Introduction

Q & A

The Right and Responsibility to Learn

The Form

The Clinical Course of a Death

Deceased’s Medical History in Death Certification

Discretion

ICD-10 Classification of Disease

A Natural Death

Compliance

The Public Interest

The Quality of Care Information Protection Act (QCIPA)

The Science

The Logic

Who is the WHO?

The Therapy Default

PTSD and Death Certification

UK Changes

Introduction

Public safety is important in our day to day lives. It forms the basis of our plans, routines and choices. There are many ways to promote or update public safety. Often however, the mechanisms are left to chug along as though they are second nature and guaranteed reliable without taking care to maintain their original purpose. Death certification joins this group. Even a casual look at this vital service reveals that it is eroding into hasty entries on to a boring form by young medical staff and viewed as paperwork that accompanies the close of a file. Somewhere along the way the point of death certification has been lost which justifies the point of this blog. It’s my wish as an ordinary citizen to sound the alert on incomplete or sloppy death certifications. In speaking for our deceased loved ones, we must make sure that their deaths are justly assessed and that their deaths become a tool for public good. When a death certification is completed with care and respect it also contributes to the healing process after a loss.

The medical certification of cause of death or Form 16, is carefully designed to individualize a death. Its format is intended as a learning opportunity, a data and research source, a checker of sudden and unexpected deaths, preventative protection against medical accident (adverse event), closure for families, a validation of a life and death and pause for thought as to exactly what just happened.

The Form 16 is clearly laid out, providing spaces for every detail of the death. Its purpose is to deliver a sequence to the death and to invite an honest and respectful understanding of the event. The Form 16 follows a structure set out by the World Health Organization in order to standardize death classifications from disease progression to manner of death. The ample provision of lines, boxes and extra sections is engineered to deliver the path of the death. It is a self-checking system of narrative, sequence and physical deterioration to shutdown. I hope this blog will refresh this crucial service and bring to everyone’s attention the phrase “use it or lose it.” We need to know about this tool of accountability and ask for it.

Q & A

What is death in the administrative sense?

Death is the process or sequence by which an individuals’ physiological deterioration occurs. There are stages comprising an underlying cause, antecedent or treatable causes and an immediate cause by which life conclusively ceases. The most valuable part of the Form 16 is the antecedent section provided on lines provided in the Form 16. These links in the chain provide the accountability section of the death and suggest to researchers how and where the death might have been prevented and can be prevented in future cases. Most death certifiers skimp on the antecedent details which constitutes poor bookkeeping and is inexcusable. Families as consumers must demand the highest level of service in this area. It is the first-line accountability of a death.

Can a death certification, Form 16 be used in a legal proceeding?

A death certification is always deemed an opinion arising from medical training and rendered in good faith. If the MCCD is referred to in a legal proceeding, it can be counter-argued by a second opinion and so on. Medical cause of death certifiers should not withhold information on a death certificate because they do not wish to be called upon to give their opinion in a legal follow-up. The facts show that when families are given full and accurate death certifications from the start, many of them do not pursue legal avenues for adverse or preventable death so certifiers have little to fear. Providing a complete and honest death certification will go far to show respect and dignity for the deceased.

Why does death certification seem so medical when many deaths occur outside a hospital?

Most societies require that deaths be registered in the same way that births are recorded. The main goals are to know who the population consists of; to verify government benefits to individuals; to assess tax obligations; to make sure that a murderer does not serialize. Every deceased person’s remains must be brought to a medical facility to be identified. Unfortunately, identification is much more important than any other as aspect of the death and will always be done for minimal government requirements. If there are other as aspects to the death beyond identification it falls to the family to instigate these measures. The government will not instigate compensatory or justice follow-up. In many cases, it will thwart these efforts for the sake of policy or systemic streamlining.

What does a Registrar-General do?

