How will a doctor certify the cause of death ?

The doctor’s responsibility is to certify that an individual has died of the particular cause/causes based on his/her individual assessment of the available medical history, symptoms, diagnostic tests, clinical treatment and medical records, based upon his/her training and knowledge of medicine.

In cases of deaths suspected of homicides, suicide, accidents and any other medico-legal cases, the post-mortem results are considered and the certificate may be completed by the medical examiner on the basis of evidence noticed by him/her.

The doctor completes the MCCD form in India called FORM No 4 (institutional deaths) and FORM No 4A (non-institutional deaths) to certify the cause of death.

Form No 4

Form No 4A

CAUSE OF DEATH – ALL WHAT YOU WANT TO KNOW !

The cause of death is defined as “all those diseases, morbid conditions or abnormalities, injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced any such injuries”.

How will a doctor certify the cause of death ?

What is the method of medical certification of cause of death?

Death often results from the combined effect of two or more independent or related conditions, that is, one condition may lead to another, which in turn leads to a third condition and so on. Where there is a sequence, the disease or injury which initiated the sequence of events, called the underlying cause of death is recorded and reported. It is:

(a) the disease or injury which initiated the train of morbid events leading directly to death;
Or
(b) the circumstances of the accident or violence which produced the fatal injury.

All the morbid conditions or injuries consequent to the underlying cause relating to death are termed as antecedent and immediate cause.

The medical part of the certificate consists of two parts-

I. Sequence of events leading to death -

First line is the immediate cause of death – the condition / disease that directly led to death / that preceded death.
The cause of death antecedent to immediate cause should be entered in line (b), and a cause further antecedent to this should be entered in line (c).
Underlying cause of death is on the lowest line of part I – It is the disease or condition that started the sequence of events; and conditions if any, as a consequence thereof will have been entered above it in ascending causal order of sequence

How many cause of death can be entered in Part I ?
Only one cause is to be entered on each line of Part I.

Example
I	Incorrect	Correct
Ia	HIV	Septicaemia
Ib	Pneumonia due to Klebsiella	Pneumonia due to Klebsiella
Ic	Septicaemia	HIV infection

I	Incorrect	Correct
Ia	Acute Diarrhoea	Severe Dehydration
Ib	Severe Dehydration	Acute Diarrhoea
Ic	Measles	Measles

What if there is only one condition?
The disease, injury or complication that immediately preceded death can be the only entry in the MCCD FORM if only one condition is present at death.

What if there is only one condition antecedent to the immediate cause?
The condition antecedent to the immediate cause should be entered in line (b). Line (c) should be kept blank.

II. Other significant conditions that contributed to the death
All other diseases or conditions believed to have unfavorably influenced the course of the disease leading to death, but were not related to the disease or condition directly causing death.

What should be entered in Part II - Other significant conditions?
Any disease, abnormality, injury or late effects of poisoning, believed to have adversely affected the deceased should be reported and also information such as:

Use of alcohol and/or other substances.
Smoking history.
Environmental factors, such as exposure to toxic fumes, history of working in specific
industry, professional exposure to toxins, specific animals etc.

Recent pregnancy, if believed to have contributed to the death.
Late effects of injury, including head injury sequelae
Surgical information, if applicable.
Any iatrogenic underlying cause

A complete example
Part I	Incorrect	Correct
Ia	Acute Lower Respiratory Infection	Cor Pulmonale
Ib	Cor Pulmonale	Acute Lower Respiratory Infection
Ic	Diabetes	Chronic Bronchitis

Part II
	Chronic Bronchitis	Smoking
	Smoking	Diabetes

Importance of reporting sequence accurately

Stating the sequence of morbid conditions in order, allows selection of the cause of death that is considered as “underlying” cause.

Take an example: A Diabetic man who had been under insulin control for many years developed Ichemic heart disease and died suddenly from a Myocardial Infarction.

