A duty to certify death

Responsibilities

In Ontario, there are approximately 80 000 deaths per year. Coroners investigate about 20 000. By conservative estimate, approximately 2.5% of the deaths investigated by coroners, or 500 deaths per year, are certified by coroners on behalf of family physicians (personal communication from J. Stanborough, Regional Supervising Coroner, March 2007) because the family physicians are either unable to attend and don’t have coverage if they are away or don’t want to be involved in certifying the deaths of their patients.

I have often been called upon, in my role as coroner in my home community, to attend natural deaths at home. The family physicians in many of these cases were not available or would not attend. When I spoke to some of these physicians, they seemed surprised and somewhat annoyed by being asked to take on this aspect of their role. Many of them did not understand the role of the coroner and seemed to expect that the coroner would attend all deaths that occurred at home. Some of these family doctors didn’t even have death certificates in their offices. If they agreed to attend the deaths of their patients, they often asked me for advice about completing the death certificates properly. Myers and Eden’s contention that family physicians are uncomfortable with this role rings true in my own experience.

Family doctors might be contacted by coroners or police officers and asked to attend the deaths of their patients at home and complete death certificates. Family doctors should understand that, in such cases, a coroner has already reviewed the case and determined that it was not a reportable death under the Coroners Act. This means that any physician familiar with the patient’s illness can complete a death certificate, as specified in the Vital Statistics Act, which states the following:

Any legally qualified medical practitioner who has been in attendance during the last illness of a deceased person or who has sufficient knowledge of the last illness shall forthwith after the death complete and sign a medical certificate of death in the prescribed form, stating the cause of death according to the classification of diseases adopted by reference in the regulations, and shall deliver the medical certificate to the funeral director or other person in charge of the body.2

Where death is expected, family physicians can be guided by the following statement in the College of Physicians and Surgeons of Ontario’s policy on end-of-life care: “Is the physician prepared to undertake to certify death in the home and to arrange for another qualified person to do so when he or she is unavailable? When death of the patient at home is the expected outcome, the persons responsible for signing the medical certificate of death are to be designated in advance. It is not acceptable to rely on the coroner to certify the death.”3

Many jurisdictions are revising legislation to allow others, such as nurse practitioners, to pronounce death. Even under these circumstances it is likely that family physicians will still be responsible for completing medical certificates of death for their patients.

Benefits

In my opinion, family doctors should not shy away from their duties around death. This is an important aspect of their practice, and they have a moral and ethical obligation to fulfil these responsibilities. By doing so they take on an important administrative role. They are also available to their patients in moments of need. They can spend time with the families, even a brief time, answering questions and relieving distress. Families appreciate this very much, and it gives a remarkable feeling of satisfaction to physicians who have cared for patients for a long time.

As Huffman has pointed out, “The responsibilities of the family physician do not end with the death of a patient. Through careful and accurate completion of death certificates, the family physician can help to ensure that the far-reaching consequences of the patient’s death are as they should be.”4

Completion of death certificates can be a confusing and somewhat intimidating task for family physicians. Many articles have described the common errors made by physicians when completing death certificates, including use of mechanisms of death rather than diseases, insufficient diagnostic specificity, lack of timing, and inappropriate sequencing when many factors are involved.5,6

Family physicians need to realize that through accurate completion of death certificates they are providing Canada with the primary data for demographic and epidemiologic trends—everything from life expectancy to disease-specific mortality rates.

Educational opportunities

Myers and Eden show that an educational intervention can increase physicians’ skill at completing death certificates. Unfortunately, there are few educational opportunities for family doctors to learn about this aspect of practice, and this area receives little emphasis during medical school and residency.

The introduction to the Coroners Act for residents in my own community involves a 10-minute talk during resident orientation and reference to written material on the hospital website. Many studies have shown that access to written material alone does not produce significant change in accuracy of death certificate completion and knowledge of the Coroners Act. It seems clear from the article by Myers and Eden and other studies that small-group interactive workshops lead to increased knowledge, improved death certificate completion, and greater satisfaction among family doctors.

It would be interesting to see whether such workshops influenced family doctors to be more involved in end-of-life care, including completing the administrative duties related to the deaths of their patients. I believe family doctors would step up and take on their responsibilities if they had the educational support that such workshops provide. Death certification should be on the agenda of all family physician conferences in Canada.