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Death Certification
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Virtual
course on properly completing
Death Certificates
1
Introduction
Original title:
Virtual course on properly completing and filing Death Certificates
Summary: Course developed by the Latin American and Caribbean Network
for Strengthening Health Information Systems (RELACSIS), in partnership
with the Pan American Health Organization (PAHO) and MEASURE-
Evaluation with the Mexican Center for the Classification of Diseases and
Collaboration Centre for the WHO-FIC in Mexico (CEMECE), the Argentine
Center for Classification of Diseases (CACE) of Argentina, and the National
Health Information Unit of the Ministry of Public Health of Uruguay (UINS-
Epidemiologa-DIGESA-MSP). Conceptual content by Danuta Rajs, Advisor
of the Chilean Reference Centre for the WHO Family of International
Classifications and Humberto Rocha, active CEMECE member. Course
content digitization: Alicia Escard (Verum, Uruguay) in collaboration with
Manuel Yez (Directorate General of Health Information, Mexico).
The contributions made by colleagues from various institutions in the review
of conceptual documents and the design of the virtual course are very much
appreciated. Thanks as well to countries that provided national
documentation and to PAHOs Health Information and Analysis Unit.
RELACSIS Secretariat:
Alejandro Giusti (PAHO), Beatriz Plaza (MEASURE/Evaluation), Patricia
Ruz (PAHO)
Person responsible at CEMECE:
Aline P. Jimnez
Person responsible at CACE:
Elida Marconi
Person responsible at UINS:
Giselle Tomasso
PAHO in Mexico:
Tamara Mancero
2
ISBN 222-22-22-22222-2 (NLM Classification: WA110)
Copyright
www.relacsis.org
www.paho.org
www.measure.org
www.dgis.salud.gob.mx
www.deis.gov.ar
3
Index
Page
Preamble
5
Purpose
of
the
course
6
Learning
objectives
6
1)
Introduction
7
2)
Death
Certificate
usefulness
16
3)
Process
for
generating
mortality
statistics
18
4)
Definition
and
International
Form
of
Medical
19
Certificate
of
Cause
of
Death
5)
Guidelines
for
certification
29
6)
Bibliography
59
7)
Acknowledgements
60
4
Preamble
This
preamble
has
been
adapted
from
the
original,
written
in
Spanish.
This
course
is
the
result
of
a
joint
effort
to
improve
the
health
of
the
population
in
several
countries
in
Latin
America
and
the
Caribbean.
It
was
first
developed
in
Spanish
and
then
translated
into
English.
In
both
cases,
we
tried
to
respect
the
most
universal
usage
of
the
language
and
current
grammar
rules
while
at
the
same
time
recognizing
variations
at
the
national
and
subnational
levels
in
our
region.
This
version
of
the
course
particularly
targets
the
English-speaking
Caribbean
and
serves
as
a
resource
for
the
Dutch-speaking
Caribbean.
It
should
be
noted
that
the
content
is
not
tailored
to
each
country
but
outlines
the
general
concepts.
Across
the
Caribbean,
the
practices
and
legal
requirements
related
to
processing
death
certificates
vary
from
country
to
country.
For
example,
in
some
countries
the
distinction
is
made
between
what
is
completed
by
the
physician
a
medical
certificate
of
cause
of
death,
and
what
is
provided
to
the
family
of
the
deceased
a
death
certificate.
While
working
through
this
course
the
distinction
is
not
made
and
the
use
of
these
two
terms
overlap;
death
certificate
is
used
synonymously
with
medical
certificate
of
cause
of
death.
The
focus
of
the
course
is
on
the
correct
completion
of
the
medical
certificate
of
cause
of
death.
For
the
sake
of
reading
fluency
and
giving
preference
to
understanding
the
subject
matter,
we
are
neither
mentioning
nor
identifying
by
gender
those
who
have
died
or
are
involved
in
the
certification
of
death,
but
with
the
understanding
that
gender
is
an
integral
part
of
our
work.
Hence
it
is
important
for
our
readers
to
understand
that
when
we
mention
the
doctor,
the
deceased,
the
family
member
or
mourner,
or
the
respondent
that
we
refer
to
both
females
and
males.
Similarly
we
are
generally
encouraged
by
the
spirit
of
the
Universal
Declaration
of
Human
Rights,
so
that
the
fact
that
we
do
not
individualize
here
all
segments
of
the
human
population
does
not
imply
that
we
do
not
recognize
their
existence
or
that
we
do
not
constantly
keep
their
rights
in
perspective.
