How to certify death and write medical cause of death certifcate correctly

1. Death is so final, whereas Life is full of possibilities
Medical Certification of
Cause of Death
Dr Chetan Kumar
Assist. Prof., Forensic Medicine Dept.,
Parul Institute of Medical Sciences & Research
Limda, Vadodara

2. Definition of Death
• Total stoppage of circulation of the blood &
consequent thereupon cessation of the vital functions.
• Somatic death : complete loss of sensivity and the
ability to move and there is complete cessation of the
functions of the heart, the brain and the lungs.
• Molecular death : death of the tissue and the cells
individually.

3. Fact of life:
Man is mortal & Death is inevitable
Death certificate is permanent record of the fact of death
Legal definition
• Death means the permanent disappearance of all
evidence of life at any time after live-birth has taken
place.
(The Registration of Births and Deaths Act, 1969).

4. Legal definition
• “Deceased person” means a person in whom
permanent disappearance of all evidence of life
occurs, by reason of brain-stem death or in a cardio-
pulmonary sense, at any time after live birth has taken
place.
• Brain-stem death” means the stage at which all
functions of the brain stem have permanently and
irreversibly ceased.
(the transplantation of human organs act, 1994).

5. Circulation stoppage tests
1. Occulo-cephalic test : moving head on both sides.
2. Vestibulo-ocular : using cold water.
3. Eye examination : Light reflex & Corneal reflex.
4. Apnoea test : put on ventilator with 100 % for 30
minutes.
5. Magnus test : placing a ligature round the base of a
finger.
6. Diaphanous test : looking through the web of the
fingers at a bright light.
7. Icard`s test : injecting a solution of fluorescin.
8. Application & withdrawal of pressure.
9. Application of heat.
10. Cutting a small artery.
11. ECG tracing.

6. Respiration stoppage test
• Mirror in front of open mouth and nostrils.
• Feather or cotton fibers in front of open mouth
and nostrils.

7. Test to certify brain-stem death
1. Pupillary reflex.
2. Extra-ocular movements.
3. Corneal reflex.
4. Gag reflex.
5. Cough reflex.
6. EEG.

8. Death Registration & Certification
To explain the importance of death registration.
To define what is meant by causes of death and
the underlying cause of death.
To identify & properly complete the form of the
medical certificate of the cause of death.

9. Cause of Death Certification
(definition)
It is the official recording of a person’s death.
It usually include: name, age, sex of person, date
of death.
It records the cause of death of a person as
stated by a doctor or another responsible heath
worker.

10. Importance of Death Certificate
Useful in providing data for mortality statistics
Useful in surveillance of specific diseases particularly in
countries where registration is complete
Useful in evaluation of disease control programs
Rise in certified deaths from a particular cause is an
indicator for a serious outbreak.
The completed death registration form is a permanent
legal record of the fact of death of an individual.

11. Accurate cause-of-death information is important
• To the public health community in evaluating
and improving the health of all citizens,
&
Often to the family, now and in the future, and
to the person settling the decedent's estate .

12. Data used by Govt. agencies, Researchers,
clinicians, educational institutions for
• To assess the health status of the population and determine changes in status over
time;
• To identify regional differences in death rates and investigate reasons for these
differences;
• To monitor trends in public health issues such as infant and maternal mortality,
infectious diseases, and accidents and suicides;
• To identify risks associated with environmental and occupational factors and lifestyle;
• To determine health research and health care priorities and allocate resources;
• To plan health facilities, services and manpower;
• To plan prevention and screening programmes and assess the results of these
programs; and
• To develop health promotion programmes and evaluate their results.

13. Benefits of death registration to family
• Hospital reimbursement
• LIC claims
• Settling Property claims
• To obtain succession certificates
• Releasing gratuity & Provident fund claims
• Deleting deceased’s name from ration card,
voter list etc.

15. Cause of death is defined as:
All those diseases, morbid conditions or injuries
which either resulted in or contributed to death
and the circumstances of the accident or
violence which produced any such injuries.
Direct leading cause of Death.

