Death Certification Errors and the Effect on Mortality Statistics

McGivern, Lauri; Shulman, Leanne; Carney, Jan; Shapiro, Steven L.; Bundock, Elizabeth A.

doi:10.1177/0033354917736514

Cited by 154 publications

(161 citation statements)

References 21 publications

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“…Death certificates are the basis from which disease prevalence data and national morbidity and mortality data are derived in the United States. 3,[11][12] Thus, death certification accuracy is key in ensuring that governmental prioritization of public health priorities and allocation of health funding for a multitude of conditions such as coronary heart disease, dementia, and various infections-to name a few-is appropriate. [13][14][15][16] Autopsy remains the standard against which clinician death certification accuracy is assessed.…”

Section: Discussionmentioning

confidence: 99%

Death Certification: Errors and Interventions

2019

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Death certificates are legal documents containing critical information. Despite the importance of accurate certification, errors remain common. Estimates of error prevalence vary between studies, and error classification systems are often unclear. Relatively few studies have assessed the frequency at which death certification errors occur in US hospitals, and even fewer have attempted a standardized classification of errors based on their severity. In the current study, our objective was to evaluate the frequency of death certification errors at an academic center, implement a standardized method of categorizing error severity, and analyze sources of error to better identify ways to improve death certification accuracy. Design: We retrospectively reviewed the accuracy of cause and manner of death certification at our regional academic institution for 179 cases in which autopsy was performed between 2013-2016. We compared non-pathologist physician completed death certificates with the cause and manner of death ultimately determined at autopsy. Methods: Errors were classified via a 5-point scale of increasing error severity. Grades I-IIc were considered minor errors, while III-V were considered severe. Sources of error were analyzed. Results: In the majority of cases (85%), death certificates contained ≥ one error, with multiple errors (51%) being more common than single (33%). The most frequent error type was Grade 1 (53%), followed by Grade III (30%), and Grade IIb (18%). The more severe Grade IV errors were seen in 23% of cases; no Grade V errors were found. No amendments were made to any death certificates following finalization of autopsy results during the study period. Conclusion: This study reaffirms the importance of autopsy and autopsy pathologists in ensuring accurate and complete death certification. It also suggests that death certification errors may be more frequent than previously reported. We propose a method by which death certification errors can be classified in terms of increasing severity. By understanding the types of errors occurring on death certificates, academic institutions can work to improve certification accuracy. Better clinician education, coordination with autopsy pathologists, and implementation of a systematic approach to ensuring concordance of death certificates with autopsy results is recommended.

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Section: Discussionmentioning

confidence: 99%

Death Certification: Errors and Interventions

2019

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“…This situation, a consequence of the division of powers, has introduced great variability in the practice of death classification generally, not just in the context of MAID. It is thus unsurprising that a search of the medical literature reveals numerous examples of studies demonstrating significant variability in the classification of the manner of death by various professionals (e.g., attending physicians, coroners and medical examiners) in response to scenarios [33].…”

