Caribbean Epidemiology Centre

(CAREC)/PAHO/WHO

Caribbean Epidemiology Centre

(CAREC)/PAHO/WHO

2007

For further information on completing the Medical Certificate of Death, please contact your:

Health Information Unit

Medical Records Department or

Central Statistical Office

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Completion of the Medical Certificate of Death The information on this digital video disc (DVD) is issued for general distribution. It may be reviewed or reproduced for research and education but not for sale or for use for commercial purposes. The information source should be acknowledged and cited. CAREC accepts no responsibility for the accuracy of reproduced items.

First Edition 2007

© Caribbean Epidemiology Centre (CAREC) 2007 Pan American Health Organisation/World Health Organisation (PAHO/WHO)

Material published by the Publications of Caribbean Epidemiology Centre (CAREC), enjoys copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention; unless otherwise stated. All rights are reserved.

Medical Certification of Death: Instructions for Physicians on Use of International Form of Medical Certificate of Cause of Death. WHO 1979.

International Statistical Classification of Disease and Related Health Problems. 10th Revision. 2nd Edition. WHO 2004.

Kircher T, Anderson RE. Cause of Death: Proper Completion of the Death Certificate. JAMA 1987; 258 (3): 349-352.

Manual on Certification of Causes of Death in Europe. Italian National Institute of Statistics. December 2003.

Cause of Death Certification - Maldives: A Guide for Health Professionals in completing Certificates of Cause of Death. Health Information and Research Unit, Maldives. 2003.

References

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Source: Health Information and Research Unit, Ministry of Health, Maldives. Cause of Death Certification Maldives: A Guide for Health Professionals in Completing Certificates of Cause of Death. 2003

Tetanus

If following minor injury (specify); If following major injury (specify); Puerperal, obstetric

Tetany Parathyroid, rickets, convulsions Thrombosis

Arterial (specify artery); Intra cranial sinus: pyogenic, non-pyogenic; Late effect, post-abortive, puerperal, venous (specify site), portal; If post-operative or due to confinement in bed, specify condition which necessitated operation or immobilization.

Toxaemia

Underlying cause Pregnancy (specify): albuminuria, eclampsia, hyperemesis, hepatitis, hypertension, pre-eclampsia.

Toxoplasmosis If due to AIDS or other HIV illness Tuberculosis

Primary site; Associated pneumoconiosis if present. Organs affected, including pleura and parts of respiratory system e.g. TB: abdomen, brain, Colliers. Associated pneumoconsis if present. Avoid terms miliary and disseminated unless defined by localization e.g. acute generalized military tuberculosis.

Tumours See Neoplasms

Ulcer Site; Perforated or with haemorrhage. Ulcer, leg

Nature (e.g. peripheral, varicose) Cause (e.g. atherosclerosis)

Uraemia

Site and Cause; whether perforated. Cause if known e.g. acute, subacute, or chronic nephritis. Associated childbirth or pregnancy

Urinary tract infection

Primary: specify organism and precise location, e.g. ureter or kidney; Secondary: specify underlying disease, e.g. diabetes

URTI Complication leading to death; Organism if identified

Valvular disease Valve(s) affected; Acute or chronic; If rheumatic: active or inactive; If non-rheumatic: specify cause

Vascular disease Nature (e.g. hypertensive, peripheral) Cause

Wounds Site. Cause. Yellow atrophy of liver

Cause if known e.g. acute infective hepatitis, post-immunization, post-transfusion, toxaemia of pregnancy or of puerperium.

Term Additional Information Required

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COMPLETION OF THE MEDICAL CERTIFICATE OF DEATH

About this DVD

This DVD is about the Completion of the Medical Certificate of Death and was developed to provide physicians with a quick reference source on issues related to completion of the certificates and examples on how to complete them. It utilizes the WHO guidelines for certification of death.

The DVD is also intended to provide Ministries of Health with an educational tool for present and future physicians.

This DVD can be viewed on both television and computer. However, optimal viewing is obtained using the computer.

Purpose of the Medical Certificate of Death

Aside from providing the family of the deceased with the requisite information for burial and processing of insurance, the medical certificate of death is also a public health surveillance tool. This is the primary source of mortality data. The cause of death section of the medical certificate of death provides vital statistics which are analysed to provide information on conditions leading to death, the potential years of life lost and trends in leading causes of death. The statistics obtained from this instrument are not only key for epidemiological studies but also utilized by the Ministry of Health to develop public health policies, guide resource allocation and plan intervention programmes.

