Determining the Cause of Death

NCHS Recommendations for Entry of Cause of Death

A death certificate is a permanent record of the fact of death of an individual. It provides important personal information about the decedent and about the circumstances and cause of death. Information on cause of death is important to the family to bring closure, peace-of-mind, and to document the exact cause of death. Cause of death is also used for medical and epidemiological research on disease etiology and evaluating the effectiveness of national and international levels.

Physician’s responsibility

The physician’s primary responsibility in completing the cause-of-death section is to report to the best of his or her knowledge, based upon available information, the causal chain that led to the death. The causal chain should begin with the cause that was closest to the time of death and work backwards to the initiating condition which is called the underlying cause of death. For example, the physician might report a death for which staphylococcus pneumonia occurs closest to the time of death; however the physician also reports that the pneumonia is due to carcinoma metastatic to both lungs, which in turn, is due to poorly differentiated adenocarcinoma, unknown primary site.

Medical examiner/coroner’s responsibility

The medical examiner/coroner investigates deaths that are unexpected, unexplained, or if an injury or poisoning was involved. State laws provide guidelines for when a medical examiner/coroner must be notified. In the case of deaths known or suspected to have resulted from injury or poisoning, report the death to the medical examiner/coroner as required by State law. The medical examiner/coroner will either complete the cause-of-death section of the death certificate or waive that responsibility. If the medical examiner/coroner does not accept the case, then the certifier will need to complete the cause-of-death section.

General instructions for completing cause of death

• Cause-of-death information should be your best medical opinion.
• List only one condition per line in Part I. Additional lines may be added as needed.
• Each condition in Part I should cause the condition above it.
• Abbreviations and parentheses should be avoided in reporting causes of death.
• Provide the best estimate of the interval between the presumed onset of each condition and death.
• The original death certificate should be amended if additional medical information or autopsy findings become available that would change the cause of death originally reported.
• For deaths caused by injury or poisoning, complete only if the medical examiner or coroner instructs you to do so.
• The terminal event (e.g., cardiac arrest or respiratory arrest) should not be used. You should report the causes of the terminal event (e.g., cardiac arrest due to coronary artery atherosclerosis or cardiac arrest due to blunt impact to chest).
• If an organ system failure such as congestive heart failure, hepatic failure, renal failure, or respiratory failure is listed as a cause of death, always report its etiology on the line(s) beneath it (e.g., renal failure due to Type I diabetes mellitus). When indicating neoplasms as a cause of death, include the following: 1) primary site or that the primary site is unknown, 2) benign or malignant, 3) cell type or that the cell type is unknown, 4) grade of neoplasm, and 5) part or lobe of organ affected (e.g., primary well-differentiated squamous cell carcinoma, lung, left upper lobe).
• Always report the fatal injury (e.g., stab wound of chest), the trauma (e.g., transection of subclavian vein), and impairment of function (e.g., air embolism).
• In Part II, report all diseases or conditions contributing to death that were not reported in the chain of events in Part I and that did not result in the underlying cause of death.
• If two or more possible sequences resulted in death, or if two conditions seem to have added together, report in Part I the one that, in your opinion, most directly caused death. Report in Part II the other conditions or diseases.