Are Death Certificate Discrepancies Misguiding Health Policy?
Are Death Certificate Discrepancies Misguiding Health Policy?

By Sheramy Tsai

In 2020, a family mourning the loss of their elderly matriarch to Alzheimer’s was stunned to find ‘COVID-19’ listed as a concurrent cause on her death certificate. The woman had never been tested for the virus, and no family members had contracted it. Her passing showed no signs of COVID-19; she breathed easily until the end.

The case is not an isolated one. Researchers have found death certificates across the country are rife with unsettling discrepancies, casting doubts on the reliability of our health records and health care priorities.

Public Health Consequences of Erroneous Death Certifications

Death certificates arm epidemiologists with vital insight into disease patterns. Beyond pinpointing causes of death, they influence key policy decisions, steer research funds, and mold community initiatives.

“Inaccurate cause of death reporting compromises our mortality data, which is foundational to policy-making and resource distribution,” Dr. Robert Anderson, Chief of the Mortality Statistics Branch at the National Center for Health Statistics (NCHS), told The Epoch Times. “The risk is that policies and resource allocation may be misguided.”

The ripple effects of such inaccuracies stretch wide. For instance, there are signs cardiovascular disease is over-represented in mortality data while pressing issues like medical errors, adverse vaccine outcomes, or maternal-related deaths might be underestimated.

Unearthing Death Certificate Discrepancies

The Electronic Death Registration System (EDRS) moved death reporting beyond paper’s limitations, offering real-time reporting opportunities. Yet even with the majority of U.S. states embracing the EDRS, accurate cause-of-death documentation remains an uphill battle.

Evidence of this challenge emerged in a 2017 collaborative study by the CDC, the Vermont Department of Health, and the Vital Statistics Cooperative Program. They scrutinized Vermont’s EDRS and found glaring issues: more than half of the 601 death certificates examined bore significant flaws. A staggering 51 percent masked the true causes of death with major inaccuracies. Alarmingly, 93 percent displayed errors in their ICD-10 coding—a diagnostic foundation from 1949 that underpins national mortality statistics.

Echoing these concerns, a University of Wisconsin study found that 85 percent of death certificates contained errors. The authors noted, “The majority of the errors detected on review of death certificates at our institution were not due to novel findings at autopsy, but rather omissions of known conditions or illogical sequencing of known events leading to death.”

Experts believe the issue is endemic across the United States.

Unequipped Doctors

Physicians face two critical challenges in recording accurate death certifications: inexperience and a conspicuous lack of training.

When confronted with their first patient deaths, young physicians frequently turn to senior colleagues for guidance. However, these seasoned doctors, often absent at the time of the patient’s passing, are sometimes ill-equipped themselves, lacking formal certification training.

“Most physicians receive no training on how to properly certify the cause of death,” Dr. Anderson shared.

A survey across multiple institutions revealed that 76 percent of nearly 600 resident physicians lacked formal training in death certification. When presented with a case involving urosepsis, a grave urinary tract infection, 77 percent faltered, and almost half mistakenly attributed the death to a cardiovascular event.

This lack of training is intensified by fleeting doctor-patient dynamics. Frequently, the doctor tasked with drafting the death certificate has little connection with the deceased, leaning heavily on potentially incomplete medical records. This can cloud an accurate understanding of the patient’s health trajectory. In cases such as home hospice deaths, the certifying physician may never have spoken with the patient.

The Challenge of Determining Cause of Death

Recording a person’s cause of death isn’t a mere checkbox task. It’s a detailed process steered by the World Health Organization’s guidelines. A physician, medical examiner, or coroner must meticulously examine the deceased’s medical history.

Pinpointing the precise cause of death without resorting to vague terms like “cardiac arrest” is difficult.

Once these certificates pass verification, they become public records, highlighting the immediate cause of death rather than the deceased’s entire medical history.

Herein lies an inherent challenge: interpretation. A patient may have multiple chronic conditions, as well as an acute infection. Doctors can have different views on why the patient died. The CDC aptly remarks, “Causes of death on the death certificate represent a medical opinion that might vary among individual physicians.”

