Quantified Death

Cause of death on this 1937 death certificate? “Senile gangrene.”

I’ve always had nagging doubts about filling out death certificates.

An excellent article in the trade paper “American Medical News” by Carolyne Krupa explores the “inexactitude” of the custom.

As Krupa points out, doctors are never taught how to fill out the documents. She quotes Randy Hanzlick, MD, chief medical examiner for Fulton County, GA:

“Training is a big problem. There are very few medical schools that teach it,” he said. “For many physicians, the first time they see it is when they are doing their internship or residency and one of their patients dies. The nurse hands them a death certificate and says, ‘Fill this out.’ ”

That’s pretty much how it works. Though sometimes the person that comes calling with the death certificate is a hospital clerk. And she will make you fill out the form carefully, using only ‘allowable’ causes of death.

Of course, everyone dies from the same thing:lack of oxygen to the brain. But you can’t list that. Nor can you list common “jargon-y” favorites like “cardiopulmonary arrest,” “respiratory failure,” “sepsis,” or “multi-system organ failure.” All of which are true, but too inexact to be useful.

It’s intimidating to be the one to “pronounce” someone dead, and be the final arbiter of the cause. Isn’t that why we have medical examiners/pathologists?

We don’t autopsy patients much anymore, a trend that concerns many in the industry but doesn’t seem likely to change. That leaves interns and residents (at teaching hospitals) and community docs (in the real world) in charge of filling out these important statistical and historic documents.

When you care for a patient that dies in the hospital, your guess as to the cause can be pretty close. But without allowing for processes and instead requiring specifics (“pneumonia” instead of “respiratory failure”) it’s no wonder that when I was a resident, it seemed as though every patient died of a heart attack (“myocardial infarction”). This was one of the ‘allowable’ causes that seemed to apply whether it made the most sense or not.

If someone is really old and their body starts giving out, we can nearly always choose to say it’s because of their heart giving out. But what they most likely die from is “brain failure”–but there’s no category or term for that. The brain is the conductor of the body’s orchestra; but aside from ‘stroke’ (“cerebrovascular accident or disease”) we usually don’t list the brain in any of the causes (though stroke itself is #3 after heart disease and cancer).

Imagine getting a call from the police that a patient has died at home-a patient that you may not even know (when covering for a colleague, for example). How could I possibly know what the cause of death is?

Turns out our best guesses have to suffice. I’d favor a system that produces more reliable data.

John H. Schumann, MD is a general internist and medical educator at the University of Oklahoma School of Community Medicine in Tulsa, OK . He is also author of the blog,GlassHospital (@GlassHospital), where this post originally appeared.

6 replies »

  1. Very interesting post. Raises a follow up question.

    Under the current quality reporting system docs and by extension hospitals get dinged if they get “assigned” responsibility for an outcome we don’t want – but the assessment is shockingly primitive.

    Was the surgeon who did the procedure responsible? Was the infection a system error? A mistake made by a clueless OR nurse? What really happened?

    We won’t understand quality until we start getting to that information…

  2. Do you think peer review situations like mortality and morbidity conferences have something to do with how “allowable” a cause of death is? Changing how documentation of such things starts with establishing accountability – be that by doctors, paramedics, cops, etc

  3. Hmm.

    I wasn’t calling for more autopsies. I pointed out that many pundits lament their decline. (See the ProPublica link.)

    I’m suggesting that the way we fill out death certificates and keep the statistics is shoddy. The counterclaim to my question is “Who’s more qualified to do it?”

    Caregiving family members?


  4. Thanks for this
    I have been under the impression that autopsies are both routine and required. I can understand if there is some real uncertainty, but absent that or some suspicions on the part of a police investigator, autopsies strike me as red meat for lawyers and avaricious survivors.
    If there is no requirement, is it a crazy idea to include something in one’s advance directive forbidding it?
    A kind of postmortem DNR. How about DNR/ DNA ? (But that might be confused with the other kind of DNA…)
    Seriously, since all patients will eventually die, the costs of autopsies may be yet another unnecessary addition to the overall costs of — I guess it’s no longer “health” care — but that’s how it is probably added as a journal entry for accounting purposes.

  5. The truth about medical autopsies is that they rarely provide any worthwhile information that can affect forward change for patient management. Knowing that someone died of a myocardial infarction or pulmonary embolism is fine and dandy, but it ultimately serves no purpose in patient care: the patient is dead, and one autopsy is not a study based on evidence to help change management for future patients. Physicians’ first obligation is to the patient, not to data collection, which runs counter to prioritizing autopsies over patient diagnosis.

    Most pathologists despise autopsies because they are massive time-sinks that distract pathologists from diagnosing living patients. If more medical practitioners understood the costs and huge diminishing returns of autopsies, they would probably be as loathe to request them as pathologists are.

    The autopsy stands as a relic of years past, before imaging and deep scientific understanding of disease , and serves only to drain the system of precious resources that could be used to care for those still alive.

    Most pathologists despise autopsies because they are massive time-sinks that distract pathologists from diagnosing living patients. If more medical practitioners understood the costs and huge diminishing returns of autopsies, they would probably be as loathe to do them as pathologists are.

    Aside from forensics, the autopsy is a waste of time. We should abandon it.