The statistical information obtained from certificates is only as good as the raw data provided. As such, doctors’ best medical opinion is required to provide precise and complete diagnosis on the cause of death section of the certificate. It should be noted that the medical certificate of death is a legal document and as such, there is a legal requirement to complete the certificate as accurately as possible.

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Use of Mortality Statistics

Mortality statistics obtained from the cause of death section of the medical certificate of death can provide the following:

• Demographic and medical information

• A means of identifying public health problems

• The leading causes of death and years of potential life lost in a population

• An assessment of the general health of the population and problems prevalent among select population

• Information for developing health policy, planning, resource allocation

• Information to monitor interventions and develop epidemiological/medical research.

The data also provides evidence for the allocation of resources to:

• Health education programmes

• Primary prevention programmes

• Training of medical staff

• Purchasing hospital equipment and pharmaceuticals

• Research.

Ultimately, mortality statistics are used to prevent untimely death by stymieing the sequence of events leading to death and preventing the precipitating cause. This is done by assessing the information on the cause of death section and determining the underlying cause of death. This is defined as the disease or injury that started the train of morbid events leading directly to death or the circumstances of the accident or violence that produced the (fatal) injury. This is the primary target for disease prevention and control.

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Reticulosis

Reticulosarcoma: reticulo-engotheliosis; lymphoid follicular reticulosis

Rheumatic fever

Active or inactive With: nature of heart disease hypertrophy, carditis, endocarditis

Rickets Active, late effects (e.g. genu valgum), foetal, renal, scurvy

Rheumatism Acute articular, subacute articular, muscular, gonococcal. Avoid use of the term for other conditions, e.g. chronic articular should be specified as rheumatoid arthritis, osteoarthritis, spondylitis, etc.

Salpingitis Acute, chronic, gonococcal, tuberculous, post-abortive, puerperal

Sclerosis

Arterial: coronary, cerebral (specify whether disseminated or atherosclerosis) disseminated, spinal (lateral, posterior), renal

Scoliosis

Acquired (eg. tuberculous, osteoporosis) Congenital

Senility With: dementia, Alzheimer’s disease etc.

Septicaemia

Underlying illness Type of organism

Septic infection If localised, specify site and organism

Silicosis If associated with tuberculosis

Softening of brain Cause: embolic, arterioslcerotic etc.

Spondylitis

Whether: ankylosing, deformans, gonococcal, sacro-iliac, tuberculous

Stenosis, stricture Site If congenital or acquired (specify cause)

Stomatitis Aphthous, diphtheritic, mycotic, herpetic, septic, Vincent’s, vitamin deficiency

Suffocation Cause, e.g. bedclothes; inhaling food, foreign body, or smoke; mechanical, submersion, during birth

Syphilis

Site affected Type: congenital early or late, primary, tertiary, secondary

Term Additional Information Required

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Peptic ulcer

Site: stomach, gastric duodenum With: haemorrhage, perforation

Perimetritis

Cause of the condition; whether due to puerperal or post-abortive infection

Peripheral vascular disease Cause (eg. atherosclerosis)

Phthisis

Whether tuberculosis, pneumoconiosis, or both

Pleural effusion Cause, particularly whether tuberculosis

Pneumoconiosis

Whether: silicosis, anthracosilicosis, asbestosis, associated with tuberculosis, other (specify)

Pneumocystosis pneumonia If due to AIDS or other HIV illness

Pneumonia

Type of organism If hypostatic or terminal, specify underlying illness

Pneumothorax Cause

Prematurity Cause; Complication leading to death

Pregnancy

Complication causing death (see also Abortion, Childbirth)

Puerperal fever

Type of infection, and whether embolism, phlebitis, thrombosis, septicaemia. Avoid use of the term for post-abortive infection

Pulmonary embolism

If following an operation, condition for which surgery performed; If due to inactivity, the condition causing the inactivity.

Pulmonary oedema Cause

Renal disease or failure

Acute or chronic Underlying cause e.g. diabetic nephropathy With: hypertension, heart disease, necrosis

Respiratory failure Underlying cause

Respiratory infection

Nature, location and causative organism if known

Term Additional Information Required

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The Cause of Death Section

What should be entered in the Cause of Death Section?

‘All diseases, conditions or injuries that resulted in or contributed to death; and in the cases of deaths due to accidents or violence, the circumstances which produced the fatal injury’.

Cause of Death Section

Part I

a. Immediate cause (disease or condition directly leading to death)

b. Antecedent cause

c. Antecedent cause

Duration

Time (shortest unit)

Time

Time

d. Underlying cause of death (that which triggered the sequence of events)

Time (longest unit)

Part II

All other significant diseases/conditions that contributed to the fatal outcome

The Cause of Death Section has three main parts:

Part I: This gives a report on a logical sequence of events leading to death. In this section, the first cause to be entered on the first line, that is line (a), is the immediate cause of death. Proceed downward and enter the antecedent cause on the lines provided, lines (b) and (c), by asking the question ‘What gave rise to the condition entered on the line above?’. On the last line used, enter the underlying cause of death.