The Office of the Registrar General is an outlet for vital statistics such as identification documents for a fee. The Office is governed by the Vital Statistics Act but will not automatically adhere to these precepts. The Act is merely a guide to be accessed in the event that a problem occurs and will require a court process to weigh two respective views on the interpretation of the Act. In day-to-day function the Office of the Registrar General will not question a death certification for example, checking only that it is signed by a medical professional, qualified nurse or coroner. What ends up on the Form 16 is a matter for the family of the deceased to demand at the time of the death — in the office of the certifier and face to face. This means that a family would need to know quite a lot about physiology at a time where they are overwhelmed by loss. Although a lot to ask, it cannot be said enough that the best thing to do for the deceased is to insist on a proper death certification with the antecedent and time interval sections completed. It is worth the effort and will go far to heal after a loved one’s death. It is the best bet for accountability, justice and respect. Asking for anything any later will require a lot more effort and much less success.

What is a manner of death?

Manner of death is a contentious issue. It is one which is required to bypass blame but at the same time consider the intentions of someone who is connected with a death. Manner of death is therefore about blame but not in a way that accuses. The best way to think of manner of death is as an adjunct or descriptor of the cause of death. Manner of death — especially the designation of “Natural” — must not assign blame for the death to the deceased themselves or to their family. This frequently happens where a physician wishes to avoid the inconveniences associated with error or adverse events. Families must insist that error and adverse events be entered as “Accidental” on the Form 16 under manner of death. A common example is a certifier in this scenario stating a death as “Natural” because the family chose to remove life support in a medical error situation. It is ridiculous to assume that a family would have to maintain their loved one on life support in order to prove the death wasn’t by “Natural” manner and means.

How can an accurate death certification save lives if the person is dead?

If medical service providers are advised that death certification must follow a certain format and cannot be vague, the death certification will not be relied on as a way to bury the cause and manner of death along with the deceased. Moreover, if a death certificate is done sloppily, a red flag would be expected and the matter examined. Simply put, fewer errors would occur because providers would work to avoid scrutiny of a vague death certification.

/more…

The Right and Responsibility to Learn

The Medical Certification of Cause of Death (MCCD) or Form 16 is not to be confused with short form death certificates. The short forms are separate documents provided for funeral arrangements and probate purposes and not the subject of this blog. The MCCD is an account of the death and intended to explain the trajectory and differentiate it in terms of its variables This method repeated millions of times over, provides invaluable data for research, forensics, safety and effective medical care.

The general approach to the long form or MCCD has become one where it will be done for you by someone who knows how to do it and for you not to give it another thought. Clearly however, it’s an area where the consumer should learn the ropes. What if it isn’t done correctly? We have to know about the way something should be done in order to complain about it. What is the yardstick? Where will it end if we blindly trust that everyone else is doing their jobs so we don’t have to do ours as consumers.

I hope this blog or monogram encourages consumer right and responsibility to find out about death certification. The alternative is that when we have a vague feeling that something is wrong in a death certificate and we need to check it out, all we can logically receive in response is platitudes from those who are authorized to fill out lines (a) to (d). How can we expect to argue for quality if we don’t know what amounts to quality? How can we hope to know the unique details of our loved one’s death if the only means available to access this portrait deteriorates into an ‘anything goes’ chore or gamble for service providers.

There are many places to learn how MCCD death certification should be filled out. Every government office connected with vital statistics will provide a handbook for this purpose. These instructions or guidelines are also on the internet for both medical providers and the public. The point is to use the format provided.

The first thing to bear in mind as a family member checking into the cause and manner of death certification, is that the death has already happened so there is no urgency. The facts can be found and in order to get them laid out it’s important to proceed carefully. The next step is to procure the hospital or forensic records. A dying sequence is easy to pick up from the medical records and to apply to the death certification format which specifically asks for the chain of physiological demise.

The MCCD form is very effective in painting a picture. It’s exactly like a recipe where certain things logically go together. For instance, you wouldn’t see listed in the ingredients for a cake: eggs, milk, flour… and then suddenly, “a tablespoon of gravel…” Likewise, you won’t see an ingredient like flour left out. A death sequence when honest and complete will make physiological sense and click into place. Unfortunately, this is the very reason why it’s often done wrongly. Sometimes those authorized to fill it out are motivated to rely on a general diagnosis, resort to the term “complications” or worse, to throw a wrench into the works to avoid scrutiny. A good way to think of the death certification is that one can complain if it isn’t filled out correctly but if it is filled out correctly, it’s biology and we can’t complain about that.

