Death certificate - should i oblige patient's wishes?

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coolcatrina

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So, One of my patients passed away today. He is HIV + , passed due to cardiac arrest. As per ptient's family, the patient did not want HIV to be anywhere on his death certificate / wants it to be discreet . I told the family that I will see what I can do. I spoke to my senior resident about it and he said that I have to put "complication of hiv" as one of the causes of death and it is important for department of health statistics etc.

I want to honor my patients wishes but dont want to do anybillegal. Can somebody advice me about this please. Thanks!
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coolcatrina said:
So, One of my patients passed away today. He is HIV + , passed due to cardiac arrest. As per ptient's family, the patient did not want HIV to be anywhere on his death certificate / wants it to be discreet . I told the family that I will see what I can do. I spoke to my senior resident about it and he said that I have to put "complication of hiv" as one of the causes of death and it is important for department of health statistics etc.

I want to honor my patients wishes but dont want to do anybillegal. Can somebody advice me about this please. Thanks!
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Not a lawyer, but I would think it depends on the situation. Unless he clearly dies from AIDS as a proximate cause, I don’t see why you would have to record HIV, even if it was a contributing factor to what led to his demise. If someone has diabetes that leads to esrd which leads to death, I put COD as ESRD, not DM.
 
coolcatrina said:
So, One of my patients passed away today. He is HIV + , passed due to cardiac arrest. As per ptient's family, the patient did not want HIV to be anywhere on his death certificate / wants it to be discreet . I told the family that I will see what I can do. I spoke to my senior resident about it and he said that I have to put "complication of hiv" as one of the causes of death and it is important for department of health statistics etc.

I want to honor my patients wishes but dont want to do anybillegal. Can somebody advice me about this please. Thanks!
Click to expand...


Cardiac arrest 2/2 _____, should be enough.

Agree that there is no need to point out HIV unless a direct cause of death.
 
The death certificate should reflect why your patient suffered cardiac arrest and not cause of death being cardiac arrest. Everyone who dies has cardiorespiratory arrest even in case of brain death since the patient would be eventually extubated. For example, if your patient had ischemic cardiomyopathy with history of DM, hyperlipidemia, hypertension, and other vascular risk factors, and also happened to be HIV+, then HIV would be less relevant. In contrast, if your patient had HIV-associated cardiomyopathy, then HIV would have to be mentioned on the death certificate.

When I doubt, check with your hospital administration and/or public health department.
 
OP: your title says "patient's wishes", your text says "patient's family's wishes". Unless the patient disclosed their wishes to you before death, or left written instructions compiled before death, the family's wishes should not be treated as your patient's wishes.

Your final obligation to your patient is to be accurate on their death certificate. Your obligation to yourself is to comply with the rules about death certificates, which include being truthful. If your senior resident thinks that "complication of HIV" is accurate and you have no medical reason to challenge that assessment, then that is what you put in order to meet those two obligations.

I would add that it is entirely possible that the family's behaviour, as expressed to you in their wishes, indirectly helped to create the situations that led to the HIV+ status, for instance through deliberate policies of bringing a child up without any sex or drugs education or through disapproval of a gay lifestyle. Their concern for "appearances" after bereavement certainly makes me think they may not have had the patient's best interests at the centre of their minds before their death. But I'm not a doctor so I'm allowed to think these bad thoughts about them, whereas you probably need to be above the fray.
 
Two thoughts:
1) always be accurate on the death certificate, it is an official document
2) if possible, be sensitive without forsaking accuracy. This family will be purchasing numerous copies of this certificate and giving to banks, funeral home, insurance etc. they will read the cause of death everyday and this will shape how they bereave their loved one. Your patient is dead, and will likely be quickly forgotton in your memory - not so the case for his family. The words you write can have a lasting impact so choose carefully!
 
I'm going to echo what everyone else said.

1. "Cardiac arrest" is not, in general, an appropriate cause of death.
2. What caused the death (MI, heart failure, PE, drug overdose, etc) needs to be on it. If HIV was the cause or a significant contributing factor, then it should be on it. If the patient died from something else, and just happened to have HIV, then it shouldn't be listed as a cause of death.
 
