To discourage situations where no one will accept responsibility to certify a death, in March NCMB adopted a position statement entitled, “
Clinician obligation to complete certificates of death”. The position urges licensees to complete death certificates for patients (whether current, recent or remote) “as a professional, ethical, civic, and public health responsibility.”
Most refusals to complete a death certificate that come to the Board's attention involve an unattended death at home. It's not difficult to imagine the reservations some licensees have about signing the death certificate under such circumstances:
"How should I know why a patient died at home? Am I just supposed to guess the cause of death?!"
"What if I haven't seen the patient in months or even years?"
"Why can't the medical examiner just certify the death?"
At the Board's request, I am writing to offer some clarifications and additional guidance to minimize licensee confusion about NCMB’s expectations.
First and foremost, it’s important for clinicians to understand what their role is in certifying a death. Signing a death certificate does not require the clinician to definitively determine the precise anatomic or physiologic cause of death. Rather, the certifying physician, PA or NP should specify a reasonable or probable cause of death based on the best evidence available at the time. Is this a scientific means of determining the precise cause of death? Unfortunately not. The death certificate is primarily a legal document not a scientific document – entering a presumed or probable cause of death is sufficient. When specifying a cause of death you may include the term “probable” if it makes you more comfortable when faced with uncertainty. I have confirmed with staff at NC Vital Records that this is an acceptable practice.
Licensees who have shared feedback on signing death certificates with the Board frequently question the appropriateness of certifying the death of a patient the licensee may not have seen for several months, or even years. It is currently accepted practice for the medical professional who most recently treated the patient or who would be familiar with the patient’s medical history to sign the death certificate. If a patient dies unexpectedly at home, the request will almost always go to the decedent’s primary care provider of record. In such situations, licensees should use the best information available, including the patient’s history and known underlying or pre-existing medical conditions, to identify a probable cause of death. This is true whether the patient was seen a month ago, or whether they were last seen three years ago. Just do your best with what information you have.
At times there may be additional circumstances surrounding a death that reasonably cause a clinician to feel especially reluctant to certify the death. Medical examiners accept cases when there are “suspicious, unusual or unnatural circumstances”. In virtually all cases, the death will have already been evaluated to determine if it is within the medical examiner’s jurisdiction before a licensee is asked to certify the death. However, it is simply not possible for the medical examiner system in North Carolina to accept every case. In such difficult situations, the Board urges licensees to sign the death certificate as a last service to their patient.
Finally, I want to share the news that NCMB is actively pursuing changes to state law that will provide civil immunity to medical professionals who complete a death certificate in good faith and to the best of their ability. This is included in House Bill 228, if you care to track its progress. The Board itself has no interest in pursuing action against licensees who make reasonable judgments about causes of death.
I hope I’ve helped to ease some concerns on this subject. If you have questions or concerns I haven’t addressed here, look at my
earlier writings on completing death certificates or feel free to reach out to me at scott.kirby@ncmedboard.org.
