Despite protests from the medical community contained in multiple amicus curiae briefs, the Pennsylvania Superior Court recently ruled that the term “cause of death” on death certificates is ambiguous and should include any physician errors that contributed to the death — they were correct.

What they failed to consider was that, without an autopsy, the listed cause of death is often wrong, so using it to determine precipitating factors is a logical fallacy.

The case they considered was that of an elderly woman who died at home several days after a CT scan in which the radiologist saw a poorly visualized abdominal aortic aneurysm. Although there was no evidence of an autopsy, her cause of death was listed as “ruptured abdominal aortic aneurysm.”

While not ruling on the facts of the case (it was remanded for trial), the court linked the presumed cause of death with the radiologist and the primary care physician’s alleged errors contributing to her death from a ruptured aneurysm. In ruling that a malpractice case could proceed, the court perpetuated the common and potentially dangerous misconception that the cause of death listed on death certificates is always accurate and complete.

There is reason to question many if not most causes of death and the precipitating factors listed on death certificates. Particularly when no autopsy is performed, research over many decades has shown that the presumed cause of death may be speculative or incorrect, making any listed precipitating factors suspect.

The Centers for Disease Control and Prevention (CDC) describes the term “cause of death” as “an etiologic explanation of the order, type and association of events resulting in death … [including] any medical complication or error contributing to the death.”

They acknowledge, however, that without an autopsy, the “causes of death on the death certificate represents a medical opinion that might vary among individual physicians.”

More forthright, forensic pathologist Brad Randall wrote that “no universally accepted formula exists for determining the cause of death, [which] is more art than science.”

Death registration, and ultimately death certificates, were first required in the United Kingdom in 1874. Before 1910, when a standard death certificate was first developed, U.S. physicians rarely participated in determining death.

Today, signing a death certificate is a rite of passage for new physicians. Most have their first experience with this medicolegal procedure as residents, often while they are “covering” other physicians’ patients. However, most do this without receiving training in medical school or residency on how to pronounce death, complete the death certificate, and determine why their patient died.

If the patient is in an acute care hospital, the patient’s medical record may help provide some clues about a cause of death. Yet, even after clinicians scrutinize the patient with physical exams, laboratory studies, CT scans, MRIs, surgery, and similar modalities, many death certificates over-or under-report actual causes of death.

Death certificates tend to be even less accurate for those who die at home or in long-term care facilities, where physicians often sign the death certificate without examining the body.

Autopsies provide a definitive cause of death in 95% of cases were once routine medical procedures in the United States, with 50% of in-hospital deaths receiving postmortem examinations in the 1940s. By the late 1950s, some teaching hospitals autopsied up to 90% of all deaths.

Today, however, only about 12% of non-medicolegal deaths and less than 1% of those dying in nursing homes are autopsied. This drastic drop is the result of a variety of factors: minimal reimbursement for the significant time and costs required for pathologists to do autopsies, a lessened emphasis on getting autopsy permission from families, the elimination of a minimum autopsy requirement by hospital accrediting bodies, the negative attitude of funeral directors and embalmers, and a mistaken assumption that modern medical technology can provide most necessary diagnostic information.

Accurately determining causes of death in patients is vital to developing public health policies, identifying new or changing disease patterns, and generating health care budgets. Yet almost one-third of death certificates completed without an autopsy erroneously identified the cause of death.

Over the past decades, nearly 40% of autopsied cases had major unexpected (i.e., undiagnosed) findings contributing to the patient’s death; 24% had major unexpected findings not contributing to the death; and 17% had minor unexpected findings contributing to the death. This should caution courts as well as public health policymakers to carefully consider the accuracy of causes of death listed on death certificates of non-autopsied decedents.

Recognizing the scale of inaccuracy on death certificates for non-autopsied decedents should steer both courts and public health policymakers away from their reliance on potentially false presumptions about death causation when drafting their rulings and health policies.

Kenneth V. Iserson is an emergency physician.

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