Filling the medical part of a Death Certificate

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The person certifying the cause of death has to enter the sequence of events leading to death on the International Death Certificate specified by W.H.O.

There are 2 parts in this certificate:

•  Part 1

• Part 2

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• This is used for diseases related to the sequence of events leading directly to the death

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• It has 3 - 4 lines to record the sequence of events leading to death, in reverse order

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• Each event in the sequence should be recorded on a separate line

Filling the medical part of a Death Certificate

 Part 1

• In a given case, construction of a chronological sequence of events will help you identify the underlying, antecedent and immediate causes of death. The order of writing these in a death certificate is:

Part 1

Example 1

Patient A is admitted with acute gastroenteritis since 3 days and dehydration since 2 days and then develops acute renal failure lasting for 20 hours and dies in the ward.

As per the sequence of events, acute gastroenteritis is the Underlying cause of death in example 1.

Accordingly, the death certificate is filled as below:

Example 2

 Patient B is admitted with acute gastroenteritis since 3 days and dehydration since 2 days and dies in the ward.

As per the sequence of events, acute gastroenteritis is the Underlying cause of death in example 2.

Accordingly, the death certificate can be filled in any one of the following 3 ways.

It is important that acute gastroenteritis should be on the bottom filled line of Part 1 of the death certificate.

Example 3

Patient C is admitted with acute gastroenteritis since 3 days and dies in the ward.

The chronological sequence of events for example 3 is as in the picture:

As per the sequence of events, acute gastroenteritis is the Underlying cause of death in example 3.

Accordingly, the death certificate can be filled in any one of the following 3 ways.

• If there is a single cause of death, once it is filled in the death certificate, irrespective of whether you will fill it in 'a' or 'b' or 'c', it will be considered as Underlying cause of death

• If there are 2 causes of death, you can write it in multiple ways as shown in the earlier examples

• If there are 4 events in the sequence to death, write 'a','b' and 'c' then add your own line 'd'. The entry in line 'd' will be considered as underlying cause of death

Filling the medical part of a Death Certificate

Part 2

Patient D is admitted with pneumonia since 5 days in a hospital. He is a chronic smoker for the past 15 years. This acute lung infection occurred on his underlying emphysema of 5 years. His lung infection worsened and he finally expired. He also had hypertension from 10 years.

Example 4

As per the sequence of events in example 4,  the death certificate can be filled in any one of the following 3 ways. It is important that Emphysema should be on the bottom filled line of Part 1 of the death certificate.

In some cases, an individual may have 2 or 3 serious illnesses and it may be difficult for the physician to identify one of them as being the sole underlying cause of death.  In some cases, an individual may have 2 or 3 serious illnesses and it may be difficult for the physician to identify one of them as being the sole underlying cause of death.                                        Eg. Ischemic heart disease and COPD in the same individual developing congestive heart failure and dying because of that.

Dual causes of Death

Example 5

Patient E with Ischemic heart disease and COPD develops congestive heart failure and dies in the ward.

Based on the time interval between biological events, the sequence can be constructed in any of the below two ways

I (a) Congestive Heart Failure       2 days

  (b) Ischemic Heart Disease          10 days

II   COPD                                            5 yrs

I (a) Congestive Heart Failure       2 days

   (b) COPD                                      10 days

II  Ischemic Heart Disease           5 yrs

Dual causes of Death

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While in some countries, it is permissible to write both IHD & COPD jointly as the underlying CoDs, in India the recommendation to the physician is to pinpoint either one of them as being the underlying CoD and leave the other as a contributory cause.​ 

Competing cause-of-death

The term competing cause of death can be explained as two or more causally unrelated, etiologically specific diseases listed in part I of the death certificate.

This is explained in the next example.

Competing cause-of-death

Example 6:

Consider the case of this elderly man who was admitted with emphysema, influenza and pneumonia and then died subsequently in the hospital.

There are 2 competing causes of death here - Emphysema and Influenza. The construction of chronological sequence of events will be different in different scenarios.

Competing cause-of-death

There can be 2 scenarios -

Scenario 1 -

The treating physician needs to determine whether the man had very mild influenza; in which case influenza would only be contributory to events leading death. In this case then severe emphysema that caused pneumonia leading to death will be primary cause, and therefore the terminal events would be :

Competing cause-of-death

As per the sequence of events, emphysema is the Underlying cause of death in example 6 scenario 1.

Accordingly, the death certificate can be written in any one of the following 3 ways.

Competing cause-of-death

Scenario 2 -

Or on the other hand, the man might have had long-standing mild emphysema; (that was likely to have been only contributory)) but it was the recent acute influenza infection that caused the pneumonia that led to death, and therefore the terminal events would be : 

Competing cause-of-death

As per the sequence of events, influenza is the Underlying cause of death in example 6 scenario 2.

Accordingly, the death certificate can be written in any one of the following 3 ways.

Maternal and Perinatal deaths

During pregnancy or delivery or postnatal period, there may be complications leading to the death of the fetus/newborn and/or the mother

See the following examples…

Maternal and Perinatal deaths

Due to an illness in the mother such as eclampsia or due to prolonged labor, the baby may be born with no life. Such a perinatal death (death after 28 weeks of gestation and up-to 7 days after birth) should, as far as possible, be differentiated into either a late fetal death (death after 28 wks of gestation till delivery) or an early neonatal death (death in the first 7 days of life)

Maternal and Perinatal deaths

A baby that is born with no signs of life is an intrauterine death or stillbirth; a baby that is born with any sign of life (breathing or gasping or heart rate or physical movement) and then dying subsequently anytime after that (from the first minute after life till 7 days) is a early neonatal death

Early neonatal deaths explained...

Depending on the clinical diagnosis after birth, the common causes of death in newborns are usually birth asphyxia, sepsis, congenital anomalies or prematurity/low birth weight.

Except for the last one, all the others must be entered in Part I.

If LBW/prematurity is considered to be the cause of death, then for this condition alone, that should be entered in Part II and the more specific cause because of LBW or prematurity should be entered in Part I

Early neonatal deaths explained...

The death certificates will be

Early neonatal deaths explained...

The death certificates will be

Specific examples

Let us now consider a specific example of a woman who is in prolonged labor.

Specific examples

If, on the other hand, the baby was born alive but with birth asphyxia and then died later (after a few minutes or hours or in the first few days), then this should be entered in Form 4 as below

Specific examples

If in addition, because of obstructed labor, there was uterine rupture and severe hemorrhage and the mother also died unfortunately, then an additional Form 4 should be filled for the mother also as follows. Indicating the time intervals helps in thinking about the chronological sequence of events…

REMEMBER:

The cause of death written on the lowest line of the death certificate is important and will be taken as the

underlying cause of death.