5
Purpose
of
the
course:
1) To
provide
countries
in
the
region
with
a
virtual
course
to
raise
physicians
awareness
on
the
appropriate
manner
to
record
the
cause
of
death.
2) To
contribute
to
the
improvement
of
the
certification
of
deaths
and
hence
to
obtain
more
precise
statistics
on
mortality
and
causes
of
death,
thus
supporting
the
evaluation
of
public
policies
and
assertive
decision
making
for
the
health
benefit
of
the
population.
Learning
objectives:
After
completing
the
course,
the
student
will
be
able
to:
-
Adequately
complete
a
Death
Certificate
according
to
standards
established
by
the
World
Health
Organization,
taking
into
account
national
regulations
in
the
field
(legislation
timelines,
responsibilities,
Death
Certificate
formatting).
6
1.
Introduction
Certifying
the
death
of
an
individual
may
well
be
one
of
the
most
difficult
moments
for
any
doctor.
When
a
person
dies
within
the
exercise
of
our
practice,
we
as
doctors
are
most
aware
that
our
medical
vocation
entails
a
constant
struggle
against
death.
In
almost
all
countries
one
of
the
physicians
obligations
and
clinical
duties
is
to
complete
a
death
certificate
regardless
of
whether
the
patient
that
died
was
under
his
care
at
the
time
of
passing.
A
non-treating
physician
can
issue
a
death
certificate
provided
that
he
has
interviewed
the
family
members
of
the
deceased
and
performed
a
physical
examination
and
can
be
sure
that
the
person
died
as
a
result
of
a
disease
and
not
as
a
result
of
an
accident
or
injury.
This
process
is
regulated
by
each
countrys
laws,
rules
and
codes.
A
non-treating
physician
can
also
issue
a
Certificate
if
the
deceased
was
treated
at
the
health
facility
where
the
physician
works,
provided
that
such
center
has
sufficient
clinical
information
on
the
case
sometimes
medical
facilities
send
patients
home
when
there
is
no
effective
therapeutic
alternative
for
improvement.
Sometimes
physicians
refuse
to
issue
a
death
certificate
due
to
the
legal
implications
this
may
have.
However,
if
an
external
cause
can
be
reasonably
discarded
and
domestic
laws
permit
it,
a
non-treating
physician
should
not
be
afraid
to
fill
out
a
death
certificate
with
the
information
and
data
that
can
be
obtained.
In
some
countries,
doctors
employed
by
funeral
homes
end
up
issuing
death
certificates
due
to
the
refusal
to
fill
out
these
forms
by
relevant
physicians.
However,
it
has
been
observed
that
in
these
cases
the
quality
of
the
certificate
is
rather
poor
and
the
recorded
causes
do
not
always
reflect
the
real
causes
of
death.
This
also
puts
in
evidence
that
doctors
may
be
unaware
of
the
procedures
for
properly
filling
out
the
causes
of
death
on
the
certificates
or
of
their
epidemiological
and
statistical
value.
For
physicians,
issuing
a
death
certificate
goes
beyond
an
obligation,
doctors
have
been
authorized
by
the
laws
and
regulations
governing
countries
to
certify
death
because
they
have
the
knowledge
and
means
to
attest
to
it.
Of
course,
when
physicians
tend
to
patients
during
their
last
illness
they
are
also
knowledgeable
of
the
facts
and
thus
have
a
moral
obligation
to
issue
said
certificate.
It
is
important
for
physicians
to
check
the
laws
related
to
the
issuing
of
Death
Certificates
in
their
countries.
Whether
or
not
the
physician
knows
the
medical
history
of
the
deceased
person,
what
is
recorded
on
the
Certificate
is
essential
and
should
be
as
close
to
the
facts
as
possible.
The
information
in
these
certificates
informs
mortality
statistics
which
serve
as
the
basis
to
determine
the
kind
of
health
programs
that
are
to
be
developed
and
evaluated
in
a
country.
7
A
death
certificate
is
a
medical,
legal
and
administrative
tool
that
allows
not
only
for
an
interment,
cremation
or
providing
another
final
destination
for
a
persons
remains,
but
also
creates
a
profile
of
the
causes
of
death
in
a
community.
As
will
be
seen
later
in
this
document,
from
the
legal
point
of
view
a
death
certificate
is
issued
to
verify
that
a
person
is
deceased,
yet
its
importance
as
a
legal
document
and
its
statistical
and
epidemiological
applications
are
very
relevant.
In
fact,
national
mortality
statistics
are
obtained
from
official
death
certificates,
including
data
on
the
causes
of
death
which
provide
the
basis
for
decisions
and
activities
of
the
health,
demography,
labor
and
social
security,
housing,
treasury,
defense,
justice,
private
insurance
and
other
sectors.