A death certification, Form 16 is not a culpability reference to causes such as negligence or error. A death certificate functions only to document the physiological or biological failure to thrive in the setting of, for example, lack of oxygen due to a blow to the head. The manner of death in such a case would specifically serve to show the kind of the blow to the head and the physiological limits of the brain to withstand such a blow. Depending on the circumstances, it could be homicide, accident, or suicide. It would not be natural.

There are several aspects to a consumer’s right and responsibility to learn about death certification. The gain here is to dignify the family member who has passed away and by extension to improve the quality of service and product to consumers. Statistical data provided by full and accurate death certification is invaluable to the public good. The informed consumer will by virtue of insistence on a case by case basis and across the spectrum of each and all family deaths, put a damper on sloppy death narratives. Considering that a death certification awaits each of us, there is no doubt we would prefer one that fits our needs over someone else’s convenience.

The Form

While no two death are exactly alike, there is little difference in death certification formats worldwide. Apart from the deceased’s name, age, sex, date and place of death, the entry process for the death is standard. In Part I of the MCCD form the listing of death antecedents proceeds from the bottom on line (d) or underlying cause to the immediate cause of death on line (a). Time intervals are also provided for so that the duration of each stage is listed. A story of decline would be reported as the sequence of conditions or factors leading to death. An adverse event would typically be entered on the lowermost antecedent line of Part I. The process serves as both a checklist for the specific death as well as a discharge summary. When done correctly, it can only be logical and therefore physiologically sound. The section called Part II must list in order of significance, any other diseases or conditions which unfavourably influenced the course of the morbid process and contributed to the fatal outcome but were not part of the sequence of events directly leading to the death. Any recent surgeries would be entered in a separate box lower down on the form. The outcome of the surgery must be stated.

To simplify:

Part I of the MCCD lists the disease or conditions directly leading to death.
Part II lists other significant conditions which contributed to, but did not directly cause the death. A way of looking at Part II is “a situation which didn’t do the deceased any favours at the time by being there.”

Where this is completed correctly, the condition on the lowest completed line of Part I will have caused (or created the conditions for) all of the conditions on the lines above it. This initiating condition will usually be regarded as the ‘underlying cause of death’.

For Parts I and II, it is important to record (in the boxes on the right hand side of the form) the approximate time interval between the onset of each disease, injury, condition, event and death. This information provides confirmation that the entries are in the correct order and are essential for the accurate classification of the cause of death.

The Clinical Course of a Death

The goal of a death certification form is to describe an individual death according to standard parameters so that reliable data can be drawn from the growing total. The way the death certification form is structured is fully conducive to this goal. Also the format is universal, covering the whole human family and making for interesting and vital comparisons between regions and services. The most important criterion to understand is where does the death narrative begin? In order to standardize the certification, the person entering the information would be would be operating under the same set of instructions as their counterparts worldwide. They would also be the person-designate who would know the most about the deceased’s illness, accident, homicide or suicide and trained to put into effect their witness of the decedent’s clinical course (medical doctor or nurse) or their knowledge of the death by means of investigation (coroner).

A death narrative does not start outside of the hospital or forensic facility. It starts from the time the certifier is made aware of the patient in question or in the case of a corpse, the reporting of the corpse to the coroner. To use the case of a person who dies in a hospital, the clinical course will start with the patient’s presentation upon arriving at the hospital. The cause of death sequence will embody both the stage of the patient’s illness and the medical care he receives. Recovery or death of the patient depends on the dynamic between the two from this point on. The death certification in this case is very important in understanding the nature of a disease or injury as well as the medical management or investigation of the presenting signs and symptoms. Healthcare is a learning process, always the most advanced it can be at the time, and the data provided by cause and effect on lines (d) up to (a) on the MCCD points out the many chances where life saving interventions could have been, and should be, brought to bear.

Deceased’s Medical History in Death Certification

Medical history is a specific area of reference when a person finds themselves at the point of a downward turn in their safety or well-being. Medical history is not a factor in line (a) or Immediate cause of death. This would only be the case if the illness itself has a known fatal course such as atherosclerosis. There is no cure for this condition and over time it becomes fatal.

