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Am Fam Physician. 2005;71(4):652-656

It would be difficult to overstate the importance of death certificates—especially in an era of increasing reliance on evidence-based medicine (EBM)—yet physicians receive inadequate training in this important area, and their performance on this task remains less than ideal.13

For small and large populations, the definitive assessment of our success at prolonging life is the age-adjusted mortality rate, and the primary tool for measuring mortality rates is the death certificate. In addition, death certificates serve other essential functions (National Center for Health Statistics, Centers for Disease Control and Prevention [CDC] online at, including setting national, regional, statewide, and local priorities for funding, research, and interventions4; settling estates, closing bank accounts, selling stocks and bonds, and determining insurance and pension benefits; providing evidence in court cases; and providing outcome data for major research studies.

Accurate completion is essential to ensure the usefulness and reliability of the individual death certificate as well as the aggregate mortality statistics derived from it, yet data suggest that cause and manner of death are not reported in a consistent fashion. In one recent survey in which 198 experienced and trained medical examiners determined the manner of death for 23 scenarios, there was more than 90 percent agreement for only four scenarios, 13 scenarios had between 60 and 90 percent agreement, and the remaining six scenarios had less than 60 percent agreement.5

While the cause of death may be difficult to agree on sometimes, most problems with death certificates stem from failure to complete them correctly. Yet, these errors are avoidable. Myers and Farquhar showed that major errors on death certificates dropped from 32.9 to 15.7 percent (P = .01) after primary care physicians attended a 75-minute educational seminar.6 Lakkireddy and colleagues also showed that improved completion of death certificates correlated with specific training in that skill.7

Physicians without training in death certificates may not even understand the correct definitions of the following terms:

Manner of Death

The context or circumstances that surround the death; examples include accident, suicide, homicide, and natural causes. Typically, physicians can only certify natural deaths, while the coroner or medical examiner must make the final determination for suicides, homicides, and even accidents as common as drug overdoses or falls.

Immediate Cause of Death

The proximate, most recently developed, final diagnostic entity causing the death. Must be a specific etiology (e.g., Escherichia coli sepsis, acute renal failure, hypoxemia), not a general concept such as old age or terms like cardiac arrest or organ system failure that can have multiple etiologies.

Underlying Cause of Death

This is the fundamental, original, foundational diagnosis or condition from which the remainder of the etiologic sequence springs; it is the diagnosis of longest duration in the chain of events leading directly to death. Examples include human immunodeficiency virus infection (the underlying cause of acquired immunodeficiency syndrome), coronary artery atherosclerosis, and metastatic breast cancer. The description must be specific enough to make clear why the intermediate (if any) and immediate causes of death developed.

In almost all cases, a time-linked chain of causation can be established, such that the immediate cause of death was a consequence of a somewhat longer-duration diagnosis, which in turn was a consequence of an even longer-duration diagnosis, and so on through as many or few intermediate causes as necessary until reaching the true underlying cause of death. Other significant, but not directly linked, conditions must be listed separately.

Common errors in completion of death certificates include incorrect attribution of the immediate cause of death, listing causes in an incorrect or illogical order, multiple competing immediate causes of death, poor match between cause and manner of death, and failure to identify the true underlying cause or causes.3,8 Consider these examples:

• Manner: Natural. Cause: Ventricular fibrillation, due to acute myocardial infarction, due to coronary artery thrombosis, as a consequence of atherosclerotic coronary artery disease. [Satisfactory: Note plausible chain of causality.]

• Manner: Natural. Cause: Pneumonia, due to a hip fracture, due to chronic obstructive pulmonary disease, as a consequence of diabetes mellitus and hypertension. [Unsatisfactory: No causal chain; possibly competing immediate causes; etiology of pneumonia unspecified; hip fracture is usually accidental, not natural; hypertension (in this case) and other diagnoses not in the direct causal chain should be listed in Part II, Other Significant Conditions.]

• Manner: Natural. Cause: Staphylococcal sepsis, due to methicillin-resistant staphylococcal pneumonitis, due to chronic aspiration, secondary to swallowing dysfunction, as a consequence of Parkinson’s disease. [Satisfactory: Note clear and plausible chain of causality.]

• Manner: Natural. Cause: Congestive heart failure, as a consequence of ileostomy. [Unsatisfactory: No chain of causality; no clear underlying cause of the ileostomy or the heart failure.]

State statutes govern physician certification of cause of death and provide penalties for failure to complete in a timely or acceptable fashion. States require, and families depend on, certificates that are legible and clearly reproducible by photocopy and microfilm. Only permanent black ink should be used, erasures and “white-out” are not acceptable, and abbreviations should not be used. The physician who knew the decedent the best, or the attending physician, is responsible for completing the death certificate. A “probable” diagnosis is acceptable, as is listing a metastatic carcinoma of unknown primary site as an underlying cause. However, there is no “uncertain” or “unknown” category for cause of death; such cases should be referred to the medical examiner.

Based on the available data, we call for all medical students and residents to be trained to fill out death certificates correctly; for in-training, licensing, and certification examinations to assess competence in this area; and for practicing physicians to review death certificates as a part of their ongoing commitment to continuing medical education and quality of care. Excellent resources include information at the CDC8,9 and many state and local health department Web sites, online tutorials by the National Association of Medical Examiners (, and the Texas Department of Health (, and references 1, 2, and 6 listed below.

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