A recent study has put the process of filling out a death certificate in the spotlight. Barbara Wexelman, MD and coauthors published an article a couple of weeks ago in the CDC’s Preventing Chronic Disease which showed that about 50% to 60% of medical residents from more than half of residency programs in New York City have knowingly entered the incorrect cause of death on death certificates.
I’m not surprised.
I remember filling out my first death certificate as an intern in 2004. I did not have previous knowledge of the patient. He was an elderly man with the usual diabetes, heart disease, dementia, and emphysema. He had been in and out of the hospital several times in the previous months essentially failing to thrive. His family had made him comfortable a day before and now he was dead.
I was the on-call intern. As I walked over to the floor after receiving the call from the nurse, I referenced my ScutMonkey book. How am I supposed to pronounce a patient dead? I walked into his room, devoid of family, thank goodness, and fumbled through the motions that ScutMonkey said must be done to pronounce a patient dead. While doing so I conjured images of dead people coming back to life in the morgue because an inexperienced person like myself had incorrectly pronounced them dead. I did all of this even though the patient lay in a way I had never seen anyone alive lay before. So this is the face and body of death? I lingered a bit. Then I pushed back questioning thoughts about who this man was as a person and who the people were who loved him as I walked over to his chart to script a death note following the template in ScutMonkey making sure to use the word dead…not passed away, not kicked the bucket, not transitioned over, but DEAD.
Thinking I was done after briefly speaking with the next-of-kin on the phone, I proceeded to leave the floor and attend to another call when the Unit Secretary threw me a packet. “You have to fill that!”, she admonished. The dreaded Death Packet. ScutMonkey didn’t have much to say about this, so I called my resident who tried not to sound exasperated on the other end of the phone. I was instructed to “just follow the directions and call C.O.R.E, they will likely reject him, then fill out the death certificate”. Who is C.O.R.E I wondered as I hung up the phone. I called them and stumbled through answering their questions nervously flipping through the patient’s chart to make sure I got things exact.
But that’s just the thing. I couldn’t possibly be exact with a patient I had only known for about ten minutes…in death…with physician chicken scratch notes for guidance. The directions for the death certificate asked for me to list the primary cause of death and to list how many years/months/days it had been present. I was not to use generalized causes of death such as cardiopulmonary arrest or respiratory failure but rather specific diagnoses such as pneumonia, and myocardial infarction. Then, I was to list the other health conditions that may have contributed to the death. That night I learned how inaccurate the cause of death printed on death certificates are. I did not need a study to tell me. I begrudgingly did my very best to figure out which of his multiple diagnoses was the primary cause of death for my patient and which ones accelerated the process. I left that floor feeling very discouraged and unsatisfied with the experience.
A couple of years later I was in Ghana on an elective rotation at Korle-Bu Teaching Hospital sitting in Mortality and Morbidity conference and listening to the house officers getting creamed by the attending physicians as they reported the disposition of their patients. Most were death. It struck me that a lot of autopsies had been done. I wondered then why it was that we did not do autopsies often in the United States. Surely, that would help the accuracy of death certificates.
The proliferation of ancestry shows has made me acutely aware of the historical implications of my death certificate statements. I get that these are vital documents that provide information for families, for insurance companies, and for policy-makers who decide public health and research funding. Though, I am grateful that this study has been done to highlight what we in medicine already know, I am a bit miffed that the news agencies that have picked up the report have portrayed it as medical trainees cold-heartedly and purposefully lying on death certificates.
That’s not the case at all.
Obviously, things haven’t changed much between 2004 when I was an intern and 2010-2011 when this study was done, but I’m hopeful that this would help encourage the proper teaching of medical trainees in the overall care of the dying and of the dead.
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