An example showing that medical history is not part of the clinical course of a death for Form 16 “Immediate” to “Underlying” purposes is a case where infection arises. Infection can be part of a deceased’s history and mentioned in Part II of the Form 16 as “Other” but in terms of a clinical course will typically only occur as a result of negligence or error. These are litigious issues and do not serve a purpose on the Form 16. For this example, (named) organ failure due to sepsis might be described as an Immediate cause of death with the original injury site as the Underlying cause. Again, if a person has infection prior to admission for care or as a factor of medical history, this situation would fall to legal examinations of diagnostic duties and not cause of death.

Discretion

The ultimate arrangement of the narrative components on the MCCD that is, line (d) to line (a) is done at the certifier’s “discretion.” Very often this role is misunderstood and taken to mean that the certifier can skip or alter these components. This is not the case and in fact the very reason why the death certification is structured the way it is. The term “discretion” denotes the certifier’s explanation of the decline and not his invention, re-stating or omission of the events. The clinical course of the death is the path the certifier must account for according to physiological facts or forensic findings. The death certification format serves as a logical structure for this tally.

An abuse of discretion is a failure to take into proper consideration the facts relating to a particular matter; an arbitrary or unreasonable departure from common reliance. On appeal of an exercise of judicial discretion for example, “abuse of discretion” is a standard of review requiring a court to find that the lower court’s decision would “shock the conscience” of a reasonable person in order to reverse the decision rendered. Reasons and rationale must always be given. The same is true for writing death death certification.

The following explanation of certifier “discretion” is taken from the Ontario Handbook on Death Certification.

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 narratives 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

3. 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

Discretion is therefore restricted to clinical givens and does not mean physician, nurse or coroner freedom to deviate from the MCCD format or issue insufficient, mistaken or false clinical changes in the death event. Being trusted to complete a death certificate is a direct expectation of the certifier’s job description and his advantageous exposure to the bank of physiological knowledge. It is not about carte blanche in situations of hurry, inconvenience, paperwork or personal judgments.

ICD-10 Classification of Disease

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for every disease including variations within a general classification.

The expansion of healthcare delivery systems and changes in global health trends prompted a need for codes with improved clinical accuracy and specificity in causes of mortality. The codes are accompanied with distinct terminology so the underlying and contributory disease conditions can be easily and uniformly itemized on the MCCD death certification.

A Natural Death

Not meaning to sound dramatic, an entry of “Natural” manner of death can become a escape route on death certifications. It’s a great term if the certifier wants a quick end to their task. It sounds good for the deceased, makes a family imagine the death was comfortable and smooth. However this might not be the case. Often the term “natural” resembles peanut butter. It is thick and smoothed over the surface of what is underneath.

A natural death is one which occurs in sequence to a terminal illness and is expected. A natural death is one where everything has to be natural about it. So can you have a natural death with complications? The answer is no. The term “complications” must be avoided and instead broken down into antecedent lines on the Form 16. These will usually result in a manner of death which is not Natural and instead establish itself factually as Accidental or Undetermined.

It seems that common practice has watered most deaths down to patient consent which drives the understanding of Natural. If a patient freely consents to their hospitalization or procedure and accepts the risks of being there including the treatment offered, then a complication is deemed natural. It’s a strange setup and one which calls the death “foreseeable.” Hospital deaths although predicated by the same notion of risk as a skiing holiday, happen much more often than skiing deaths. Perhaps this is how the idea of Natural causes has crept into medical service deaths. Is it just more Natural to expect to die at a hospital than at a skiing resort?

All deaths are death which itself is a natural process. Once a person is rendered unable to survive by whatever means, death is always organic. Eventfully the heart stops. The two kinds of “Natural” must therefore be well understood and stated for the purpose of the death certification.

Compliance

We have seen that the death certification form is very straightforward. By the time this part of a death event is attended to, everything is known and simply needs to be entered on a form. The diagnosis is done, the autopsy is over, the forensics are completed. Many experts and specialists have provided their conclusions and charts, notes and reports are signed and delivered. Why then does death certification so often fall short in reflecting the facts of a death? Why is compliance increasingly difficult to ensure?

Uncertainty about the function of the death certification may be the reason why so many doctors believe their duty of certification is to some extent disposable. They may make modifications to the facts so as not to involve the coroner. It is further suggested that they might record a natural cause of death rather than report a case of potential suicide to the coroner so as to avoid financial loss to the family. Some doctors say they certify the cause of death in a way to spare the family from distress. Others may enter vague categories to conceal mistakes or harm to patients. There is always the desire to avoid questions from the family of the deceased.