The linchpin of these certificates is the underlying cause recorded on Part I’s conclusive line. This pivotal diagnosis is then translated into an alphanumeric code that syncs with WHO’s International Statistical Classification of Disease (ICD-10). This ensures a consistent global reading of mortality data.

The underlying cause of death identifies either the disease that set off a series of health complications or the specific incident, like an accidents or violent act, that led directly to death. It can capture root factors like prior heart attacks or coronary artery diseases that contributed to the final outcome.

For public health strategies, it’s not just about understanding the finality of death but also isolating its inception. Pinpointing root causes, such as identifying that Type II diabetes mellitus was behind end-stage renal disease, sharpens the focus for targeted prevention and disease mortality tracking. Unfortunately, this is often difficult to capture.

Unraveling Death’s Underlying Narratives

Death certificates, though a final record of an individual’s journey, often oversimplify complex medical histories. The listed cause of death can often overshadow a multitude of underlying conditions that indirectly lead to that final moment.

Take, for instance, a person with Type II diabetes mellitus. While heart disease, a common consequence of diabetes, might be penned as the direct cause of death, diabetes’ critical role often remains obscured. This selective portrayal doesn’t just misrepresent diabetes fatalities; it skews broader health trends.

Research consistently indicates that cardiovascular disease is overrepresented as a primary cause of death, potentially masking emerging health threats and intervention opportunities.

Connecticut Chief Medical Examiner Dr. James R. Gill clarifies, “Cardiopulmonary arrest is essentially a synonym for death. Every death, no matter the cause, results in a cardiopulmonary arrest.”

The CDC notes that while heart disease often fills uncertain causes due to its prevalence, its representation across states, at 20-30 percent, suggests the issue may not be as widespread as perceived.

In today’s health landscape, new concerns are emerging. For example, deaths potentially linked to vaccination side effects remain a quandary, with the traditional death certificate lacking the nuance to capture these specifics.

Another significant gap is the lack of categories for medical errors. For instance, if a drug error in a hospital hastens the death of a cancer patient, “cancer” typically dominates the certificate’s cause-of-death section. A 2016 study by Johns Hopkins highlights this omission. As Martin Makary, M.D., M.P.H., from Johns Hopkins notes, “The medical coding system was crafted more for billing purposes than gathering crucial national health data.”

The COVID-19 pandemic sprinkled its own set of complexities onto this already intricate canvas. When a precise COVID-19 diagnosis is elusive, the CDC states that death certificates may bear the “probable” or “presumed” tag. But this, in some cases, risks unintentional inflation of COVID-19 death stats.

Addressing these concerns, the CDC remarked to The Epoch Times, “We do not believe that COVID-19 statistics are inflated. If anything, we probably continue to underestimate to some extent as some certifiers will not report causes of death without confirmation, despite the guidance.”

Toward a Precise Future: Mending the Gaps

Fixing problems in the death certification process requires new approaches, and basic skills.

Key industry figures, including Dr. Anderson, emphasize a pressing need: comprehensive, up-to-date training for healthcare professionals. “We have developed materials for such training,” Dr. Anderson says, pointing out the crux: “The challenge lies in effectively disseminating these materials and ensuring physicians actively participate.”

Those could include “The Physician’s Handbook on Medical Certification of Death,” which was revised for the first time in 20 years. This essential guide tells medical professions how to navigate the U.S. vital registration system and how complete death certificates properly. 

Training isn’t the sole remedy, however. New tools like advanced electronic medical records and real-time AI insights to refine accuracy may help. Dr. Anderson says groundbreaking endeavors linking medical records with electronic death registration could offer certifiers a fluid transition to relevant medical data during the certification process.

Despite advancements, we mustn’t lose sight of the human element. For families who’ve lost loved ones, the labyrinth of healthcare isn’t just a system but a deeply personal journey. It reminds us of the profound importance of precision, matched with a heartfelt touch, in every facet of healthcare documentation.

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