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Viewpoint
June 10, 2020

The Importance of Proper Death Certification During the COVID-19 Pandemic

Author Affiliations
  • 1Office of the Chief Medical Examiner, State of Connecticut, Farmington
  • 2Department of Pathology, Yale School of Medicine, New Haven, Connecticut
JAMA. 2020;324(1):27-28. doi:10.1001/jama.2020.9536

Death certificate data are used to monitor local, regional, and national mortality trends to improve public health and public safety. Accurate death certification related to coronavirus disease 2019 (COVID-19) is vital to understand the extent and progression of the pandemic. Death certificate data can inform the public and policy makers on the progress of the COVID-19 pandemic and provide important information about who is dying, where they are from, and what were their associated medical conditions. Public health mortality data are only as good as the quality of the death certificates, but proper death certification has been a long-standing challenge in the US.1-3 The COVID-19 pandemic has highlighted shortcomings that may compromise an accurate count of COVID-19 deaths.

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    6 Comments for this article
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    Respiratory Failure Synonymous With Death
    Lewis Aldred, MD | University of Mississippi Medical Center
    I disagree that respiratory failure is synonymous with death. We admit people all the time with acute hypoxemic respiratory failure and acute hypercapnic respiratory failure that are not dead and that do not progress to death. Respiratory arrest seems to be synonymous with death, as is cardiac arrest. But just like acute (or chronic) heart failure is a disease entity that is not synonymous with cardiac arrest, acute (or chronic) respiratory failure is a disease entity that is not synonymous with death. I do agree that if one lists acute respiratory failure (either hypoxemic or hypercapnic) as the primary cause of death it should be followed with the underlying diagnosis (or the prevailing theory if no proven diagnosis).
    CONFLICT OF INTEREST: None Reported
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    Determination of Death from COVID-19
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    This detailed, important and informative Viewpoint bears serious analysis.

    Accurate death certification provided by health care professionals, nursing homes, and hospitals is informative for public health policies, and timely evaluation and optimal risk management of the disease.

    In addition to providing details of the underlying medical disease and any contributing comorbidities, probable contributing conditions leading to death include starvation and associated illnesses in many less developed countries, where government subsidies for the poor and unemployed arising from COVID-19 range from minimal to non-existent.

    Any deaths caused by temporary or permanent unemployment and poverty because of the pandemic,
    and a lack of availability of welfare payments to enable access to hospitals, nursing homes, and health care facilities, are also contributing conditions for death that are associated with COVID-19, even if the cause of death is determined to derive from medical conditions, including comorbidities.

    This is especially the case where testing for COVID-19 is not performed on patients after death for a variety of reasons.

    Inaccurate and imprecise determination of the medical causes provided by physicians on death certificates, especially in the absence of laboratory-confirmed infection, will compromise the true COVID-19 death count, and hence associated optimal public policy.
    CONFLICT OF INTEREST: None Reported
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    COVID-19 Pandemic: Research and Epidemiology Stymied by Mid-Stream Change in Reporting.
    Gary Ordog, MD, DABEM, DABMT. | County of Los Angeles, Department of Health Services (retired)
    Thank you for the excellent article on the importance of proper documentation in filling out Death Certificates. Yes, it is obvious that there are problems in documentation and thus the results of analyses of the data. You and others are fixing this system. A problem, is that we are in the middle of a pandemic, and altering the methodology of data input may stymie all research relying on this data. We are now comparing the proverbial "apples to oranges." I know that several health organizations have changed their protocols for reporting COVID-19 worldwide half-way through the pandemic, and may be diminishing the value of the conclusions that can be drawn from research using these data.
    CONFLICT OF INTEREST: None Reported
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    Coding for $$$
    Thomas Kaspar, MD and BC in ID | Crossroads Virology
    Since revenue can be generated by a COVID diagnosis with no proof other than clinical suspicion, hospitals are pressured into blaming deaths on COVID.

    Since COVID on the death certificate generates money for the hospital it is unrealistic to think this won't push numbers up.

    I have seen firsthand doctors being pressured to hang a COVID diagnosis on a death certificate by a hospital.

    Too bad we can't trust numbers from our own CDC.
    CONFLICT OF INTEREST: None Reported
    Legally Required Falsification of Cause of Death
    Richard Doerflinger, M.A., U. of Chicago | Center for Ethics and Culture, University of Notre Dame
    One disturbing reality relevant to this issue is the legally required falsification of cause of death in the nine jurisdictions, eight states and the District of Columbia that have legalized physician-assisted suicide (under various titles such "aid in dying" or "death with dignity"). In the three states with full statistical reporting of cases for 2018 (California and Washington) or 2019 (Oregon), at least 705 deaths in the last reported year (and as many as 803, due to cases where the state has not been told whether a patient to whom lethal drugs were prescribed died from ingestion or from an underlying condition) have died from the prescribed lethal drug overdose. By law, all these cases are listed on the death certificate, often by the prescribing physician, as death by natural causes from the underlying condition. Nor is it clear that these patients would have died soon in any case: The drugs are prescribed to any patient that physicians think may die in six months, and Oregon has made clear that this can include patients expected to die in that period without medical treatment even if they could have lived a long time with treatment. How statistically significant this practice is for assessing deaths from COVID-19 is uncertain, as states report the illnesses of the patients dying from the drugs only in the most generic terms, but in recent years the percentage said to have cardiac or respiratory illness has grown. Even if this policy on certification of death were due to a concern about privacy -- but especially if it is motivated by a desire to prevent outside scrutiny of whether legal requirements were followed -- one would think that the CDC at least must have access to the truth of these cases.
    CONFLICT OF INTEREST: None Reported
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    Negative Unintended Consequences of Covid 19 on Death Certificates
    Irving Kaufman, MD, Family Medicine and Geriatrics | Saint Peter’s University Hospital, Chairman Family Medicine. New Brunswick NJ
    This last week one of my dear patients age 55 passed away in the hospital from complications of hypertrophic cardiomyopathy and acute renal failure

    He had had COVID-19 two months before and was cured without sequelae.

    He had multiple nasopharyngeal swabs that were negative in the three weeks prior to his final hospitalization

    The intensivist put COVID-19 as his first diagnosis.

    An unintended consequence of this was that the funeral home would not pick up the body and the family would not be able to have a proper funeral.

    I had to intervene with the
    hospitalist and intensive care attending to change the cause of death down to hypertrophic cardiomyopathy.

    And this way the patient was able to be picked up from the hospital morgue and get embalmed and a allowing his family and loved ones and friends to be able to have a proper final farewell .

    Hence I agree with the author that COVID-19-related deaths do need to be reported to have good statistics about the pandemic..... But subsequent unrelated crisis of death and in those cases putting COVID-19 on the death certificate will preclude bereavement/mourning process for the family

    Irving Kaufman MD
    Chairman Family Medicine
    Saint peters university hospital
    New Brunswick New Jersey

    Ikaufman@saintpetersuh.com
    Office 732-745-8600 x 8682
    Cell 732-599-1835
    CONFLICT OF INTEREST: None Reported
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