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Post Mortem
Death Investigation in America

Documenting Death -- The Certificate

The U.S. started maintaining vital records in 1900 and by the mid-1930s all states were collecting mortality data. But how valuable -- and fallible -- is this information?

Why Do We Need a Death Certificate?

The IRS may disagree, but the death certificate is arguably the most important legal document in existence. It's the only legal proof that someone has died. The State uses it to stop social security payments, pensions and other benefits. Families use it to settle their affairs.

Since the reporting of death began in 1900, the information required on the death certificate has helped monitor and reflect how society is changing. Forty years ago, for example, at least two states, New Hampshire and Oklahoma didn't include ethnicity on their death certificates. In the 1970s, states began requiring information about whether an autopsy was performed. In 1987, HIV/AIDS was added as a new classification of disease. More recently, check boxes have appeared asking for information about graduate-level education, and whether a woman is pregnant at the time of death.

Is There One Standard Form?

Although states can offer their own variations, most comply with the U.S. Standard Death Certificate issued by the CDC's National Center for Health Statistics (NCHS). The agency last revised the form in 2003 and California, Idaho, New York City and State, and Montana, were the first to use it. Since then, 27 other states have followed suit and the CDC hopes that by 2013 all states will be using the form, which complies with the World Health Organization's International Classification of Diseases, helping to unify global health reporting.

What's the Most Important Part?

Beyond standard details such as age, race, gender, education, time and place of death, the most valuable documentation is cause and manner of death. It's also the most prone to error.

Health professionals commonly complain that if they see "cardiac arrest" written as the cause of death, it's often a catchall, meaning the physician couldn't determine the cause of death.

The CDC publishes a physician's handbook to help navigate the form.

In Part I, the certifier must describe the immediate cause of death -- the conditions and sequence of events that led up to the death. In Part II, they must also list the underlying causes of death over time. This can be something that happened in the hours before a person died, or be a condition revealed in the medical history from several years ago. And because there's often confusion and ambiguity, certifiers can use words like "probable" or "presumed" to qualify their decisions but they must always fill out the underlying causes.

Who Signs It?

According to the National Association of Medical Examiners about 20 percent of all death certificates are signed by a coroner or a medical examiner. Since autopsy rates have plummeted in hospitals, death investigators now perform the majority of the nation's autopsies, which remain a vital barometer for revealing causes that might otherwise have been missed. In 2007, the latest data available from the CDC, 201,000 autopsies were performed, accounting for just 8 percent of all deaths.

Others who can sign a death certificate include a primary physician, an attending physician, a non-attending physician, a medical examiner, a nurse practitioner, a forensic pathologist or a coroner, but it varies according to state law. In Texas, for example, a justice of the peace can sign. Typically, deaths have to be recorded with local health departments within 72 hours of the death, and to the state within five to seven days.

Where Does the Data Go?

Once information is recorded by a clerk at the State Vital Statistics office, it is purchased by the National Center for Health Statistics (NCHS) -- the division of the CDC responsible for compiling mortality data. The information is then used by a host of government agencies, as well as the private sector, to direct funding and future prevention policies.

The NCHS has been collecting mortality data since 1979, but Dr. Robert Anderson, head of the division, says the states are often slow to deliver. And sometimes the agency lacks the funds to pay for all the information a state can provide. Budget cuts in 1995 forced the CDC to stop collecting data on the number of autopsies being performed. Although the process began again 2003, it left an eight-year gap in vital records.

Getting a Death Certificate Changed

Other errors arise when an autopsy reveals that the original diagnosis on a death certificate was incorrect. This often happens when an autopsy has been requested because families, the courts, insurance companies or other interested parties are in dispute over how someone died. But getting that information amended on the death certificate, which is required by law, and reported back to the mortality division at the CDC can take months, sometimes years, and in some cases is never recorded as a matter of record.

The CDC is about to close its mortality file on all deaths in 2008, with around 4,000 cases still "pending investigation," because amendments did not arrive from the states in time. Once the CDC close the file, Anderson says, those "pending" cases go on the permanent record as "unknown."

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Posted Feburary 1, 2011

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