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Who Should Sign Death Certificates?

PaperworkI happened to read an article in the Columbus (Ohio) Dispatch where Ohio coroners are complaining because some doctors, including emergency physicians, are refusing to sign death certificates listing a patient’s cause of death. The coroners are concerned because they are being “burdened” with hundreds of extra cases every year that they must handle. And if other doctors don’t sign off on the cause of death, sometimes it takes two months for them to examine records, wait for test results, and make a final ruling on a patient’s death.

The treating physicians reportedly use the excuses that they haven’t seen the patients in several months or they weren’t there when the person died. Some emergency physicians expressed concern about liability if the wrong cause of death was listed.

The coroners used the article to try to add a guilt trip on doctors who won’t sign a death certificate by stating that the reluctant doctors aren’t inconveniencing the coroner, they’re inconveniencing a family.


If, according to the article, it takes coroners sometimes TWO MONTHS to determine a cause of death, then how can coroners reasonably expect other physicians to determine the cause of death on the spot? How can an emergency physician determine the cause of a patient’s death just by performing CPR on a patient for 20-30 minutes?

As far as death certificates apply to emergency medicine, if a patient comes in and has a heart attack or has a bullet wound through their chest then the cause of death is rather clear and the death certificates shouldn’t be a problem for the coroners to complete. If the cause of death isn’t so clear, then why would the coroners want to rush the completion of the death certificate? Either way you argue the point, it doesn’t make sense. If the amount of time required to complete a death certificate is marginal, then it isn’t as much of a burden as the coroners are making it out to be. If the amount of time required to complete a death certificate is substantial, then is the time spent performing non-patient care tasks really the best use of an emergency physician’s limited time?

In addition, improperly completed death certificates are a problem. In a recent article in American Medical News, one Pennsylvania coroner was quoted as saying that many physicians “don’t realize that what they put down has some real, long-term ramifications.” The article also notes that “filling out certificates inaccurately can have widespread consequences,” although in the latter case, the speaker was referring to underreporting of some diseases to federal agencies. Another vignette in the article noted how a murderer almost went free because the cause of a patient’s death was misclassified by a treating physician. I am aware of another well-publicized case in which a personal friend of mine was involved in a medical malpractice action where a coroner determined that a patient’s cause of death was “murder” without knowing all the facts of the case. Later, the coroner was involved in litigation over that determination and ultimately resigned her position due to this and other similar errors.

Requiring that people other than coroners sign death certificates is just another example of medical mission creep and it needs to stop.

It is the coroner’s job to determine the cause of a person’s death. Stop pushing that job off on other people.


  1. Not meaning to be contrary, and I’m not invovled in medicine (actualy I’m a lawyer – I know, sacrilege), but if the cause of death is obvious, why shouldn’t the treating MD, emergency or otherwise, sign the death certificate? My father died a few years ago of lung cancer, and the treating oncologist signed it as state 4 small cell carcinoma. To use your example, if a person died in the ED from a heart attack or a gunshot would in the chest, why wouildn’t the ED physician sign the death certificate as opposed to sending it to the coroner? Seems like extra work is created. Other than “its the coroner’s job”, what harm would occur in spending a couple minutes writing a cause of death and signing? Or are things I don’t know about the process, etc.?

    • I think most ED docs will sign them for the obvious terminal cancer patients, particularly, when there is a documented history of the same in the medical record.

      Crime victims who die should be a coroner’s case. There will hopefully be a criminal prosecution where the evidence will be important.

      I think the type of case the White Coat is talking about is the one that we see all the time. Patient comes in by medics after being “found down” and CPR is in progress. We never get them back, and then pronounce them dead shortly after arrival in the ED. So maybe it’s a 40 year old female who was found in the bathtub or someone’s 22 year old son who never woke up in the morning. We have no information about their history other than they are dead. If your child died, would you want an ER doc who spent 10 minutes doing CPR on her deciding how she died without any additional investigation?

      I remember a case in PHL about 15 years ago where the ER doc signed the death certificate of a lady found in the bathtub because her husband said she had a severe headache before taking a bath. And nothing seemed amiss about the husbands behavior. This was a wealthy suburb where you tend to give people the benefit of the doubt. The ER doc put the the cause as SAH. As it turns out, the guy killed his wife and ultimately was convicted of it. I can’t remember all the details, but the guy had some stripper girlfriend on the side and used up all the life insurance money on the new woman. It was a Dateline special eventually. The ER doc was made to look like a fool for believing the husband.