"Acute cardiac insufficiency" is what I was trained to write for cause of death if otherwise not specified. I have never written anything else.
 
This is one of the things that depend on the law of the state that you are in. For example, in my state, the death certificate requires:

"Enter the Chain of Events - Diseases, Injuries or Complications - That Directly Caused the Death." (underline in the original)

The bottom line is that you have to do whatever the state requires. In this case do not to listen to internet advice. Every state has different laws and requirements; what might be reasonable in one state might be illegal in another state. Listen to your senior resident. Or bump it up to the attending for verification. This is one of those apparently trivial things that can cause significant problems for you down the road. Licensing boards don't care if you gave coumadin to a patient losing blood by the liter, but they will deny you a license for "falsifying a death certificate."
 
Last edited:
There's definitely some wiggle room depending on circumstances. As an EM doc:

Vandalia said:
"Enter the Chain of Events - Diseases, Injuries or Complications - That Directly Caused the Death." (underline in the original)
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Ok. Patient arrived in cardiac arrest. Unwitnessed. Unknown downtime. CPR discontinued, patient remained dead. Cause of death: Cardiac arrest. Everytime I've gotten any pushback from the hospital administrator when listing that as the COD, I've had to explain that I know literally NOTHING about this patient except that they're dead, so cardiac arrest it is. Anything else would be speculation. They never seem to want me to write "unknown" for some reason.
 
BoardingDoc said:
There's definitely some wiggle room depending on circumstances. As an EM doc:



Ok. Patient arrived in cardiac arrest. Unwitnessed. Unknown downtime. CPR discontinued, patient remained dead. Cause of death: Cardiac arrest. Everytime I've gotten any pushback from the hospital administrator when listing that as the COD, I've had to explain that I know literally NOTHING about this patient except that they're dead, so cardiac arrest it is. Anything else would be speculation. They never seem to want me to write "unknown" for some reason.
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that's because, as someone else noted, everyone dies of cardiac arrest...its the end result, not the cause...at least of unknown etiology says " i don't know why they died"...its like SOB...its not a diagnosis but a symptom...their are lots of causes.
 
rokshana said:
that's because, as someone else noted, everyone dies of cardiac arrest...its the end result, not the cause...at least of unknown etiology says " i don't know why they died"...its like SOB...its not a diagnosis but a symptom...their are lots of causes.
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Yes, I'm obviously aware of that, which is why I stated my confusion about why the admin team never wants "unknown" as a COD.
 
BoardingDoc said:
There's definitely some wiggle room depending on circumstances. As an EM doc:



Ok. Patient arrived in cardiac arrest. Unwitnessed. Unknown downtime. CPR discontinued, patient remained dead. Cause of death: Cardiac arrest. Everytime I've gotten any pushback from the hospital administrator when listing that as the COD, I've had to explain that I know literally NOTHING about this patient except that they're dead, so cardiac arrest it is. Anything else would be speculation. They never seem to want me to write "unknown" for some reason.
Click to expand...


In this situation, should you defer to the coroner to determine cod?

You cannot be certain as to the cause, cannot be certain it is natural, and essentially the person died out of the hospital ( resusitation attempt continued untill the patient was in the ER, but failed).

It seems like you could make a case that these should go to the coroner, but i suppose they dont have the manpower to investigate all of those...
 
geripalgal said:
In this situation, should you defer to the coroner to determine cod?

You cannot be certain as to the cause, cannot be certain it is natural, and essentially the person died out of the hospital ( resusitation attempt continued untill the patient was in the ER, but failed).

It seems like you could make a case that these should go to the coroner, but i suppose they dont have the manpower to investigate all of those...
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They don't. And unless the death is under suspicious circumstances, or there's a potential legal aspect (MVC, OD, accidental gunshot, etc), they won't bother.

PCPs get death certificates to sign all the time where you just have to figure out what the most likely thing to kill them was and put that down.

FWIW, in my state, the death certificate has the proximate cause of death followed by 3 lines to put "as a consequence of...". You can fill as many of those in as you like. Mine are usually, "Multi-system organ failure" as a consequence of "metastatic cancerosis" as a consequence of "going for the smoking pack-year world record".
 
