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Apr 28 2023

Lessons from NCMB’s Disciplinary Committee: Obligation to sign death certificates

   Categories:  Lessons from the NCMB Disciplinary Committee Comments:   7 comments  Print Friendly Version  |   Share this item
In this feature, NCMB presents examples of issues that frequently come before the Disciplinary Committee but don’t often result in public action. Our hope in highlighting these topics is to help licensees avoid problems and ensure they meet appropriate professional obligations.

Case Study: Licensee obligation to complete death certificates

A general internal medicine physician receives a faxed request from a local funeral home asking that the physician complete the death certificate for a patient who recently died alone at home. The decedent is a 76-year-old male with multiple chronic health conditions including hypertension and coronary artery disease. The patient established with the practice about 20 years ago but has not been seen in almost two years. The patient was found dead at home after a grown daughter who lives in another state contacted local law enforcement for a wellness check when her father did not respond to repeated voicemails, texts and email messages. The funeral home contacted the internal medicine physician after he was identified as the patient’s primary care provider with the daughter’s help.

The physician is uncomfortable determining a cause of death due to the length of time that passed since the decedent’s last office visit. The physician has no idea why the patient died and is unsure that they are the best person to certify the death. In addition, although the physician is registered to complete death certificates online as required by state law, he has not yet had to prepare one and is not sure how.

Due to these reservations, the physician does nothing with the request. A funeral director calls and leaves multiple messages asking about the status of the death certificate. When more than a week passes after the initial request with no action, the funeral director calls the practice and asks to speak with the physician, who takes the call. After the physician expresses reluctance to certify the death, the funeral professional states that the physician has already failed to comply with state law, which requires medical professionals who complete death certificates to do so within three days of receipt of a request. The funeral director further states that if the physician does not complete the death certificate soon, he will have no choice but to file a complaint with the medical board.

Discussion

It is NCMB’s position that licensees should complete death certificates if asked as a final service to a former patient, their family members and to society at large. This view is captured in the position statement entitled, “Clinician Obligation to Complete a Certificate of Death”.

NCMB is familiar with, and sympathetic to, the reasons some licensees feel uncomfortable determining cause of death. That said, a death certificate is required for every person who dies and, by law, only physicians, physician assistants and nurse practitioners may complete them. Nonetheless, NCMB has for years received informal and formal complaints from family members and funeral professionals who encounter medical professionals who decline to certify deaths.

While it is impossible to say exactly how often refusals occur, it is evident that they create considerable delays and difficulties. Without a completed death certificate, it is not possible for families or others to move forward with funeral arrangements, close bank accounts, claim insurance benefits or handle other financial matters related to the closing of the decedent’s estate. In the most extreme cases, the decedent may be held in cold storage for months while the family and funeral home struggles to get a death certificate completed.

The introduction of the NC Database for Vital Events (NC DAVE), the online system recently implemented by the NC Department of Health and Humans Services, introduced new challenges that seem to have magnified licensees’ issues with completing death certificates. In 2022, NCMB received 90 complaints related to death certificate issues – nearly five times as many as the previous year. See companion article – Managing challenges with NC DAVE.

Licensees who complete death certificates, or could be asked to, can reduce the likelihood of a complaint by educating themselves about the process and responding in a timely manner when a request comes in. Some key points that may make licensees more comfortable:

• There is a defined process for determining who should sign the death certificate. NCGS § 130A-115 (c) lays out who should complete and sign death certificates in specific circumstances. Deaths judged to be the result of injury or violence, or that are otherwise suspicious or unusual, fall within the jurisdiction of the medical examiner system. In all other situations, the death certificate can be completed and signed by:

1. The physician, PA or NP who was “in charge of the patient's care for the illness or condition which resulted in death”;

2. The chief medical officer of the hospital or facility in which the death occurred;

3. A physician who has completed an autopsy of the deceased, with access to medical history and the opportunity to view the deceased at or near the time of death;

4. Any other physician, physician assistant, or nurse practitioner who undertakes reasonable efforts to ascertain the events surrounding the patient's death. (This option comes into play when none of the other options are viable.)

If a request to sign a death certificate comes to a medical practice, it is likely because none of the circumstances listed applied. And, as stated in the example, the clock is ticking. State law sets the expectation for clinicians to complete the death certificate within 72 hours of receipt of the request.

