Death Certificates – How Accurate Are They, Really?

The answer to this is, like so many other things in life, is that… it depends. 

The actual process of filling out a death certificate is a team effort: the family usually provides the information about birthdates, birthplaces, parents, and so forth; the funeral director handles the time and place of death; but it’s up to the doctor to fill out the actual cause, and this is the part that is of the most interest, and subject to the widest interpretation. 

On the one hand, a death certificate is one of what we call ‘vital records’, a document recording important facts about a person. As such we try to make sure they are as accurate as possible.

On the other hand, there is a lot of pressure to get them done quickly. Usually, a funeral home needs a completed death certificate before they can make a final disposition of the deceased person. The doctors completing them don’t want to let them go unfinished for too long because one’s memory of what happened at the very end can get distorted. And families generally want to get their loved one’s affairs settled and have some closure.

This doesn’t mean we try to get them done on a rush basis. It isn’t a ‘just put something in there and move on to the next case’ kind of thing. It’s a matter of how much is known, and when did the doctor know it?

When I was a med student I did a month with the neurosurgery team at MetroHealth in Cleveland. One of my attending physicians made an observation that has stuck with me through the years: “As doctors,” Dr. Likavec cautioned, “we are often called upon to make decisions based on incomplete information.” I have found this was never more true than in the death certificate. I’ve completed my fair share over the years, and sometimes even despite knowing my patients very well, those final days or hours can take some unexpected turns. Sometimes you know all the facts and it’s straightforward. But sometimes listing the cause of death can be little more than a ‘best guess’ because definitive information just isn’t available. Maybe the person wasn’t actually under their regular doctor’s care at the very end – they may have been in the emergency room, or transferred to an outside hospital, or at home, and whatever records there may be (if any) may take days or weeks to get. For myself, at such times I would try to defer the task to the ED doctor/hospitalist/hospice staff because they were actually there and saw what happened (and would have the records). Sometimes I would have the chance to talk to them myself and get the story. And sometimes I would just have to make the best assessment I could with the information I had. I always tried to be accurate, but there can be obstacles that can be hard to overcome in a timely fashion.

“What about an autopsy?” you may ask. While these are pretty much the gold standard when it comes to cause of death, they are only carried out in specific circumstances (see your state’s laws for particulars) and the vast majority of times, won’t be done (unless you want to pay for it). 

On a side note, a few years ago during the pandemic, there was a lot of talk about death certificates having ‘COVID-19’ listed as a cause of death when it shouldn’t have been. I can say from the perspective of a physician that, any doctor filling out a death certificate knows it’s their signature, and their license, on the line – literally. There is no place to list who they worked for or whatever pressures they may have felt from higher-ups to put something down as a cause. To write something knowingly false on a vital record is illegal but you can’t just blame that on your hospital CEO. But keep in mind that the death certificate lists an ‘immediate cause of death’ and then leaves space for a number of possible ‘contributing factors’, and sometimes these are the diagnoses that we suspect but lack concrete evidence for. Also keep in mind that, at the time, we didn’t know a lot about COVID-19, didn’t have a good test for it, and often it may have been listed because it was suspected to possibly have been a factor. 

On the other hand, I’ve dealt with enough hospital administrators to know that they can put a lot of pressure on a doctor, and when the federal government is earmarking funds to deal with the fallout of a health crisis, there’s an awful lot of incentive to list something as a ‘contributing cause’ with only the barest of connections.

What this all means is that the causes of death listed on a death certificate are not etched in stone. It may be a good, solid assessment, or it may be only a guess hampered by a lack of information. Only a thorough review of the records, and a knowledge of the person’s health, can really sort out what actually happened.