I kinda understand where the family is coming from, because I think we all have stories about friends/families death certificates that just make you shake your head. For instance, on my great-uncle's they listed "smoking" as a contributory cause after he passed away from lung cancer. We just cracked up. My uncle would smoke one small cigar on Saturday night. However, the fact that he worked for 30 years in the gypsum mill apparently had nothing to do with it....😛
 
BoardingDoc said:
There's definitely some wiggle room depending on circumstances. As an EM doc:
Ok. Patient arrived in cardiac arrest. Unwitnessed. Unknown downtime. CPR discontinued, patient remained dead. Cause of death: Cardiac arrest. Everytime I've gotten any pushback from the hospital administrator when listing that as the COD, I've had to explain that I know literally NOTHING about this patient except that they're dead, so cardiac arrest it is. Anything else would be speculation. They never seem to want me to write "unknown" for some reason.
Click to expand...

Everything is local, but here, we would never do that death certificate. If they were followed by another physician, and he or she felt comfortable establishing a cause of death, they would fill out the death certificate. In your case, with a 75 yo man for example, it would most likely be something like "Sudden Cardiac Death, Hypertension, Hyperlipidemia, DM" If not, it would go to the coroner because we have no clue as to the manner of death; suicide? homicide? accident? "Unattended deaths" have to go to the coroner. (And the definition of "unattended" is not obvious.)
 
Vandalia said:
In your case, with a 75 yo man for example, it would most likely be something like "Sudden Cardiac Death, Hypertension, Hyperlipidemia, DM"
Click to expand...

When I rotated at a ME's office as a med student, we would sign out these types of cases as "atherosclerotic cardiovascular disease" with external examination only to document absence of trauma.
 
kchan99 said:
When I rotated at a ME's office as a med student, we would sign out these types of cases as "atherosclerotic cardiovascular disease" with external examination only to document absence of trauma.
Click to expand...
Type 3 NSTEMI...
 
aProgDirector said:
This thread should remind everyone that any research done using death certificates is next to worthless.
Click to expand...
Yeah. That was a real bummer to learn. It's a real PITA to do real epi, but death certificates are worthless. And, now I feel pangs of guilt every time I fill one out. Sigh - garbage in, garbage out...
 
coolcatrina said:
So, One of my patients passed away today. He is HIV + , passed due to cardiac arrest. As per ptient's family, the patient did not want HIV to be anywhere on his death certificate / wants it to be discreet . I told the family that I will see what I can do. I spoke to my senior resident about it and he said that I have to put "complication of hiv" as one of the causes of death and it is important for department of health statistics etc.

I want to honor my patients wishes but dont want to do anybillegal. Can somebody advice me about this please. Thanks!
Click to expand...

Reach out to risk management dept. for their advice.
 
geripalgal said:
In this situation, should you defer to the coroner to determine cod?

You cannot be certain as to the cause, cannot be certain it is natural, and essentially the person died out of the hospital ( resusitation attempt continued untill the patient was in the ER, but failed).

It seems like you could make a case that these should go to the coroner, but i suppose they dont have the manpower to investigate all of those...
Click to expand...

Yeah, a lot of MEs offices won't accept the case depending on age and other comorbidities. Person would have to be found in suspicious circumstances/accidental stuff otherwise.
 
Keep in mind that every state has a different structure for dealing with death.

For example, above, I spoke of the coroner. Here, that is not a pathologist, it is almost always not even a doctor; in fact I think the only legal requirement is that the person have a high school diploma. They have at least one full time investigator who actually does the initial investigation of the body and perhaps interviews the people who found them, and decides if it is turned over to a pathologist. Again, here, if the cause of death is not obvious and/or there is a primary care physician who will sign the death certificate, it ends up with the coroner's office who decide the course from there. In EM, It is very rare for us to handle the death certificate.

To get back to the core point, once again, every state is different. That is why it is critical for the OP to do what the senior resident says, or to ask a faculty member.
 
drcrispmd said:
Can residents even sign the death certificate? The attending at to sign them in Tennessee. Better make sure before you sign it as a resident.
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I wasn't aware residents weren't allowed to in some places. Must be state specific then, although it wouldn't surprise me if there are some hospitals out there that restrict it to attendings-only even if not required by law.
 
rokshana said:
that must be state dependent...we signed death certificates as residents in Georgia.
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As with everything about death certificates...it's state dependent.