16. Underlying cause of death is defined as:
The disease or injury that initiated the train of
morbid events leading directly to death.
The circumstances of the accident or violence
which produced the fatal injury.

17. Approximate
interval between
onset and death
Cause of death
…………………a)………………..due
to( or as a consequence
of)
Part1
disease or condition
directly leading to
death
………………….b)…………due to (or
as a consequnence of)
c) ………..due to (or as
a consequnence of)
d)…………
Antecedent causes
Morbid conditions, if
any, giving rise to the
above cause, station
undrlying condition
last
………………………………………………………
…………………………
………….
Part II
Other significant
conditions contributing
to the death but not
related to the disease
or condition causing it,

18. Design and structure of Death Certification
• Part I:
Records (a) immediate cause and (b) the morbid condition, if any,
giving rise to the immediate cause.
In which the cause leading to death stated on line (a).
And also the antecedent conditions (reported on line (b),( c) &( d) that
gave rise to the cause reported in line (a).
No entry is necessary in lines (b) and ( c) if the disease or condition
directly leading to death, stated in line (a), describes completely the
chain of events.

19. Cause A : Respiration or Brain or Circulation
OR Heart arrest.
Cause B : Symptom or Sign that cause direct
leading cause A.
Cause C : Pathology that lead to cause B.

20. • Part II
Records any other significant condition ( if
important ) contributing to death but not related
to the immediate cause of death.
In which any other significant condition that
unfavorably influenced the course of the morbid
process and thus contributed to fatal outcome is
written.

25. Duty of the doctor
Who attended the person in last 7 days.
Fill the prescribed format form 4.
No refusal / no delay.
No fee.
Forward to the registering authority.
Symptomatology or modes of death should not be recorded
as cause of death without mentioning the underlying
pathological cause.

26. Duty of the doctor
In any of the domiciliary deaths not attended by a
medical person before death, a statement from the
relatives of the deceased should be obtained in writing
to that effect, clearly mentioning the morbidity condition
with sign and symptoms prevailed preceding death, with
duration of such illness so that the most possible cause
of death could be entered.

27. ‘Medical Certificate of Death’ should be
• prepared accurately
• legible, typed whenever possible or printed
clearly using permanent ink
• an original, not a reproduction, of a current
version of the Medical Certificate of Death
• Any alterations or errors are initialed;
• Abbreviations are to be avoided;

28. • No copies are made after the medical certificate has been
completed and certified and
• The original, not a reproduction, accompany the body of
the deceased upon transfer to the funeral /cremation place
to be provided to the funeral incharge.
• Terminal events like circulatory failure, respiratory failure
etc. and modes of dying should be avoided as they are
no more than signs of death and provide no useful
information as to the underlying disease process.
• If at all entered, the disease which led to them must be
entered in the next line. They can not be the sole entries.

29. Old age
• Death due to old age is also a natural death and
the underlying cause of death then is entered as
Senility under I (a). However, senility as
underlying cause of death is to be entered only
when no other disease or its complication has
caused death.

30. When not to issue
1. The injured is brought dead
2. A crime has already been registering by the police.
3. The police has already been informed about the case.
4. The cause of death is unknown.

31. Points to be kept in mind by the M.O concerning the
issuance of medical certificate of cause of death
• (a) He should not delay, for any reason, issuing the medical certificate
of cause of death, once he is sure of the cause of death.(The death report
(Form 4) and MCCD (Form 8/8A) should reach the registrar with in 14 days of occurrence of
death. )
• (b) He cannot charge any fees for issuing this certificate.
• (c) He should not withhold issuance of medical certificate of cause of
death even if his dues have not been cleared by the relatives.
• (d) No medical officer should sign medical certificate of cause of
death in advance (i.e. before the individual has died) or without
viewing and examining the dead body personally.

32. Special circumstances
• For organ donation cases.
• For withholding life support in terminally ill person in ICU
settings.