• Certifying a death is a legal process not a medical diagnosis. When certifying a death, the clinician’s job is simply to state a reasonable probable cause of death based on the information available to them. In the example provided, the physician would refer to the patient’s medical records, even though the patient had not been seen recently. The state’s online death certification system, NC DAVE, was designed to improve accuracy and reduce “guess work” by guiding clinicians to a cause of death based on the information entered.

• There is no penalty for “getting it wrong”. In the rare circumstance that a family arranges to have their loved one privately autopsied after the death is certified, and the cause of death is determined to be something other than what the certifying clinician listed on the death certificate, the clinician cannot be disciplined by the medical board or be held civilly liable. NCGS § 130A-115(f) ensures that, provided the clinician completed the death certificate to the best of their ability, without fraud or malice, they are held harmless.

In closing, while the professional obligation to complete death certificates may be challenging, licensees can integrate the process into their practices with a little planning, preparation and patience.

Send questions and feedback to forum@ncmedboard.org.

Go to companion article, Managing challenges with NC DAVE




 Comments on this article:

Well, this article nicely summarizes the issues it addresses.  It helpfully bridges the gap between the legal necessities and the perspective brought by the practicing physician and should provide confidence where a certain amount of uncertainty may occur.  Very useful.

By thomasberner on Apr 30, 2023 at 9:36am

Thank you for this article- it was very helpful.  Both of my parents recently died, and I am so grateful to the physicians who completed the death certificates in a timely fashion.

By Theresa Flynn on Apr 30, 2023 at 10:04am

Thank you for your article on the legal obligation for MDs to complete Online Death certificates in NC. However your article does not mention that for me at least a major cause for slowness in submitting the NC DAVE death certificate is that the Database is clumsy and not user friendly and I always have to call the help desk a few times to get assistance to complete the death certificates and that this process slows down the decedant’s family from getting the Death Certificates in a timely faction
Thank you

By Jack Pulwers MD on Apr 30, 2023 at 10:50am

As an emergency physician, I frequently see patients brought to the Emergency Department by EMS in cardiac arrest. While some of these patients are successfully resuscitated, the majority are not and are pronounced dead.

In the absence of trauma or another clear cause of death, it is extremely difficult for an emergency physician to ascertain the cause of death in these patients - after all, I only “met” them after they died, can only perform an external exam, and often have minimal history that is focused on the acute event.

When it comes to completing the death certificate, the NCMB rules as reviewed above seem to clearly indicate that the patient’s primary care provider is in the best position to certify the cause of death.

It would be very helpful if the board would give some guidance to address this situation and clarify that even if the patient had an attempted resuscitation in the ED, that the PCP remains the optimal person to complete the death certificate.

By William P. Bozeman, MD, FACEP on Apr 30, 2023 at 1:00pm

My understanding is that deaths unattended by a physician full into the jurisdiction of the county medical examiner based on § 130A-383.  In the scenario described, if I was contacted by the funeral home, and I no longer cared for the patient, I would have referred the case to the medical examiner.  They are compensated for these cases which fall in their jurisdiction.  For me to complete the certificate would either be guesswork, or require me to perform uncompensated work to reach a level of professional judgement requisite to legally certify a cause of death, and ensure there was no inconsistent facts regarding the manner of death. The hierarchy of who completes the death certificate seems to skip over the unattended deaths in the jurisdiction of the county medical examiner who can complete that death certificate without a complete OCME autopsy.

By Matthew Vreeland on Apr 30, 2023 at 7:34pm

In the vignette, it would have been a much easier task for the physician to simply ask “did law enforcement see any sign of burglary, abuse or other suspicious circumstances?” One must assume that law-enforcement would have so stated but the vignette did not clarify those vital facts. I have had this exact same experience and that was my approach.  Without suspicious circumstances declared by law enforcement there should be no issues of refusing to sign the death certificate. In one situation I asked to speak to the medical examiner to see if the case would fall into his/her purview. When the answer was negative, I felt comfortable signing off on the death.  Common sense should prevail and in lieu of that a reprimand might be in order.

By Ray Sullivan MD on May 01, 2023 at 9:29am

Yet another case of good physicians feeling pressured and even receiving a reprimand or even penalties (?!) when they are asked to “just sign it.” 
Would any other professional, plumber, policeman, airplane mechanic or even this medical board certify something or someone they hadn’t seen in 2 years nor had any direct involvement with nor opportunity to evaluate?  These cases should have the funeral home state their findings and have a medical examiner perhaps validate those findings by signing their own name to the certificate.

By Anonymous on May 06, 2023 at 8:49am
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