Where I am, residents (and PAs ) can sign them but must also put the attending physician's name on the form.
 
I got burned with a death certificate one time. Some older guy had a MVA when he drove off the road into a ditch. Had some fractures and post-op complications and ended up in NH. 6 months later he was still convalescing from complication after complications and showed up with bacteremia with multi-organ failure and family pulled plug. I was covering that night and didn’t know the patient and just came to pronounce pt. I wrote on death certificate that the patient died from septicemia/multi-organ failure and did not mention the MVA as contributory.
10 months later I got a call from the family to change the death certificate as they were unable to claim insurance money. It was a PITA to make those calls to the state health department.
 
Everything about this is state dependent. The ME I rotated with explicitly told me about instances where patient families made requests for aspects of the COD, and he most of the time obliged provided that it was accurate to do so (i.e. you could argue that the specific additional cause was superfluous or only a minor contribution to COD).

If it were me and it was reasonable to do so, I wouldn't mention HIV if the family requested not to and it fit the generally accurate/legal requirement for COD (state dependent). Obviously, if its the direct and only reasonable cause, then your hands are bit tied, but this may also vary by state.

Also, a request like that doesn't inherently mean the family didn't support the deceased. We know nothing of their personal life, their interactions, etc. I wouldn't presume to know that as a physician only transiently involved in their care.
 
hallowmann said:
... We know nothing of their personal life, their interactions, etc. I wouldn't presume to know that as a physician only transiently involved in their care.
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This is probably what bugs me the most about this issue, recently. I'm doing a lot of death certificates these days (nursing home work). And, I cringe ever thinking that this is an actual source of data for public health statistics (it's the epidemiologist in me). I may see someone just for their last month of hospice, or who have been in with multiple years of dementia but overall not that sick for someone in their 90's. Families and medical records are borderline useless in a lot of cases. I feel like you're trying to summarize someone's whole life into a "sign on the dotted line" form.

But, I also know I take things too seriously 90% of the time. Ultimately, we're being asked to certify the death --- just the life event that occurred, as a matter of bookkeeping. I want to worry about things that I think are important, like "Why? How? When did this start?". But, ultimately... it's "this is what happened at 4:50 am this morning" and the body is going to X funeral home or ME.
 
drcrispmd said:
Can residents even sign the death certificate? The attending at to sign them in Tennessee. Better make sure before you sign it as a resident.


Sent from my iPhone using SDN mobile
Click to expand...
CA just requires it be a licensed physician. Got my license a few months into second year and started doing my own death certificates at that point.
 
Raryn said:
CA just requires it be a licensed physician. Got my license a few months into second year and started doing my own death certificates at that point.
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I hope that's the rule in South Carolina. I think I filled out a couple my first day of internship. Senior had to tell me I couldn't use cardiac arrest.
Now in TX I don't do them. Either their PCP or ME will do it.
 
DrSnips said:
You can just put aspiration. People may lose out on their hopes and dreams, but they will still have their aspirations.
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Yeah, but in our electronic system, aspiration triggers as a death other than "natural". You can override it, but it's a pain in the butt. Same for any time you mention intracranial hemorrhage or falls / fractures.
 
fantasty said:
Yeah, but in our electronic system, aspiration triggers as a death other than "natural". You can override it, but it's a pain in the butt. Same for any time you mention intracranial hemorrhage or falls / fractures.
Click to expand...

I wasn't aware deaths were classified by natural vs unnatural. I guess natural means atherosclerotic disease from a lifetime of eating man-made foodstuffs, while unnatural would be death from a natural disaster.
 
The standard one here in that situation is "failure to thrive."
 
DrSnips said:
I wasn't aware deaths were classified by natural vs unnatural. I guess natural means atherosclerotic disease from a lifetime of eating man-made foodstuffs, while unnatural would be death from a natural disaster.
Click to expand...
No.

Unnatural typically means accident, murder, or suicide.
 
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