Part of the fault may lie with the medical consumer. Quality of service is always a two-way street. If decedents’ families don’t seem to mind that their loved one’s death certificates says “complications of a brain lesion” then the shorthand will continue. I will go out on a limb and state that the Registrar-General is also to blame for not maintaining an eye on quality. Public Health must also educate itself on the death certification format in order to monitor the value of this service in the big picture.

Where there are high standards in death certification, certifier and caregiver accountability will follow. Lives will be saved in anticipation of their professional requirement to account for the death sequence and these, subject to regular verification of detail, duration and decline.

National recommendations require that a doctor who knows what happened to the patient should meet with relatives at the time of issue of each certificate to explain the content of the MCCD. In cases of rapidly progressive illness or sudden death, physician clarity reduces traumatic effect on the family. In a universal sense, these private meetings happening everywhere at any time of the day or night become a huge body of public benefit. The concept of public interest is not about multiple over individual. It is about the individual occurring many, many times over.

The Public Interest

The part played by individual death certifications in the global public interest is extensively misunderstood or misused. It can be chilling to consider that unless this relationship is ironed out for once and for all, the death certification service will never amount to its potential. My impression is that the philosophy of the death certification service has devolved to conflict with the idea of public interest which itself has devolved to a cultural value. We might even say that what goes into death certification differs from country to country based on each country’s tastes and moral code. Of all the sections or elements the topic of death certification can be broken down into (as I, for my part, have done on this site) the most important is this one. Therefore the process of death certification must adhere to biology which transcends all passing fancies, styles and trends.

The Quality of Care Information Protection Act (QCIPA)

The purpose of this Act in Ontario and its equivalent in other provinces of Canada, is to enable confidential discussions in which information relating to errors, systemic problems and opportunities for quality improvement in health care delivery can be shared within health facilities in order to improve the quality of health care delivered to patients. The QCIPA assures that the names and details of in-house reviews are kept secret but the fact that there was a review is not secret. Anyone with an authorized interest in the death including the family is free to obtain the medical records and check for themselves, the medical facts of the illness and prescribed treatment. It is possible for a comparison between the individual decedent’s medical records and the general description of the disease and treatment to yield up where things went wrong regardless of the fact that the hospital does not divulge its review and findings. What is not allowed is a direct report from the staff of the hospital concerned to anyone outside the ‘bubble’ who treated the patient at the time of the critical incident. This structure is designed to encourage medical practitioners to come forward when adverse events occur.

These discussions follow critical, adverse incidents meaning any unintended event that occurs when a patient receives health care from a health facility that

(a) results in death, or serious disability, injury or harm to the patient, and

(b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing the health care.

It is very important that this confidentiality not affect the accuracy of the physiological sequence and manner of a death. Since terms used in death certification cannot be used against anyone i.e. “accident” as opposed to “negligence,” there is no reason to spare the details required on the death certification document.

The Science

We see in examples provided of sloppy death certification that there is no pride of ownership so to speak among the authors of these death certifications. One has to wonder what’s the rush? The form isn’t complicated. The death is there for all to see, the dying process falling into accordance with known medical science and hindsight now in full swing. This would be the perfect time to reflect on what should have been done, what could have been done, what was done well and of course, to learn how people die. Each death mix is different and underpins the science. If people donate their bodies to science so that medical students can understand how the pieces fit together so too can the facts of individual deaths be a way for doctors to understand the failure of living systems. Performing a death certification can be as glamorous and dramatic as any feat of treating disease or saving a life. It is a full-circle proof of true understanding.

To reiterate, there are three main purposes to be served by a system of certification and registration of deaths. One is to provide an accurate record of deaths for administrative purposes. Another is to identify as accurately as the science bears out, the cause of each death. This information is needed for the purposes of medical research and for the allocation of the resources of respective health services. A third is that the system must provide a safeguard against the concealment of accidents leading to death. If a death certificate is not filled in properly, the question should be asked why this is the case by the Registrar-General or the family. At the other end, a certifier would know in advance that the death certification process is not a tool of concealment but rather a tool of public safety.