Section: Resultsmentioning

confidence: 99%

Refusing care as a legal pathway to medical assistance in dying

Downie

Bowes²

2019

bioethics

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Article abstractCan a competent individual refuse care in order to make their natural death reasonably foreseeable in order to qualify for medical assistance in dying (MAiD)? Consider a competent patient with left-side paralysis following a right brain stroke who is not expected to die for many years; normally his cause of death would not be predictable. However, he refuses regular turning, so his physician can predict that pressure ulcers will develop, leading to infection for which he will refuse treatment and consequently die. Is he now eligible for MAiD? Consider a competent patient with spinal stenosis (a non-fatal condition) who refuses food (but not liquids in order not to lose capacity from dehydration). Consequently, her physician can predict death from starvation. Is she now eligible for MAiD? Answering these questions requires that we answer three sub-questions: 1) do competent patients have the right to refuse care?; 2) do healthcare providers have a duty to respect such refusals?; and 3) are deaths resulting from refusals of care natural for the purposes of determining whether a patient is eligible for MAiD? If a competent patient has the right to refuse some particular care, and healthcare providers have a duty to respect that refusal, and if the death that would result from the refusal of that care is natural, then that refusal of care is a legal pathway to MAiD. However, if the competent patient does not have the right to refuse some particular care, or if healthcare providers do not have a duty to respect that refusal, or if the death that would result from the refusal of that care is not natural, then that refusal of care is not a legal pathway to MAiD. In this paper, we explore this complex legal terrain with the most profound of ethical implications -access to MAiD. RésuméAbstract Une personne compétente peut-elle refuser des soins afin de rendre son décès naturel raisonnablement prévisible pour être admissible à l'aide médicale à mourir (AMM)? Prenons l'exemple d'un patient compétent atteint d'une paralysie du côté gauche à la suite d'un accident vasculaire cérébral droit qui ne devrait pas mourir avant de nombreuses années ; normalement, la cause de son décès ne serait pas prévisible. Cependant, il refuse de se retourner régulièrement, de sorte que son médecin peut prédire que des plaies de pression se développeront, entraînant une infection pour laquelle il refusera le traitement et mourra par conséquent. Est-il maintenant admissible à l'AMM? Prenons l'exemple d'un patient compétent atteint d'une sténose spinale (affection non mortelle) qui refuse de manger (mais pas de boire pour ne pas perdre sa capacité à cause de la déshydratation). Par conséquent, son médecin peut prédire la mort par famine. Est-elle maintenant admissible à l'AMM? Pour répondre à ces questions, nous devons répondre à trois sous-questions : 1) les patients compétents ont-ils le droit de refuser des soins ; 2) les prestataires de soins de santé ont-ils l'obligation de respecter ces refus ; et 3) les décès résultant de re...

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“…One found an error rate of 39% in a national cohort including 336 deaths [23]; another conducted in selected Kansas City and St. Louis hospitals found an error rate of 45.8% [24]. A study in Vermont revealed that 51% of death certificates completed by non-medical examiners had major errors, and that certificates for hospital deaths were more error prone than those completed for residential deaths (59% vs. 39% errors) [25]. A nationally representative sample of older Americans who died while hospitalized found that there was significant disagreement between Medicare records and the assigned cause of death on certificates, and that the contributing nature of infections was under-reported [26].…”

Section: Discussionmentioning

confidence: 99%

Differences in Race and Ethnicity in Muscular Dystrophy Mortality Rates for Males under 40 Years of Age, 2006–2015

2018

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Background/Aims: Duchenne Muscular Dystrophy (DMD) has childhood onset, primarily affects males, and is usually fatal before the age of 40 years. Previous studies have indicated that this X-linked condition is more prevalent in whites than in blacks, but those were based on active surveillance, and limited to smaller populations and younger ages. Methods: US death data were used to calculate mortality rates by race and ethnicity, with MD as either the underlying or multiple cause of death (MCD). Poisson approximation was used for confidence intervals; chi-square was used to compare rates. Results: From 2006 to 2015, there were 3,256 deaths in males <40 years with MD as MCD, and 71% of these were aged 15–29 years. For whites, the average annual death rate was 0.43/100,000, which was significantly higher (p < 0.0001) that that of blacks (0.28), American Indian/Alaska Natives (0.20), and Asian/Pacific Islanders (0.21). The rate for non-Hispanic whites (0.46) was significantly higher (p < 0.0001) than the rates for Hispanic whites (0.31), Hispanic blacks (0.07), and non-Hispanic blacks (0.29). Conclusion: Since DMD is the primary cause of deaths in young males with MD, mortality rates are a reasonable proxy for the relative difference in racial prevalence. It appears that DMD is significantly more common in white males than in males of other races.

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Death Certification Errors and the Effect on Mortality Statistics

Cited by 154 publications

References 21 publications

Death Certification: Errors and Interventions

Death Certification: Errors and Interventions

Refusing care as a legal pathway to medical assistance in dying

Differences in Race and Ethnicity in Muscular Dystrophy Mortality Rates for Males under 40 Years of Age, 2006–2015

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