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

An excellent article in American Medical News explores the “inexactitude” of the custom.

Doctors are never taught how to fill out the documents. The article 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 Schumann is an internal medicine physician who blogs at GlassHospital.