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How Should EPs Handle the Signing of Death Certificates? 
 
opening statement
Signing Death Certificates Is a Simple, Final Kindness
by Michael Silverman, MD
 
I’ve discussed this topic colleagues and read about it on listservs, blogs, and the like and I’ve discovered that there is little overall consensus across the country. Unlike many things where a national standard of care exists, the standard for signing death certificates probably exists on the local (community, county, and state) level and perhaps even at the individual hospital level. What you need to understand is why your director is having you sign the death certificates and the implications of doing so. Also, I hope you will come to see that your training did provide a good bit of knowledge that qualifies you to make medical judgements as to why someone died.

Too Many Deaths, Too Little Time
Staffing and availability of medical examiner’s vary from state to state and even within the state. I’m in an urban area where the MEs are kept busy with violent and drug-related deaths. They don’t have the time or personnel to physically review every death, though they help with any death by way of a phone call. Other areas are so rural where it becomes impractical for the M.E. to review every ED death in person. For the non-controversial deaths (not young, not traumatic, apparent clear etiology) that my M.E. turns down, my practice is to review the case on the phone to determine most likely cause of death, document the conversation, and complete the death certificate. It saves the M.E. time and helps my reasoning process.

Give the Family What They Want
When you talk to a family about a loved one dying, I suspect you’ve already put together some of the ideas as to why the patient died. “60 year old, shoveling, collapsed” equals sudden cardiac death. “42 year old out shopping, collapsed, CT with blood” equals subarachnoid hemorrhage. You get the idea. What the family really wants is to know that their loved one didn’t suffer. They want some explanation of the cause, which you’ve already given, and to get the body released from the hospital to the funeral home so they can begin preparing the funeral. Many hospitals require the death certificate be signed prior to the body being released and so timeliness is important.

To be fair, there is the fear of writing the wrong thing and having the family sue you. Perhaps what you documented as cause of death didn’t let the family get the life insurance they thought was coming to them.

First, I’ve never heard of an actual case like this, though I’ll admit, it’s reasonably possible. But let’s consider what you’re signing. Read the death certificate carefully and it likely says something to the fact that to the best of your ability, you believe cause of death to be “X”. There is no guarantee that you’re providing a definitive cause of death. Also, let’s be realistic, what percent of ED deaths that the M.E. doesn’t take (again, not young, traumatic, controversial, weird) would you sign where the possibility of getting sued for wrongful diagnosis exists? I suspect it’s extremely small.

Help the Family, Help the Hospital
Your hospital wants to work with the family to get the body from the morgue to the funeral home. Let’s face it, grieving family members complaining to administration about a delay in funeral arrangements just seems ugly. Sometimes the patient’s PMD comes to the hospital, and, with proper communication, signs the death certificate in a timely enough fashion. However, what the hospital doesn’t want is to have to serve as a courier service, taking the original death certificate to an outside physician for them to complete, then returning to the hospital and filing it with the body for funeral home release.

A Final Act of Kindness
I wasn’t necessarily trained in death certificates as a resident, but in my first job, signing death certificates fell on the emergency physicians. Some cases went to the M.E., but otherwise I learned to write carefully and neatly and to not abbreviate when I completed the form. I review cases with the M.E. over the phone and probably sign some people as ASCVD and miss the PE. While I recognize that I may skew the national death database, I don’t feel like it changes the bottom line—non-suspicious and non-traumatic death. For patient’s whose doc comes to my facility, I review the case with them and typically offer to sign it as a favor to them. They frequently appreciate it and it may save them a trip to the hospital. Yes, sometimes I insist that the M.E. come out to inspect the body or take the body for autopsy and then sign the death certificate, but this is really the exception. I’m not aware of anyone that I’ve ever worked with being sued or formally complained about for wrong diagnosis. However, I occasionally get a complaint from a family member because a death certificate was incomplete and delayed the funeral arrangements.

In the long run, I find that signing death certificates for patients that present in cardiac arrest and/or die in the ED, can certainly be part of the job of the emergency physician. In many ways, it’s a final act of kindness for the family. Plus, don’t we take care of everyone else’s scut work already?

