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Certification of Death | Print |

When it has been determined that the death of a patient does not meet the criteria for the Medical Examiner to take jurisdiction and therefore certify death, completion of the death certificate becomes the responsibility of the attending physician. The requirement for certification is a statement of the disease processes or sequence of condition(s) which started the sequence of fatal events and ultimately resulted in death.

Some physicians express uncertainty about why a patient died even though they have been treating the patient for a condition that is associated with sudden death; e.g., a hypertensive patient, apparently well controlled, who collapses suddenly and dies in view of many witnesses. The physician may feel that such a death is unexplained and needs an autopsy for specific anatomic diagnosis. Depending on the age of the patient and other factors, this death would possibly be viewed as being outside the Medical Examiner's jurisdiction since the medical history provides a background for a reasonable, natural cause of death; i.e., hypertensive heart disease.

A second example may be useful. A patient with diagnosed, long-standing alcoholic cirrhosis may die suddenly with no suspicion surrounding death. The anatomical reason may be ruptured esophageal varices or pneumonia or pulmonary embolus. However, the certification requirement is simply alcoholic cirrhosis; the terminal condition (e.g., varices) does not necessarily have to be established to certify death, although it is desirable to do so in order to certify the death as accurately and completely as possible.

A well-written cause-of-death statement makes clear the entire sequence of conditions which led to death, such as:

Bilateral aspiration pneumonia

due to or as a consequence of:

Subarachoid hemorrhage

due to or as a consequence of:

Rupture of berry aneurysm, anterior communicating cerebral artery

Other significant conditions: Systemic arterial hypertension

Absolute certainty is not needed to certify a death. The stated cause of death merely reflects the best opinion of the certifier based on information that is available. Only reasonable medical probability is required ("more likely than not"). If a significant error is discovered at a later date, death certificates can be changed (amended). It is acceptable to use probable to identify a suspected final event; i.e., "probable rupture of esophageal varices due to or as a consequence of alcoholic cirrhosis of the liver," or "probable atherosclerotic coronary artery disease."

The most important item to list in the cause of death is the underlying cause of death (such as atherosclerotic coronary artery disease), which is the disease that started all of the medical complications that lead to death. It is also desirable to include the immediate cause of death (such as acute myocardial infarction) that ultimately caused death and any intermediary causes (such as coronary artery thrombosis). Sometimes, however, the immediate and intermediary causes may not be known although the underlying cause is virtually certain. In such cases, it is acceptable to list only the underlying cause of death.

If a more specific determination of the cause of death is desired by the physician, he/she is free to seek autopsy permission from the family after clearing the death with the Medical Examiner.

Mechanistic terminal events include cardiac arrest, cardio-respiratory arrest, etc., and are so general as to be meaningless for purposes of death certification. They should not be written on the death certificate. If a physician has difficulty in completing the death certificate, she/he may consult with the Medical Examiner's Office. Other guidance is also available on the internet at http://www.thename.org/.  To go there, click here >>  Writing Causes of Death

If an accident or any type of injury (such as hip fracture due to a fall) causes or contributes to the death, the death is within the jurisdiction of the Medical Examiner and should be reported. Common types of cases that may be overlooked as medical examiner cases include delayed complications of burns, post-traumatic seizure disorders, pulmonary embolism due to immobility related to an injury, and complications of falls in the elderly.

If you are certifying a death and are tempted to certify the manner of death as an accident, suicide, homicide, or undetermined, you should report the death to the medical examiner. Physicians who are not medical examiners should only certify deaths which are due solely to natural causes (disease and/or the aging process).


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Fulton County Medical Examiner

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Atlanta, Georgia 30312
Phone: 404-613-4400
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