.