33. Who will certify
• Board of medical experts consist of four doctors.
• Examine the person on two occasion.

35. Procedure to be followed
• The bottom portion of the medical certificate of cause of death is to be
filled up by the certifier, detached and handed over to the relatives.
• This document enables them to get the municipal permission for
cremation as well as acts as reference to obtain the extract of the
death register (Death Certificate) from the registering authority.
• It may be noted that this portion, handed over to the relatives does not
mention the medical cause of death.
• Even the Death Certificate issued by the registering authority does not
mention the medical cause of death
• This procedure is adopted to maintain confidentiality of information of
the cause of death in accordance with section 17(1) (b) of Registration of
Births & Deaths Act of 1969

36. The dilemma
Are there circumstances in which you would
agree to a request to omit HIV from a
death certificate from a patient or a relative?.

39. Example
I - a) Septic shock
b) Infected decubitus ulcers
c) Complications of cerebral infarction
d) Cerebral artery atherosclerosis
II - Insulin-dependent diabetes mellitus
This above cause-of-death statement is
complete:

41. • If not completed properly, information may be
missing from the cause-of death section, so
someone reading the cause of death would not
know why the condition on the lowest used line
developed.
• For example: I a) Pneumonia
• b) Malnutrition
• c) __________
• II ___________
• This example does not explain what caused
malnutrition. A variety of different circumstances
could cause malnutrition, so the statement is
incomplete and ambiguous.

42. Indian Medical Council
• If a serious communicable disease has
contributed to the cause of death, you must
record this on the death certificate.

44. Why is accurate information on MCCD important?
Death certificate or medical certificate of the cause of
death (MCCD)
Statistical information on deaths by underlying
cause is important:
• for monitoring the health of the population.
• designing and evaluating public health
interventions.
• recognising priorities for health services and
medical research,
• planning health services and assessing the
effectiveness of those services.

45. Health risk state
• You will need to make decisions on a case by case basis,
taking account of the context, the views of others where
appropriate, and using your clinical judgement.
• It is important to note that failure to disclose
information concerning notifiable infectious diseases
and body contamination may be regarded as a criminal
offence.

46. Avoid the following…
• Avoid “NATURAL CAUSES” alone with no specification of any disease.
Natural causes is not a cause of death, it is a manner (classification) of
death.
• Specify “natural causes, exact cause unknown” only if a medical or
surgical condition that may have contributed to the death is also
mentioned in Part I or Part II.
• ORGAN FAILURE - Avoid reported organ or (multi)system failure alone
(e.g. congestive heart failure, renal failure, respiratory failure). If an
organ or system failure is listed as an immediate cause of death, always
report its etiology on the line(s) beneath.
• MODE OF DEATH- Modes of dying should not be entered as the sole
entry in Part I or used as the underlying cause of death. These include
terms such as cardiac arrest, respiratory arrest, hypoxia, asphyxia,
syncope, shock etc.
• Also avoid very vague statements such as cardiovascular
event/incident, asthenia, debility or frailty.

47. Wherever applicable report/Include ..
• Use of alcohol and/or other substances
• Smoking history
• Environmental factors, such as exposure to toxic fumes, history of
working in the mining industry, etc.
• Recent pregnancy, if believed to have contributed to the death
• Late effects of injury
• Surgical information, if applicable
• Any iatrogenic underlying cause.
• Any disease, abnormality, injury or late effects of poisoning, believed to
have adversely affected the decedent should be reported

48. EXAMPLE
• The casualty officer on-call receives a 68 year-old female who
was diagnosed 6 months ago with carcinoma of the lung. She
has a 45-year history of smoking 2 ppd, a 5 year history of
COPD with frequent bouts of pneumonia and bronchitis. She
stops breathing and dies bedside.
• Part I …(a) Respiratory Arrest ______________________ hours
due to
(b) Metastases to abdomen and pleura ___ 2 months
due to
(c) Bone metastases _____________________ 2 months
due to
(d) Carcinoma of lung (primary) __________ 6 months
• Part II Smoking, 45 years COPD, _______________ 5 years
Smoking is reported in Part II as a contributing factor. When
reporting neoplasms always indicate the organ or part FIRST affected
(the primary site) and secondary sites if they are known.