Note: Only enter one condition per line and do not enter the mode of dying, e.g. heart failure and respiratory failure.

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Part II: Enter all other significant conditions that contributed to the fatal outcome but is not related to the disease or condition causing it.

A condition that does not fit the logical sequence in Part I should be considered for Part II provided that it is a significant contributory condition. Enter in order of significance and only if they influenced the course of morbid events and contributed to the fatal outcome.

Duration: Enter the time interval between the onset of each disease/condition and the date of death. Complete where known – even approximately, and always record the unit of time: minutes, hours, days, weeks, months and years.

In completing the certificate please remember the following:

• Use legible writing • Avoid the use of abbreviations • Always have an entry on the first line in Part I • Use logical sequences in Part I • Do not use the mode of dying (e.g. respiratory failure,

cardiac arrest, etc) • Do not place the underlying cause in Part II • Always enter detail on duration.

Additionally, when completing the certificate try to be concise while not being vague:

• Record diagnosis as precisely as possible • Utilize additional reports: (autopsy reports; lab reports) • Give information on disease and the details or circumstance

of injury.

Unfortunately, sometimes even with in-depth investigations, such as autopsy and laboratory, the cause of death remains unknown. In such instances, indicate on the certificate that ‘cause could not be determined’ rather than ‘unknown’.

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Nephritis / Glomerulonephritis

Type: acute, sub-acute, chronic with oedema, infective or toxic (cause).

If associated with: hypertension, arteriosclerosis, heart disease, pregnancy

Neuritis Location: cause (e.g. alcohol, lead, rheumatism)

Obstruction of intestine

Cause If paralytic following operation, state condition for which surgery performed

Obstructive airways disease

Type: chronic acute lower respiratory infection acute exacerbation of asthma, bronchiectasis, emphysema, etc.

Occlusion - cerebral

Site With: infarction, due to embolism, thrombosis

Old age Disease which hastened death, if any was present

Oedema of lungs

Type: acute hypostatic secondary to heart disease with hypertension. If hypostatic or terminal, specify conditions necessitating inactivity. If chronic and due to external agents (specify cause)

Operation

Reason why performed; if therapeutic, what was underlying cause of condition for which operation was performed; if non-therapeutic, how operation caused death (e.g. anaesthetic)

Paget’s disease Of bone, breast, skin (specify site) or Malignant

Paralysis, paresis

Cause (e.g. due to birth injury, syphilis) Precise form (e.g. infantile, agitans)

Paralytic ileus Underlying cause

Paraplegia

Spastic due to birth injury; due to cerebral lesion; due to spinal lesion

Parkinsonism, Parkinson’s syndrome

Whether paralysis agitans is meant, or a late effect of acute infectious encephalitis

Pelvic abscess Parametritis Peritonitis Phlebitis

Cause, particularly whether due to puerperal or post-abortive infection

Term Additional Information Required

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Infarction - myocardial

Site Acute, healed or old

Lymphadenitis Cause (e.g. tuberculous, septic wound)

Lymphoma Type (e.g. Hodgkin’s disease; Non-Hodgkin’s lymphoma, mixed-cell type)

Malaria Benign tertian, malignant tertian, quartan, ovale, blackwater fever, recurrent induced

Malformation Congenital or acquired; type and organ involved

Malnutrition Type: congenital, if due to deprivation or disease (specify) protein deficient, (specify type and degree of severity)

Marasmus Cause

Melaena Underlying cause e.g. carcinoma of colon

Meningitis Cause: meningococcal, tuberculous, haemophilus influenzae, other organism (specify)

Mental retardation Underlying physical condition

Metritis See Endometritis

Myocarditis Acute or chronic Cause (e.g. rheumatic fever, atherosclerosis)

Neoplasms Neoplasms are classified according to type (i.e. benign or malignant) and by site.

The primary site should always be indicated, even though the primary growth may have been removed long before death.

If a secondary growth is included in the sequence of events leading to death, state the site of the secondary spread due to the site of the primary growth. If the primary site is unknown, this should be stated on the certificate.

The precise site should be indicated. In particular, distinguish between corpus and cervix uteri, parts of the intestinal tract, mouth, lung and throat. The histological type should also be stated if known. For neoplasms of bone, if the histological type is not stated, the kind of tissue of origin (e.g. marrow, osseous tissue) should be indicated.

