Cause of Death and the Death CertificateCer tificate Important Information for Physicians, Coroners, Medical Examiners, and the Public Randy Hanzlick, MD, FCAP, editor Advancing Excellence Cause of Death and the Death Certificate Important Information for Physicians, Coroners, Medical Examiners, And the Public Advancing Excellence College of American Pathologists 325 Waukegan Road Northfield, Illinois 60093 800-323-4040 Prepared by the Forensic Pathology, Autopsy, and Neuropathology Committees of the College of American Pathologists in conjunction with the National Association of Medical Examiners Randy Hanzlick, MD, Editor ©2006. College of American Pathologists (CAP). All rights reserved. None of the contents of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of the publisher. The inclusion of a vendor, company, product name, or service in a CAP publication should not be construed as an endorsement of such vendor, company, product, or service, nor is failure to include the name of a vendor, company, product, or service to be construed as disapproval. Library of Congress Control Number: 2006927351 ISBN: 093030490X College of American Pathologists Sponsoring Committees (2006) Forensic Pathology Committee Gregory J. Davis, MD, Chair Michael J. Dobersen, MD, Vice Chair J. Scott Denton, MD Louis N. Finelli, DO Wendy M. Gunther, MD Craig T. Mallak, MD Jeffrey S. Nine, MD John E. Pless, MD Carolyn H. Revercomb, MD Cynthia Anna Schandl, MD, PhD Nicholas Ike Batalis, MD, Junior Member Arby Uy, Staff Autopsy Committee Kim A. Collins, MD, Chair John Sinard, MD, PhD, Vice Chair Elizabeth Burton, MD Stephen J. Cina, MD Richard Michael Conran, MD, PhD, JD Jeremy S. Ditelberg, MD David L. Gang, MD Edward C. Klatt, MD Mary Ann Sens, MD, PhD Ashley Brooke O'Bannon, MD, Junior Member Adriana Turriago, Staff Neuropathology Committee Joseph E. Parisi, MD, Chair Philip J. Boyer, MD, PhD Elizabeth J. Cochran, MD Bette K. DeMasters, MD David Dolinak, MD Roger E. McLendon, MD Suzanne Zein-Eldin Powell, MD Richard Anthony Prayson, MD Anthony Thomas Yachnis, MD Brian E. Moore, MD, Junior Member Annabel Dizon, Staff Jill Kachin, Staff National Association of Medical Examiners Atlanta, Georgia © 2006 College of American Pathologists i ii © 2006 College of American Pathologists Table of Contents Preface........................................................................................................... v Part I Summary of Basic Principles ......................................................................... 1 Part II Protocol for Writing Cause-of-Death Statements for Natural Causes............ 33 Part III The Medical Cause of Death Manual ........................................................... 51 Part IV Issues Involved in Specific Types of Death................................................ 105 Cause-of-Death Statements and the Elderly................................................ 106 Options for Reporting Dementias and Psychiatric Illness when Writing Cause-of-Death Statements ........................................................... 116 Options for Writing Cause-of-Death Statements for Deaths Due to External Causes (eg, Injury or Poisoning) .................................................. 123 Options for Writing Cause-of-Death Statements for Periprocedural Deaths (Complications of Medical Care).................................................... 137 Options for Writing Cause-of-Death Statements for Neonatal and Infant Deaths ............................................................................................. 155 Sudden Infant Death Syndrome and Related Scenarios .............................. 163 Options for Writing Cause-of-Death Statements for Deaths Due to Human Immunodeficiency Virus (HIV) Infection ...................................... 177 When Disease and Injury Seem Inseparable............................................... 182 Mechanisms of Death and Cause-of-Death Statements: Principles for Including or Excluding “Mechanisms” of Death................... 188 Part V A Guide for Manner of Death Classification .............................................. 195 Part VI Current Issues ............................................................................................ 211 Part VII Glossary .................................................................................................... 215 Part VIII Bibliography and Suggested Reading......................................................... 219 Index ......................................................................................................... 223 © 2006 College of American Pathologists iii iv © 2006 College of American Pathologists Preface This book is intended for persons who must prepare, review, or interpret cause-of-death statements appearing on death certificates or other medical documents, such as autopsy reports. It is a comprehensive summary derived from previous publications, including: • The Medical Cause of Death Manual. College of American Pathologists, 1994. • Cause-of-Death Statements and Certification of Natural and Unnatural Deaths: Protocol and Options. College of American Pathologists, 1997. • Physician’s Handbook on Medical Certification of Death. 2003 Revision. DHHS, CDC, NCHS, 2003. • Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting. 2003 Revision. DHHS, CDC, NCHS, 2003. Since the publication of the College of American Pathologists (CAP) manuals referenced above, some processes and strategies for death certification and registration have changed. For example, the Federal Government issued a new U.S. Standard Certificate of Death in 2003, and the approach to certification of sudden unexplained infant deaths has changed in at least some parts of the country. This book includes updated information on these and many other issues, and has been broadened in content to provide information not only useful to physicians, medical examiners, and coroners, but to the public as well. Most individuals will eventually experience the death of a loved one; when this occurs, knowledge of death certification and registration processes can help people deal with death by having advance knowledge of what to expect—or even what should be expected—when a death certificate is prepared. Cause of Death and the Death Certificate is organized as follows: • Part I. A Summary of Basic Principles to allow quick review of concepts. • Part II. Protocol for Writing Cause-of-Death Statements for Natural Causes • Part III. An updated version of The Medical Cause of Death Manual, which contains more in-depth discussion of death certification principles. • Part IV. An updated version of Cause-of-Death Statements and Certification of Natural and Unnatural Deaths: Protocol and Options, including discussion and examples of specific types of deaths that pose dilemmas or involve special considerations in regard to completing the cause-of-death statement. • Part V. A Guide for Manner of Death Classification, prepared by the National Association of Medical Examiners (2002). • Part VI. Current Issues. • Part VII. Glossary. • Part VIII. Bibliography and Suggested Reading. © 2006 College of American Pathologists v There is some intentional redundancy from one part of this book to another, but each part also contains information, additional principles, or examples that are unique from other parts. Various readers will probably find some parts of the book more useful or focused than others, relevant to personal need and interest. It is once again my pleasure to serve as editor of this CAP publication, prepared by the CAP Autopsy, Forensic Pathology, and Neuropathology committees, in conjunction with the National Association of Medical Examiners. It is hoped that this book will improve death certification practice and further the mission of the National Center for Health Statistics. Randy Hanzlick, MD, Editor vi © 2006 College of American Pathologists Cause of Death and the Death Certificate Part I Summary of Basic Principles Part I contains: • Background information on the history of the death certificate • Responsibilities of various parties in regard to the death certificate • Basic principles for completing cause-of-death statements Part I is provided as a brief, yet comprehensive, general summary of death certification issues, and may be useful for quick review and basic courses or lectures about death certification. What is the Death Certificate? Each state has vital statistics regulations that require that a death certificate be completed and officially filed when the death of a human being occurs. The death certificate serves multiple purposes, including: • Legal documentation that the named person is dead • Information about the deceased, such as age, race, sex, date of birth, birth place, and other basic descriptive information • Information that may be used to evaluate the cause, manner, and circumstances of death • Information that may be used to settle the deceased’s estate • Information about disposition of the remains, such as where burial occurred, and the funeral director or other agent responsible for making that disposition • Information that may be used by the government, public health agencies, other state or federal agencies, or researchers to plan or fund programs designed to analyze, reduce, or prevent mortality In some states, the death certificate