49. EXAMPLE 2
• A 79 year-old female has suffered a right hip fracture due
to a fall at home four months previous. Since the date of
the injury, her health declined to the point that it rendered
her bedridden and immobile. She has a long history of
osteoporosis.
• Part I (a) Respiratory arrest..............................................minutes
due to
(b) Pneumonia.......................................................10 days
due to
(c) Immobility….....................................................4 months
due to
(d) Right hip fracture………...................................4 months
• Part II Osteoporosis..............................................................years
Where a cause of death is an injury or fracture reported in Part I or in Part II,
you are required to complete the accidental or violent death section in the DC.

50. EXAMPLE 3
• A 59 year-old female with a history of hypertension for 10 years
was admitted to hospital for investigation following complaint of
persistent headache for weeks. Exploratory craniotomy revealed
she was suffering from an inoperable tumor of left temporal lobe.
Biopsy showed tumor to be an astrocytoma. Patient wished to die
at home. Palliative care was instituted through discussion with
family and physician. Patient died after 2 months.
• Part I(a) Astrocytoma of left temporal lobe..........Months
• Part II Hypertension (benign) ........................10 years
• In some cases a single disease or cause of death which describes
completely the sequence of events or may be wholly responsible
for the death may be reported alone in Part I.
• The death may have been expected and occurred at home but not
witnessed by anyone. In such cases line 1(a) can serve as both the
underlying and immediate cause of death.

51. • A 33 year-old male was diagnosed HIV positive five years ago. He was
transferred to a hospice for palliative care after he developed AIDS and
diagnosed with Pneumocystis Carinii Pneumonia.
• Part I(a) Pneumocystis carinii pneumonia…1.5
weeks
due to
(b) AIDS...............................................4 months
due to
(c) HIV infection ....................................5 years
• Part II Kaposi’s sarcoma...............................4
months

52. A lady was admitted with 80% suicidal burns injuries died of septicemia
after 3 days of admssion
Part I(a) Septicemic shock ------------------3 days
(b) Burn(80% superficial & deep)- 3 days
(c) Intentional self harm by fire & flames-3 days
back
Part II ..............Nil
Manner of death
1. Natural 2. Accident 3. Suicide 4. Homicide 5. pending investigation

53. • A diabetic man who had been under insulin control for many years
developed ischemic heart disease and died suddenly from a myocardial
infarction. Depending on the physician’s documented medical
diagnosis, the following certifications are possible and would be
acceptable:
1. If the physician considered that the heart condition resulted from the long-standing diabetes,
the sequence would be:
• Part I (a) Myocardial infarction..........................1 hour
due to
• (b) Chronic ischemic heart disease..........5 years
due to
• (c) Diabetes mellitus..............................12 years
2. If the physician considered that the heart condition developed independently of the diabetes,
the certification would be:
• Part I (a) Myocardial infarction................................................1 hour
due to
• (b) Chronic ischemic heart disease..............................5 years
• Part II Diabetes mellitus….............................................12 years

54. • If the man had instead died from some other expected
complication of the diabetes, such as nephropathy, the heart
condition playing only a subsidiary part in the death and the
physician being uncertain that it arose from the diabetes at all,
the sequence would be:
Part I (a) Acute renal failure..................1 week
due to
(b) Nephropathy........................... … 4 years
due to
(c) Diabetes mellitus…...................12 years
Part II Chronic ischemic heart disease

55. Further reading
• Handbook on Medical Certification of Death
(http://www.publications.serviceontario.ca/ecomlinks/016600.pdf)
• http://medind.nic.in/maa/t04/i3/maa
• http://www.mlam.in/pdf/medicalcertificates/mccd.pdft04i3p261.pdf

56. «Thank You»