The word “investigation” typically accompanies anything scientific. A cause of death is a biological investigation where the meticulous matters. There must be nothing creative about an MCCD.

The Logic

The learning aspect of accurate death certification is found in its listing of the dying person’s deterioration. Looking at the steps from the bottom up including Part 2, can paint a compelling picture of where an intervention might have been made to avoid the deadly outcome. This is the point made in a Statistics Canada Health Report:

Multiple-cause data provide an opportunity to study the complexity of morbid conditions that are involved in death and the contribution of these conditions to mortality rates. From a public health policy perspective, multiple-cause data are valuable for revealing disorders that are relatively infrequent selections as the underlying cause of death, but which contribute to frailty, and ultimately, to the risk of dying. Because a death may result from a certain combination of conditions rather than a single cause, it may be possible to delay it by intervening in one or more of the non-underlying causes.

Who is the WHO?

The WHO (World Health Organization) is a vital oversight in the quality of healthcare. Healthcare must progress and by that it must become organized as much as it must involve scientific advances. To the WHO, death certification is a big part of both these aspects. A simple but superbly structured form, the Medical Certificate of the Cause of Death (MCCD) is sadly under-utilized. It is seen as a chore, something a junior person does. However, the MCCD when done correctly, serves to inform the sequence of a death and introduces cumulative diagnostic strengths going forward. It provides data for interventions and knowledge of when to perform these. It prevents hospital adverse events since staff and practitioners know in advance that every step of the dying sequence will have to be accounted for. At present, lines (d) to (a) or “underlying” to “immediate” cause of death is hardly taken seriously. Some countries in the world are worse at it than others. It’s a huge loss that complacency, hierarchy and even cover-up affects this great medical record basic. The benefits of having a well-organized medical service will probably find no better fit than in the area of accurate death reporting. The WHO advocates for this oversight as an organizational tool. It provides guidelines and an exhaustive training manual towards full understanding of the death certification process.

The Therapy Default

Something the death certificate is not, is an instrument of therapy. It shouldn’t be the product of a negotiation between a family and a doctor, nurse or coroner. It isn’t a favour which is done for the family and above all, it isn’t something which can be touched up or tweaked until everyone is happy. That would suit the objectives of a therapy session but for death certification, the facts are the goal and where facts are concerned, the facts do the talking.

In many environments, certifier discretion is erroneously viewed as the power to design a death certificate which satisfies a want rather than the facts. However, discretionary power is not about absolute power. To have discretion is to act responsibly and within limits of a defined task. It refers to knowledge and training of a specific field. It has nothing to do with judging people, shaping an agenda, personal gain, doling out rewards or exacting punishments. The death certification process is a public institution and independent of winds and whims.

Often death certification is at the centre of a conflict between the decedent’s family and the doctor or investigator. This situation can have at its root, misunderstood information, gaps in the timeline and no real will to access the facts. Or it can be the victim of secrecy. For something so routine and banal, death certification can be a Pandora’s Box. It is in this circumstance that the therapy default will often rear its head and it’s the worst way to proceed.

In therapy mode, the family will be led through every official channel or series of “next steps” when collectively working with a doctor or coroner to establish a standardized, factual, neutral, death certification. They will be treated with apparent respect and patience for a time. They will be asked to contribute and play a continuing role even offering their own medical research and opinions. They will receive confirmation letters on official stationery with a credible logo and agency motto. The language will sound fair and open. Throughout the experience the family will begin to feel better and count on the process to do right by their dead relative. The last step of the therapy will be a summation of the steps taken but this time, with a draconian sense of finality on the part of the certifier. The therapy ends with a verdict that “the concerns” provided by the family “at the time” were fully reviewed and a decision made. Sadly, there will be no respect shown the deceased whatsoever since therapy led the show.

Therapy-default death certification will typically result in a single line entry for cause of death and the manner entered as “natural.” Sometimes the term “complications” will be added as an extra touch to the cause. The complications will not be described.

When death certification turns out this way, there is a good chance the actual cause and manner of death are being ignored. Here, the family is caught between residing in the glow of relief they believed they were getting or being jolted into outrage by their sudden sense of abandonment. The sad fact about this outcome is that therapy opportunistically given can turn to trauma really fast if the family cannot maintain the positive feelings they originally bought into. PTSD can result.