Term Additional Information Required

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Definition of Key Terms

Term Definition Comment

Underlying cause of death (synonyms: primary, proximate)

The disease or injury that initiated the train of morbid events resulting in death or the circumstances or violence that produced the fatal injury

In the absence of the underlying cause, that patient would be alive today

Immediate cause of death

The disease, injury or complication that directly preceded death

The ultimate and final consequence of the underlying cause

Antecedent/ Intervening cause(s) of death

Other conditions that contribute to death and are a result of the underlying cause

The conditions are to be listed in physiological sequence

Mechanism of death (synonym: mode)

A physiologic derangement or biochemical disturbance produced by a cause of death

The means by which cause exerts an effect

Manner of death

Explanation of how the cause of death arose

Natural or unnatural

Source: Kircher T, Anderson R. Cause of Death: Proper Completion of the Death Certificate.

JAMA 1987; 258 (3):349-352

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1. The underlying cause must always be (a) aetiologically specific and (b) antecedent to all other causes with respect to time and pathologic relationship.

2. Always provide the time interval between disease onset and death. The interval between the underlying cause and immediate causes of death may be long (years) or short (seconds).

3. A single entry can be made in Part I if only one condition was present at death and was both the underlying cause and the immediate cause.

4. For decedents with long and complicated medical histories, four elements should be considered when determining the underlying cause:

a. The complete medical history

b. The clinical picture of the present illness, including symptoms, laboratory data, results of biopsy or surgical pathology reports and toxicology

c. The circumstances of death and

d. Autopsy findings.

5. With longevity, aging is often accompanied by the development of degenerative and chronic processes that affect many body systems making it more difficult to determine which of several may have caused death. Use one’s best judgement and list all other conditions as intervening causes. Avoid the use of ‘old age’.

Things to Note:

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Hemiplegia

Cause and duration (eg. spinal cord injury from MVA - 20 years previously)

Hepatitis

Type: acute or chronic, alcoholic, of newborn, of pregnancy, childbirth or puerperium, viral (and if so, whether Type A, B, C, D, E)

Hydrocephalus Congenital or if acquired, and if so, the underlying cause

Hypertension

With: heart involvement, cerebrovascular involvement, renal involvement, in pregnancy. If secondary, specify underlying cause

Immaturity Cause Complication leading to death

Influenza With: pneumonia other manifestation (specify)

Injury

Site and type of injury circumstances surrounding the injury(s) and if due to accident, suicide, homicide.

Insanity Form of mental disorder; direct cause of death; underlying congenital condition, cerebral disease, arteriosclerosis, syphilis

Intestinal infection Causative organism Intestinal obstruction, occlusion, stenosis or stricture

Cause

Jaundice Catarrhal, epidemic, haematogenous, obstructive spirochaetal, toxic; cause of obstruction or toxaemia if any, and whether occurring during pregnancy or the puerperium, or following immunization or transfusion. Avoid the term “malignant jaundice”.

Kaposi’s sarcoma If due to AIDS or other HIV illness

Laryngitis Acute, chronic, tuberculous

Leukaemia

Acute, subacute or chronic Type eg. Lymphatic, myeloid, monocytic

Liver failure; hepatic failure Cause (eg. acute infective, postimmunisation, post-transfusion, toxaemia of pregnancy or of puerperium)

Lung disease (chronic) Nature of disease (e.g. obstructive)

Infarction - cerebral If due to occlusion, stenosis, embolism /thrombosis

Term Additional Information Required

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Diabetes mellitus

Type: insulin dependent or non-insulin dependent diabetes

With: complication(s) e.g. nephropathy, peripheral vascular disease

Diarrhoea

Underlying cause (if unknown, whether believed infectious or not)

Dysentery

Type: amoebic (and, if so, whether acute or chronic) bacterial other protozoal

Eclampsia Cause, and whether apparent before delivery

Embolism

Site If following an operation: condition for which surgery performed. If due to inactivity: underlying condition causing the inactivity

Encephalitis

Type: acute viral late effect of viral postvaccinal idiopathic meningococcal suppurative tuberculous

Endocarditis

Acute or chronic Site: mitral valve, aortic valve Cause: rheumatic, bacterial

Endometritis Whether puerperal infection

Failure, Renal

Acute or chronic Cause: analgesic, diabetes etc.

Fatty degeneration Site (e.g. of heart or liver)

Fits Apoplectic, epileptic, eclampsia, hysteria

Fractures

Site; Pathological or traumatic (if due to trauma, state circumstances of trauma)

Gangrene

Site; Type: atherosclerotic, diabetic, due to gas bacillus etc.

