Death: the Final Complication

By Dr Nichola Davis

Most junior doctors will tell you that signing their first death certificate is one of the most surreal experiences in their career.

This duty appears to be one of the last remaining bastions exclusive to medical practitioners yet it barely rates a mention in most medical school curricula. Usually the first time a recent graduate sees a death certificate is when they are handed a blank one by a nurse who says, "Fill this out".

A Medical Certificate of Cause of Death (MCCD) more commonly recognised as a "death certificate" is a legally required record of a person's passing (although apparently no one has seen Bin Laden's). The certificate is usually required immediately following a death by family members in order to proceed with funeral arrangements. As a result MIPS members are often urgently called upon to consider their position.

The format of Australian death certificates varies slightly in each state and is beyond the scope of this article however all Australian certificates are based on the World Health Organisation framework in order that international mortality statistics can be collated.

Medical practitioners have a legal, ethical and moral duty to ensure the accuracy of such death certificates for the following reasons:

Statistical and Public Health reasons
Legal/Financial ramifications. (Heath Ledger's $10 million life insurance was disputed for a number of reasons connected with the cause of death written by a medical practitioner on his death certificate.)
Family history ramifications
To safeguard against crime and the inappropriate disposal of bodies.

Reportable deaths

"I am not sure of the cause of death but the family want me to write a Death Certificate" is a common clinico-legal enquiry received by MIPS. Each situation is very different, however it is appropriate for a practitioner to write a death certificate if he/she is "comfortably satisfied" as to the cause of death and the circumstances of a person's death do not constitute a "reportable death". It should be noted that if a person's death is reported to the Coroner, a death certificate should not be issued.

In general, a death must be reported to a coroner in the following instances (although what constitutes a "reportable death" varies by jurisdiction):

Where the person died unexpectedly and the cause of death is unknown
Where the person died in a violent or unnatural manner
Where the person's death is healthcare related and the death was an unexpected outcome
Where the person was 'held in care' or in custody immediately before they died
Where a doctor has been unable to sign a death certificate giving the cause of death
Where the identity of the person who has died is not known

Providing a death certificate

MIPS' experience is that practitioners are uncomfortable writing a death certificate if they have not seen the patient for some time. Whilst this is understandable it is not always justified. In most States there is no requirement for the deceased to have recently attended the practitioner (exceptions are in the ACT where a certificate can be issued if a person has attended any medical practitioner within three months and NSW where this time period is six months). Similarly members are often surprised to be informed that in most states (not NSW), a Death Certificate can in fact be issued by a practitioner who has never seen the patient or the body. It is of course vital that the practitioner who writes a certificate has an opinion regarding the probable cause of death and this may be obtained through perusal of the medical record or discussion with other treating medical practitioners.

Many members who have been contacted while on vacation to supply a certificate for a faithful patient who has passed away can now use the "electronic death certificate" available on the Department of Births, Deaths and Marriages websites in Victoria. As well as being easily accessible this should increase accuracy and the standardisation of certificates.

If a member is unsure whether to write a certificate, MIPS suggests that the practitioner should call the local Coronial Registrar or Office of the State Coroner in their state to discuss their knowledge of the patient's medical history and their position. If a medical practitioner still wishes to decline issuing a certificate then as always MIPS recommends thorough documentation of that decision.

Coroner's inquests

In a situation where a coroner is investigating a reported death, members often receive a request for notes or a report. MIPS advice would be to promptly comply with this request and advise MIPS of the circumstances and any potential involvement. Members are sometimes disappointed to hear that they can't charge the coroner for this service! However as a treating practitioner a member is entitled to a copy of a coroner's report.

Patient records

Lastly it is important to remember that although government organisations such as the state Coroner and the Public Trustee have the legal right to obtain patient information, all practitioners should still treat a deceased patient's medical records with confidentiality. Family may request access to the records and this should only be permitted if they have the permission of the Executor of the Estate.

Don't be too keen

It may sound obvious but certificates should not be issued when the patient is still alive! This can lead to all sorts of complications. On one occasion a junior doctor eager to please an organised family, queried whether he could issue a certificate now for a patient who was clearly terminal.

Some clinico-legal calls to our 24 hour support line are easier to answer than others, but we are always pleased when members contact us!

Death: the Final Complication

By Dr Nichola Davis

Reportable deaths

Providing a death certificate

Coroner's inquests

Patient records

Don't be too keen

Further reading

Dr Davis is a clinico-legal adviser for MIPS and a practicing GP.

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