PTSD and Death Certification

The mention of PTSD in the context of death certification might seem incongruous but a certifier cannot assume there will be no consequence to a poorly produced death certificate. A family might be deeply affected by suggestions of apathy or insult on the part of the certifier towards their deceased loved one. The thought is bound to creep in that the deceased’s true situation has been covered up. Rather than heal from the death, a family member will naturally tend to wonder what really happened and have the nasty spectre of PTSD enter their lives. For this very important reason it is far better for the certifier to be professional about the task than to assume it’s just paperwork. Truth, no matter how brutal, is easier to cope with than forever wondering what the truth is.

There are various references to attitudes regarding death certification and death investigations. The fact that there is more than one signifies there is a range to attitudes and that some might be deleterious to the recovery of a grieving family member. Two examples, one from a Canadian publication and the other from a British journal exemplify this range. In the first, the goal is purely to offer therapy after which the family member must fend for themselves. Lip service is deemed to be sufficient, this coming from a hierarchical superior with (administrative) closure in mind.

1.

Ontario’s Death Investigation Oversight Council is the first body of its kind in Canada. The council administers a public complaints process regarding death investigations to help grieving families, and also makes recommendations to the chief coroner, the chief forensic pathologist and the Minister of Community Safety and Correctional Services on matters related to the province’s death investigation system.”

https://news.ontario.ca/mcscs/en/2016/09/new-regulation-strengthens-death-investigation-system.html

2.

The second example is much more generous of spirit. Here, poor death certification itself is cited as causing “negative effect on bereavement” such that a complaints process would not have to exist. A complaints process is a horrible venue in which to address the issue of death certification and one which already has standards spelled out. In terms of death certification or investigation, why would a bereaved person wish to be seen as a complainant? Or run the risk of being exponentially hurt by way of an official condemnation, refusal and administrative condolences?

Some useful excerpts from the second article are:

“The functions of the death certificate and the wide ranging impact of poor certification are summarized. Trying to satisfy so many priorities can become confusing and achieving improvements is slow, lines of responsibilities unclear. The one group on whom poor certification has little impact is the certifiers themselves.

Poor certification represents a substantial burden especially at the registration and coding stages and ultimately distorts national mortality data. Certifiers receive virtually no feedback on their certificates regardless of quality because there is no one with a governance responsibility for scrutinizing certificates. The consequences of poor certification are remote both in practical and chronological terms from the certifier.

Expectations are changing and it is worth considering steps to help relatives. You can use lay terms on certificates along side technical terms (such as ‘stroke’ or ‘broken hip.’) Real or perceived stigma around some diagnoses may make you consider being economical with the information, but obfuscation is illegal and may emerge when the registrar interviews the informants. Pay attention to voiced concerns… Do not leave these concerns to fester, as initiating investigations after a death is registered is complicated. Within current arrangements, the safest course is to include details of any contributing factors in the ‘cause of death’ sequence and consider whether you need to discuss these with the coroner’s officer.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222168/

UK Changes

A Health Service Safety Investigations Bill in the UK will put the existing Healthcare Safety Investigation Branch on a statutory footing. This bill was set up in 2017 to examine omissions on death certifications.

The safety bill will also amend the Coroners and Justice Act 2009 to allow trusts to appoint medical examiners, whose job is to routinely review deaths. Death certification is a big part of these reviews and serves as a signpost where a death was avoidable whether at the start or during the antecedent stages. What is written on a death certification is as important as what is left out.

Across the world, health science study alone doesn’t guarantee health service. Professional attitudes and integrity are vital to bringing about fair health outcomes but consumers of this service must remain current with any slippery slopes in the name of “common practice.” Robust data is vital to good medical care and the sustainable cost of that care.

Respect for the dead and their families comes across loud and strong in a well written death certificate, Form 16. Death isn’t going away. The living are left to figure it out.

This document is written in an ongoing format from a consumer standpoint. It is designed to encourage interest and participation in the death certification service. Please compare the points expressed here with other sources widely available online. If there are mistakes or errors in this document, feel free to adjust your perspective.