Gastro-enteritis Cause: infectious or non-infectious

General paralysis Of insane, or disease causing the condition

Goitre

Type: simple, toxic, diffuse, uninodular multinodular

Haemoptysis Whether tuberculous

Haematemesis

Cause: gastric ulcer, adverse effects of medication etc.

Haemorrhage

Site. Cause (if due to trauma, state circumstances of trauma)

Term Additional Information Required

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Abortion

Spontaneous or induced and reason if induced; period of gestation; whether Sepsis or toxaemia.

Abscess Site; Cause / organism

Adhesions

If following an operation, the underlying condition for which surgery was performed and length of time since surgery.

Agranulocytosis

Cause. If due to drug therapy, specify condition for which drug given.

Airways disease (chronic) Nature of disease (e.g. obstructive)

Anaemia

Primary (specify type) Secondary (specify underlying cause)

Aneurysm

Site e.g. cerebral, aortic; Cause e.g. arterioscle-rotic, ruptured or dissecting

Angina

Agranulocytic, diphtheritic, faucium, streptococcal, Vincent’s; pectoris

Apoplexy Site of lesion; recent or late effects

Antepartum haemorrhage Cause e.g. coagulation defects, placenta Praevia

Anoxia (fetal) If occurred before or during labour

Appendicitis

Whether acute or chronic; With: peritonitis or abscess

Arteriosclerosis, Atheroma or Atherosclerosis

If associated with hypertension specify type e.g. benign, malignant; Arteries involved e.g. coronary, cerebral

Arteritis

Arteries involved e.g. coronary, cerebral cause e.g. arteriosclerotic, syphilitic

Arthritis

Type (rheumatoid, juvenile); Cause (e.g. traumatic) Site

Ascites Cause of the condition Asphyxia Cause of the condition Asphyxia (fetal) If occurred before or during labour

Term Additional Information Required

Terms Inadequate for Cause of Death Coding

The list of terms below should as far as possible be avoided for classification of death unless additional information as indicated in the list is provided.

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Aspiration of vomitus

Cause e.g. acute alcoholic toxicity, drug overdose, chronic alcohol abuse, or circumstances of drug use i.e. addict, occasional user

Asthma Allergic or late onset

Atelectasis Underlying cause

Atheroma Aorta, artery, valve of heart

Birth injury Site, Type of injury, Cause

Bright’s disease Acute, subacute, chronic

Bronchitis Type: acute or chronic; With: asthma, emphysema etc

Bronchopneumonia

Primary, hypostatic or aspiration; Causative agent and underlying cause if any contributing disease or condition

Burns Site; Percentage and degree of burns.

Cachexia See ’Malnutrition’

Calculus Site and if with obstruction

Cancer, carcinoma See Neoplasms

Carbuncle Site

Cardiac

Failure dilation hypertrophy

Underlying disease casing this condition

Cardiovascular disease Specific disease condition e.g. hypertensive

Carditis

Site: myocardium, endocardium, pericardium; Type: acute, rheumatic, meningococcal or viral

Cellulitis Cause; part affected

Cerebral degeneration Underlying cause

Cerebral effusion Underlying cause

Cerebral sclerosis Atherosclerosis or disseminated sclerosis.

Term Additional Information Required

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Cerebrovascular disease

Nature of disease (e.g. atherosclerosis causing infarction. haemorrhage, occlusion - thrombotic/embolic)

Cerebrospinal Meningitis Meningococcal, turberculosis, or other cause

Cerebrovascular Accident (CVA)

Cause: infarction, haemorrhage, thrombotic/embolic

Childbirth Complication and whether apparent before delivery

Chorea

Type: rheumatic with heart involvement or without heart involvement. Huntington’s Gravidarum

Cirrhosis of liver Cause (e.g. alcoholic)

Convulsion, croup Cause

Cor pulmonale Underlying cause, and whether acute or chronic

Coryza Complication leading to death

Crushing Whether fracture, internal injury; external cause

Curvature of spine

Type: acquired (e.g. tuberculous) congenital; With: heart disease and/or hypertension

Cyst Site; congenital, multiple, hydatid, dermoid, retention

Cytomegalic inclusion disease If due to AIDS or other HIV illness

Debility Underlying cause

Deep venous thrombosis

If following an operation, condition for which operation performed. If due to inactivity, the condition causing the inactivity

Dementia

Cause (e.g. senile, alcoholic, atherosclerotic, Alzheimer’s or multi-infarct)

Dermatitis

Type Cause e.g. drug induced (state condition necessitating drug therapy)

Term Additional Information Required

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