Updated October 2022; The information in this article has been updated. For the most current policy regarding NCMB's stance on the licensee obligation to sign death certificates,
GO HERE.
NCMB continues to receive regular calls from funeral directors, families and others who report physician refusals to complete death certificates. When physicians (or other medical professionals authorized to certify deaths) refuse to perform this final essential service for a patient, the result is needless delays and complications with funeral arrangements, estate proceedings and other legal and personal matters that are of paramount importance to the decedent’s loved ones.
It is the Board’s view that, if requested to certify a death, physicians and/or physician assistants have an obligation to complete the death certificate for their patient to the best of their ability and in a timely manner. This article updates guidance from Associate Medical Director Scott G. Kirby, MD, which was originally published in the Fall 2013 issue of the
Forum.
Q: What types of patient deaths/cases are most likely to result in licensee refusals to complete a death certificate?
A: Most instances NCMB has heard about arise from unattended deaths from natural causes. Typically, these decedents had an established relationship with the physician or PA, but for a variety of reasons, the identified provider is reluctant to certify the death. The decedent may not have been seen for several months, or the individual may have been under treatment for stable conditions that posed no apparent immediate threat to his or her life (hypertension, diabetes, etc.). Often, when asked, the physician or PA indicates that he or she feels that they have no idea why the patient died.
Q: What types of medical professionals may lawfully complete death certificates?
A: In North Carolina, death certificates must be completed by a licensed physician or by a physician assistant or nurse practitioner who has been specifically authorized by his or her supervising physician to certify deaths. PAs and NPs have been legally able to certify deaths since fall of 2011.
Q: What steps must a supervising physician take to delegate completion of death certificates to a PA or NP?
A: Amendments to NCGS 90-18.1 require that PAs and NPs be explicitly authorized to complete death certificates by the supervising physician in the written supervisory arrangement or collaborative practice agreement. As with any other delegated tasks, the supervising physician is responsible for ensuring that death certificates are properly filled out and filed.
Q: Who determines which medical professional should complete the death certificate for an unattended death?
A: In situations where a person dies at home and is brought by ambulance to a hospital emergency department, it is common practice for hospital staff to check the person’s medical records to determine if he or she had an established relationship with a primary care doctor or other physician. If so, the hospital will generally ask the decedent’s physician to certify the death. It is the Board’s view that this is a reasonable practice, as physicians or other professionals who have examined and treated a patient in the past are arguably in the best position to make an educated guess about the probable cause of death, even if the patient had not been seen recently.
Q: How accurate must the clinician’s conclusion about cause of death be when certifying a death?
A: A death certificate is a legal and not a scientific document. As such, physicians are NOT required to establish a specific anatomical reason that caused the death. The requirement for death certification is a statement of the condition most likely responsible for death. The patient’s medical history should provide adequate information to state a reasonable cause of death that meets legal requirements. Clinicians are expected to exercise their best clinical judgment under the circumstances, just as they would in diagnosing treatment for a living patient. It is acceptable to use terms such as “probable” or “presumed” to identify a suspected final cause of death.
Q: Why can’t the decedent be referred to a state Medical Examiner if a clinician is uncertain of the cause of death?
A: The function of the North Carolina Medical Examiner system is to investigate deaths due to injury or violence, as well as natural deaths that are suspicious or unusual. Understand that, before a physician or other clinician is contacted about signing the death certificate, an assessment of the circumstances has almost always been made by EMS, law enforcement, or a medical examiner. If a death falls within the Medical Examiners’ jurisdiction, it will be referred accordingly.
Q: What are some consequences of refusing to sign a death certificate and forcing a case to be accepted by the state Medical Examiner system?
A: Deflecting a case to the Medical Examiner will result in delays and unnecessary hassle for the decedent’s family, and costs the county about $300 per case. It is NOT likely to result in an autopsy being done to determine the specific cause of an unattended natural death. In most cases, the Medical Examiner will not perform an autopsy but will simply certify the death based on review of available patient medical records, just as the decedent’s established provider could have done.
Q: Could a physician or PA be disciplined by the Medical Board for inaccurately identifying a patient’s cause of death?
A: There is no precedent for this. The Board is not interested in pursuing disciplinary action against licensees who complete death certificates in good faith to the best of their abilities. The chance of facing investigation by the Board, or other adverse legal consequences, related to the completion of a death certificate in good faith is remote and should not deter a physician from performing this duty.
Q: How quickly must death certificates be completed?
A: In North Carolina, state law (NCGS §130A 115) specifies that death certificates must be completed within three days of receipt of the request. However, the Board has received reports of families waiting for several weeks to have a loved one’s body released due to a physician’s unwillingness to certify the death.
Q: How can clinicians educate themselves about certifying deaths?
A: The U.S. Centers for Disease Control and Prevention booklet, The Physician’s Handbook of Medical Certification of Death, is an excellent resource that provides detailed guidance to clinicians. This can be accessed at
www.ncmedboard.org/DeathCertificates.