      We typically have very little information, and in those situations, we should not be determining a cause of death. That’s what we are being bullied into doing.

      • Latex salesman Craig Rabinowitz and a stripper named Summer. I kid you not. Got life. A small child was place with a family member.

      • Yep, it’s all coming back to me now. The one weird detail that I remember was they went to a restaurant called “That Thai Place” which I always thought was an awesome name for a restaurant.

  2. How about The Thai Thable?

  3. Not that coroners pay much attention anyway. My mother had Parkinson’s Disease and ultimately died, as most Parkinson’s patients do, from pneumonia. The cause of death on her death certificate was dementia.

    My father had an abdominal aortic aneurysm for which he had had two stent procedures. When it began leaking, he refused surgery. His death certificate says cardiac disease.

    I will say, delaying the death certificate really DOES inconvenience the family. You need the death certificate before you can do anything at all with the estate, including paying hospital and funeral bills.

    My sister died in Florida recently, and it turns out Florida releases death certificates two ways: with a cause of death, and without. The cause of death is still not known; she was only 50 and she died alone in a hotel room while she was on vacation. She was found facedown. No sign of stroke, and her coronary arteries were clear. The only drugs in the room were OTC cold remedies and an antibiotic prescription for one of her dogs. Tox screen still hasn’t come back. But we have a death certificate. That’s a helpful system that probably more states should adopt.

    And medical researchers should stop doing studies based on the cause of death listed on death certificates. Whenever I see a study done that way, I immediately dismiss it as deeply flawed.

  4. The author of the article is correct in saying that if it takes the coroners several weeks to determine the cause of death, then the cause would not be obvious to any physician. The real problem is when the cause of death is clearly natural from a known disease such as a heart attack. The refusal by physicians familiar with the case to sign a DC, puts the burden on the coroner or medical examiner who must spend taxpayer money to transport the body, use taxpayer funds to process and then generate documents. If it is a heart attack, why should taxpayers foot the bill for a DC that is not in the taxpayers’ interest?

  5. People who write while upset tend to generalize specific perceived problems into broad absolutes. While there may be someone out there who is asking a physician with no knowledge of a patient other than performing CPR, or pronouncing fact of death, to fill out a death certificate, that should not be a regularity (and is not a regularity, in my experience) — if it is, it’s a problem with a person or their education in death investigation, just as a physician regularly refusing to sign a death certificate for an individual who dies under apparent natural circumstances with a significant medical history well documented by that physician is a problem.

    Most of the time an ER physician can be left out of the equation beyond sharing information with the ME/coroner especially in suspected non-natural deaths, and/or the decedent’s primary care physician especially in apparent natural deaths. Sometimes an ER physician has had an opportunity to develop a very sound diagnosis and follow the progression to death, in which case they are likely best suited to fill out the death certificate. An ME/coroner case might take only as long as investigating and obtaining and reviewing medical records, or it might take as long as performing an autopsy and awaiting tox, microbiology, histology, etc. A case which an ME/coroner declines should generally be the apparent natural death of an individual with a history of a potentially fatal natural disease which fits the circumstances — i.e., a case which only requires a knowledge of the circumstances, which the ME/coroner and law enforcement might help clarify, and medical history, which is already in the clinician’s hands…not an autopsy, tox, etc.

    It’s unfortunate that some physicians feel uncomfortable in dealing with the final medical duty to their patients, or are blindly certain as they do things “wrong”, but this is a problem with education and experience — which, perhaps not so incidentally, non-physician coroners have even less of and most physician but non-forensic-pathologist coroners have no more of than any other physician..but that’s more about how some coroner systems are set up, generally in contrast to most ME systems. However the vast, vast majority of death certificates are and have been filled out in reasonable fashion by clinicians familiar with the decedent.

    In my experience most physicians and ME/coroners simply want to be taken seriously and have a non-dismissive discussion about their issues and concerns, either in general or about a specific case. This sorts out the vast majority of problems I’ve encountered. The ones that aren’t readily cleared up are usually those in which one party really didn’t want to have any discussion at all, or simply wanted to rant.

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