Mike Silverman, MD is the chairman of emergency medicine at Harbor Hospital in Baltimore and is on the faculty at the TeamHealth Leadership Academy
 
 
Continue reading for the Counter Argument by Kevin Klauer, DO
{mospagebreak title=Counter Argument}
 
 
How Should EPs Handle the Signing of Death Certificates? 

counter argument
Say No to Death Certs, Our Work is With the Living
by Kevin Klauer, DO
 
I’m all about service: Service to those who appreciate it and building relationships through service for those who hold our fate in their hands. But when does service cross the line? Emergency physicians are abused daily by those who have no accountability and are more than willing to shift their responsibilities to anyone who they can con into accepting them. The list is endless and runs the gamut from in-house emergencies to completing workers comp forms. With completing death certificates, I have to draw the line. For me, the answer is no. No discussion. No bargaining. Just plain no.

In-House Code? Sure.
OK. If you ask me to respond to an in-house code after hours, at least you’re asking me to do  something I have been trained to do and no one else is available. When it comes to signing death certificates, emergency physicians just don’t have enough expertise or information to accurately perform this task. We may as well use our “magic 8 ball.” Shake it and pick a diagnosis.  Is it really possible that every patient who presents to the ED in cardiopulmonary arrest died from atherosclerotic cardiovascular disease (ASCVD)? No way! Unfortunately, this is one of the common presumptive causes of death EPs list on death certificates.

No Time, No Expertise
Not only are we not qualified to determine the actual cause of death, we don’t have the time to waste doing other people’s paperwork. There are only two ways to determine the cause of death, a post-mortem examination or selecting the probable cause of death based on a long-standing relationship with the patient and intimate knowledge of their medical history. Anything else is really just a crapshoot. Yes, we know they ultimately died of cardiopulmonary arrest. However, that diagnosis is not acceptable for a final cause of death in many jurisdictions and even where it is, what value does “cardiopulmonary arrest” provide to anyone in search of the actual cause of death?

The only two acceptable avenues for a non-guessing emergency physician are to leave it to the coroner or confirm that the primary care physician will complete and sign the death certificate. We don’t treat dead people. Our work is with the living and there is plenty of that to go around. Distractions like completing death certificates are scut work that we simply can’t afford.

Patients Deserve a PCP’s Care
Don’t patients’ families expect to know the truth? Don’t they deserve the attention a primary care physician should provide them in such times? I can’t believe that a primary care physician who cares about his or her patients and their families would abandon them in such a time of need. I know it’s inconvenient to deal with such details. However, nobody forced them to pursue a career in primary care. 

I know that the likelihood of getting sued for inaccurately completing a death certificate is almost non-existent. It’s not liability I’m worried about. My concerns are twofold. First, what is the most likely means to get the right cause of death on a death certificate and second, who should be performing this work?

With the limited information we obtain from EMS, family, etc., there is no way we can say with certainty, in many cases, that no unusual or suspicious circumstances exist, warranting an autopsy or at least a coroner’s investigation. Again, the primary care physician, with intimate, long-term knowledge of the patient’s medical and social circumstances is better suited for this task. If they don’t have enough information to make this determination, we certainly can’t claim to. In those circumstances, the coroner must step in.

EPs Can’t Be All Things to All People
Do you want me to run upstairs to an in-house code? Sure, I’ll go! Will I write transition orders for your admission so that you won’t be awoken again tonight? Why not! Should I evaluate all of your nursing home patients in the ED after 5 pm? Absolutely! Those patients are well served by the services we provide. Will I sign a death certificate? No way. Who benefits from that? The only persons benefiting from the emergency physician completing a death certificate are those trying to avoid doing it themselves.  Although we are the “safety net” for our health care system, and specifically because we serve that function, we shouldn’t be burdened by accepting tasks clearly owned by others.  Being all things to all people will only leave our patients waiting longer and our waiting rooms more full.

Kevin Klauer, DO, is the Editor-in-Chief of Emergency Physicians Monthly and the Director of Quality and Clinical Education for Emergency Medicine Physicians (EMP)
 
 

 

Comments   

# how to know?john frey 2009-11-19 15:19
Not only is no training received on determining cause of death, but there is no integrity in saying it was 'natural', when it was really poisoning/suffo cation/etc. Can we reliably tell the difference?
There is a limit to 'go along to get along'. And if a line is to be drawn, helping murderers go free is a good place to start. Can we know this isn't happening when the ER doc signs the certificate? No. This is more than rolling the dice. It can be helping people get away with murder.
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# Adan 2009-11-26 01:20
I guess it all depends in where you work. In my rural hospital the ME covers 3 counties and we serve a huge number of uninsured patients with no insurance, so WE are their ONLY source of care. If we ask who can sign the certificate, the most common answer is... US !
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