1. Doctor considers heart condition resulted from the long-standing diabetes, the sequence of cause of death would be :-

2. If the doctor considers that heart condition developed independently of the diabetes, the certification would be:-

Part I
Ia	Myocardial Infarction	1 hour
Ib	Chronic Ischaemic heart disease	5 Years
Ic	Diabetes mellitus	12 Years

Diabetes is the underlying cause of death

Part I
Ia	Myocardial Infarction	1 hour
Ib	Chronic Ischaemic heart disease	5 Years
Part II
	Diabetes mellitus	12 Years

Heart condition would be recorded as the underlying cause.

What is the method of medical certification of cause of death?

Importance of reporting sequence accurately

What should you avoid while completing MCCD ?

AVOID ABBREVIATIONS –

Incorrect	Correct
CRF	CRF could be Cardio respiratory failure or Chronic Renal failure
MI	Myocardial Infarction / Mitral Incompetence
AD	Acute Diarrhoea / Alzheimer`s Dementia
MS	Mitral Stenosis / Multiple Sclerosis
RTI	Respiratory Tract Infection / Reproductive Tract Infection

AVOID MODE OF DYING as CAUSE OF DEATH – Mode of dying merely tells you that death has occurred and is not specifically related to the disease process.

Mode of Dying

Example

Cardiac Arrest/Heart Attack

Emaciation

	Incorrect	Correct
Ia	Hypovolemic Shock	Hypovolemia
Ib		Haemetemesis
Ic		Oesophagial Varices

Cardio Respiratory Failure

Exhaustion

Cardio Respiratory Arrest

Heart failure

Respiratory Failure/Arrest

Liver failure

Shock

Hepatorenal failure

Heart Failure

Syncope

Coma/Brain Failure

Uraemia

Multi Organ/System Failure

Vagal inhibition

Debility

Vasovagal attack

AVOID VAGUE TERMS OR AMBIGUITY – sometimes it is difficult to provide a simple description of cause of death when there are no medical records or a doctor is seeing the patient in a critical condition for the first time or the doctor is not the treating physician.

Incorrect	Correct
Irrelevant talking and feverishness	Delirium due to fever
Very poor nourishment	Severe Malnutrition
Less healthy at birth	Low birth weight / Congenital Anomaly

AVOID SHORT FORMS / INCOMPLETE DESCRIPTION -

Incorrect	Correct
Ca Br	Cancer Breast / Cancer Brain
Ac. Infarct	Acute Myocardial Infarction / Acute Cerebral Infarction
Sev Mal	Severe Malaria / Severe Malnutrition

AVOID SYMPTOMS / SIGNS

Incorrect	Correct
Jaundice	Hepatitis
Fever	Infection
Chest pain	Angina

AVOID terms such as senescence, old age, senility, infirmity, and advanced age. This term cannot be the immediate cause of death. There may be 1 or 2 conditions that have been due to old age and thus the etiologic sequence should be specified.

Part I	Incorrect	Correct
Ia	Bed ridden	Aspiration Pneumonia
Ib	Old Age	Stroke
Ic	Hypertension
Part II
I		Hypertension

If old age was a contributory factor, it should be entered in Part II. Example : Ia Chronic bronchitis, II old age.

What should you avoid while completing MCCD ?

What are the important points / aspects one should mention while certifying the cause of death ?

The following pertinent details are required to be clearly specified in the medical part of the certificate corresponding to the major cause groups of mortality:

Sl No	Major Cause	Details
1	Infections	Acute, sub-acute or chronic, name of the disease and/or infecting organism, the site if localised; mode of transmission, where relevant.
2	Neoplasms	The morphological type if known; malignant, benign etc., site of origin of primary growth and sites of secondary growths.
3	Endocrine disorders	Nature of disease process or disturbance of function: For thyroid diseases, whether toxic: for diabetes, nature of complication or manifestation in particular site.
4	Nutritional disorders	Type of deficiency, etc., and severity.
5	Blood disorders	Nature of disease process; type and nature of any deficiency for anemias; whether hereditary (where relevant)
6	Nervous system disorders	Disease process; infecting organism (where relevant) whether hereditary (where relevant).
7	Circulatory diseases	Nature of disease process; site, if localized; acute or chronic where relevant, specify rheumatic or other etiology for valvular heart conditions; any complications.
8	Respiratory diseases	Nature of disease process; acute or chronic; infecting organism, any external cause.
9	Digestive diseases	Nature of disease process; site of ulcers, hernias, diverticula, etc. Acute or chronic where relevant, nature of any complication for ulcers, appendicitis, hernias.
10	Genitourinary disorders	Acute or chronic, clinical syndrome and pathological lesions; site of calculi, infecting organism and site of infections; nature of complications.
11	Maternal deaths	Nature of complication: whether obstruction occurred during labour; timing of death in relation to delivery; for abortions, whether spontaneous or induced, legal or illegal, if induced.
12	Musculoskeletal disorders	Nature of disease process, infecting organism, underlying systemic diseases (where relevant); site; complication, whether congenital or acquired for deformities.
13	Congenital anomalies	Site and type, complications.
14	Perinatal deaths	Condition in fetus or infant; conditions in mother or of placenta, cord or membranes, if believed to have affected the fetus or infant; for deaths associated with immaturity, state length of gestation and/or birth weight; type of birth trauma; and complications, etc.
15	Injuries	Type, site, complications.
16	Poisoning	Substance involved; whether accidental (if suicide or homicide is ruled out).
17	Adverse effects of drugs in therapeutic use	State this fact and name or drug, nature of adverse effect, complications; condition treated.
18	External cause of accidents	For transport accidents, state vehicle involved, whether deceased was driver, passenger, etc. Description of accident place of occurrence, for other accidents, specifies circumstances and place of occurrence
19	Old age or senility	This should not be given if a more specific cause is known. If old age was a contributory factor it should be entered in part II only

What are the important points / aspects one should mention while certifying the cause of death ?

What is manner of death?

Manner of death could be natural ( an illness or an internal malfunction of the body) like death due to complications from influenza (an infection) or a heart attack (an internal body malfunction)
OR
Unnatural deaths where an external event or force is involved such as Accident, Suicide, Homicide. Even the deaths caused by external events have a definite pathophysiological sequence which ultimately leads to death. Cause of death has to be identified from that sequence.

AVOID terms such as Natural / Natural death / Normal death as cause of death.

What is manner of death?

What do you write on Injury ?

Explain the nature of injuries and parts of body injured; whether accident, suicide, homicide, war injury; place and circumstances of accident. This will help in completing cause of death sequence.

Part I	Example 1	Example 2	Example 3
Ia	Brain Injury	Fracture of vault of skull	Cardiac tamponade
Ib	Fall at home	Collision between car he was driving and heavy truck on road.	Perforation of heart
Ic	Chronic alcoholic	-	Gunshot wound to thorax

What do you write on Injury ?

Death due to pregnancy or delivery

Be sure to answer YES /NO on the question on pregnancy and delivery. This information is needed for all women of child-bearing age (15 to 49 years), even though the pregnancy may have had nothing to do with the death.

Death due to pregnancy or delivery

How do you overcome uncertainty in cause of death?

Many times doctors find it difficult to describe the process of death as they are uncertain what illness led to what illness.

List the health conditions / diseases / sickness presentations of the deceased.
Think through the causes about which you are confident and what could be the possible/probable reasons/etiologies that could have resulted in these conditions.
You should select the causes that are suspected to have been involved and use words such as "probable" or "presumed" to indicate that the description provided is not completely certain.
The initiating condition could be the immediate cause of death. If this was caused by a pre-existing condition, this could be noted down. But if the causes for these are unknown, it should be noted as unknown, undetermined, or unspecified, so it is clear that the doctor did not have enough information to provide a cause of death description.

What the physician will mention as cause of death when he is seeing the patient after death has occurred and no previous medical information is available ?
In such case physician has to certify on the basis of information available in medical records or autopsy (pathological or medicolegal ) report.

Other points to remember

When malnutrition is involved, the certifier should consider if other medical conditions could have led to malnutrition.
When a number of conditions or multiple organ/system failure resulted in death, the doctor should choose a single sequence to describe the process leading to death and list the other conditions in Part II of the certification section.

How do you overcome uncertainty in cause of death?

References: 1: Report on Medical Certification of Cause of Death 2015 by ORGI, India.
2: Physicians' Manual on Medical Certification of Cause of Death by ORGI, India.