Apr 29, 2019 Scott G. Kirby, MD Newsletter: March-April 2019 Categories: From the Office of the Medical Director Comments: 6 comments Print Friendly Version | Share this item
To discourage situations where no one will accept responsibility to certify a death, in March NCMB adopted a position statement entitled, “Clinician obligation to complete certificates of death”. The position urges licensees to complete death certificates for patients (whether current, recent or remote) “as a professional, ethical, civic, and public health responsibility.”
Most refusals to complete a death certificate that come to the Board's attention involve an unattended death at home. It's not difficult to imagine the reservations some licensees have about signing the death certificate under such circumstances:
"How should I know why a patient died at home? Am I just supposed to guess the cause of death?!"
"What if I haven't seen the patient in months or even years?"
"Why can't the medical examiner just certify the death?"
At the Board's request, I am writing to offer some clarifications and additional guidance to minimize licensee confusion about NCMB’s expectations.
First and foremost, it’s important for clinicians to understand what their role is in certifying a death. Signing a death certificate does not require the clinician to definitively determine the precise anatomic or physiologic cause of death. Rather, the certifying physician, PA or NP should specify a reasonable or probable cause of death based on the best evidence available at the time. Is this a scientific means of determining the precise cause of death? Unfortunately not. The death certificate is primarily a legal document not a scientific document – entering a presumed or probable cause of death is sufficient. When specifying a cause of death you may include the term “probable” if it makes you more comfortable when faced with uncertainty. I have confirmed with staff at NC Vital Records that this is an acceptable practice.
Licensees who have shared feedback on signing death certificates with the Board frequently question the appropriateness of certifying the death of a patient the licensee may not have seen for several months, or even years. It is currently accepted practice for the medical professional who most recently treated the patient or who would be familiar with the patient’s medical history to sign the death certificate. If a patient dies unexpectedly at home, the request will almost always go to the decedent’s primary care provider of record. In such situations, licensees should use the best information available, including the patient’s history and known underlying or pre-existing medical conditions, to identify a probable cause of death. This is true whether the patient was seen a month ago, or whether they were last seen three years ago. Just do your best with what information you have.
At times there may be additional circumstances surrounding a death that reasonably cause a clinician to feel especially reluctant to certify the death. Medical examiners accept cases when there are “suspicious, unusual or unnatural circumstances”. In virtually all cases, the death will have already been evaluated to determine if it is within the medical examiner’s jurisdiction before a licensee is asked to certify the death. However, it is simply not possible for the medical examiner system in North Carolina to accept every case. In such difficult situations, the Board urges licensees to sign the death certificate as a last service to their patient.
Finally, I want to share the news that NCMB is actively pursuing changes to state law that will provide civil immunity to medical professionals who complete a death certificate in good faith and to the best of their ability. This is included in House Bill 228, if you care to track its progress. The Board itself has no interest in pursuing action against licensees who make reasonable judgments about causes of death.
I hope I’ve helped to ease some concerns on this subject. If you have questions or concerns I haven’t addressed here, look at my earlier writings on completing death certificates or feel free to reach out to me at scott.kirby@ncmedboard.org.
As a 30-year veteran of the Eastern Regional Medical Examiners Office, now the Eastern Regional Autopsy Center, I urge clinicians to obtain the circumstances of death—usually they are benign. If the medical examiner has declined jurisdiction, that means the circumstances are benign—not suspicious for an unnatural death. Sometimes the medical examiner has the information about circumstances and can provide it to you to help you be more confident in providing this closure for families. MGF Gilliland MD
By MGF Gilliland MD on Apr 30, 2019 at 2:33pm
This position that the NCMB has taken or is about to take is ludicrous. To presume that I would or should know what a patient died of whose last office encounter may have been 2 - 3 years ago is just a manner of dumping this problem in the laps of the primary care physicians. The “death certificate being a legal document and not a scientific document” doesn’t seem to make any sense. Therefore, it doesn’t need to be accurate? And if we need to contact the medical examiner for the circumstances surrounding the death, the ME already has more information in these situations than we do. If accuracy is not paramount, then why doesn’t he/she sign off on the death certificate as “probable cause of death”. After all, the accuracy of it all apparently doesn’t really seem to be of importance. The arguments made by this author are nonsensical. If I have had reasonably recent contact with the patient and it is a long time patient with established medical problems, I, as I am sure many others, would have no issues with filling out the death certificate. But in the case where I may have had a short exposure to an patient from an unassigned ER admission and he/she fails follow-up in the office and now I am to certify a cause of death a year later? It makes the document worthless . period! I have called the Board in the recent past because I was threated by the Ambulance service to be reported to the NCMB if I didn’t agree to sign the certificate. So I called the NCMB myself to report this incidence and was assured that I had no obligation to sign such a document and would not have to fear any retaliatory action by the Board if such a report were to be made at some point in time in the future. Please someone, use some common sense. Don’t use this as a solution to the ME’s services being overwhelmed. Let them sign off on it as they see fit. Best case scenario, they solve their own problems.
By Gerald Ahigian, M.D. on Apr 30, 2019 at 6:10pm
This is welcomed news….my practice site is part of a large hospital system with patients tending to migrate from one clinic to the other being cared for by residents often who frequently rotate from one clinic to the other. It is often difficult to determine who the latest provider is/was at the demise of patient. Providers frequently have conversations over who is “responsible” for the signing of a death certificate…. this makes it more clear…. we all are.
By Earl Cummings, PA on Apr 30, 2019 at 8:38pm
I personally feel more comfortable speaking to the police officer who investigated the circumstances, especially if the patient was on pain medications or if there was something worrisome in their background. Maybe it would be better to have law enforcement certify the death and have the physician just fill out a medical addendum on history and significant known illnesses that might have contributed to the death. If I haven’t seen the patient in a while, and there is no obvious reason for him/her to die, there is always “natural causes” and then list possible “contributing illnesses” such as smoking, obesity, sleep apnea, hypertension, CAD, etc. Natural causes probably drives the epidemiologists crazy, but it is actually more accurate than making up something when we really do not know what happened.
By Lillian Burke MD on Apr 30, 2019 at 10:25pm
Prosecution and persecution of signers of death certificates remains a problem.I have never shirked the responsibility. Yet if the Board obligates a physician to do the necessary at the time of death then immunity from all legal entanglements should also be obligatory.If the case needs to be reviewed by a Medical Examiner afterward and the death certificate revised the original signer should also be held blameless. Death certificate assignation is a community service, not a patient nor family matter, and as such must be a blameless act immune from malpractice considerations.
By Keith Raymond, MD on May 01, 2019 at 12:18am
The problem arises when a family member gets the document, then wants to know why we have determined the reason as the cause of their loved ones death. This will surely arouse distrust if we cannot provide evidence. As a “legal document”, practitioners should not be guessing as to a cause of death and this is especially true when a patient has not been recently seen by the practitioner. I’m afraid that “fudging a legal document puts us all at risk!
By C Benson MD on May 01, 2019 at 12:27pm