Hence
the
importance
of
a
physicians
contribution
to
properly
registering
the
causes
of
death
in
a
certificate.
A
correctly
completed
death
certificate
will
guarantee,
better
than
any
other
element,
the
quality
of
mortality
statistics,
and
avoid
adopting
wrong
or
inadequate
decisions
in
all
areas
of
the
States
domain
and
the
economy
in
general,
but
primarily
in
health-related
matters. No
other
sector
uses
mortality
data
and
causes
of
death
to
the
extent
or
as
often
as
the
health
sector
does.
The
certification
of
death
is
not
just
one
more
burden
for
the
doctor.
It
is
an
opportunity
to
provide
testimony
on
the
death
of
a
person,
as
to
the
causes
that
provoked
it
and
the
socio-demographic
factors
associated
with
it,
which
serves
to
evaluate
the
state
of
health
overall
and
thus
prevent
early
deaths.
Therefore,
the
information
obtained
through
the
Certificate
should
be
factual.
The
same
care
taken
to
record
the
causes
of
death
must
be
given
to
other
socio-demographic
variables
since
any
errors
in
these
areas
can
cause
legal
problems
for
the
bereaved,
and
in
the
case
of
the
causes
of
death,
may
provide
the
wrong
information
regarding
the
state
of
health
and
disease
behavior
of
the
population
having
an
adverse
effect
on
implementing
health
policies
and
programs.
Mortality
statistics
are
the
most
used
data
to
assess
a
States
state
of
health
and
to
set
health
policies
thanks
to
their
broader
coverage
and
reliability;
however,
should
this
data
be
affected
by
any
errors
in
the
registry
of
causes
of
death,
the
information
will
not
be
useful.
One
must
also
consider
that
physicians
receive
inadequate
training
on
how
to
properly
fill
out
a
death
certificate
during
their
professional
training.
Physicians
routinely
fill
out
the
forms
incorrectly
just
as
they
were
taught
by
other
doctors
who
didnt
know
themselves
how
to
properly
do
so;
they
fill
out
the
forms
without
supervision
or
periodic
review
by
a
knowledgeable
professional,
perpetuating
the
erroneous
certification
of
deaths.
It
is
not
common
practice
to
analyze
and
critique
completed
death
certificates
during
clinical
sessions
in
hospitals
and
therefore
they
cannot
effectively
gain
experience.
8
These
are
some
of
the
factors
that
affect
the
quality
of
the
information
recorded
by
the
physician:1
Physicians
lack
of
knowledge
on
how
to
properly
record
the
cause
of
death
in
the
certificate
and
on
the
concepts
of
direct,
intervening,
underlying
and
contributing
causes
of
death.
Failure
to
inform
physicians
on
the
uses
given
to
the
information
obtained
from
the
death
certificates.
Lack
of
understanding
on
the
importance
of
describing
as
closely
as
possible
each
of
the
causes
of
the
death,
and
how
this
information
is
used
in
developing
mortality
statistics.
Partial
availability
of
information
on
the
diseases
and
complications
that
caused
the
death,
be
it
because
it
is
not
part
of
the
health
record
or
because
the
informant
did
not
know
about
it.
Difficulty
understanding
how
to
determine
the
direct,
immediate,
intervening
and
underlying
causes
of
death
(See
Section
4,
Definitions
and
International
Form
of
Medical
Certificate
of
Cause
of
Death),
especially
in
elderly
patients
on
whom
several
chronic
diseases
interact,
triggering
death.
Last-attending
physicians
lack
of
knowledge
-
or
by
the
physician
asked
to
provide
a
death
certificate
(because
the
deceased
persons
disease
does
not
correspond
to
her/his
specialty
or
domain).
It
is
also
worth
considering
that
the
medical
field
does
not
yet
know
all
details
on
emerging
diseases.
Errors
in
the
diagnostic
or
incomplete
incorporation
of
the
diagnosis
in
the
certificate
due
to
time
constraints,
failures
or
delays
in
diagnostic
and
therapeutic
procedures,
as
well
as
lack
of
necropsy.
Physician's
preference
for
certain
diagnoses.
Sometimes
when
uncertain
of
the
deceased
persons
cause
of
death,
certain
diagnoses
which
do
not
correspond
to
the
fact
are
used
instead
(that
is
invented
diagnoses
or
terminal
complications
common
to
many
other
deaths).
There
are
certain
deliberate
omissions
in
some
countries
wen
the
causes
are
considered
socially
or
culturally
inconvenient
(suicide,
AIDS,
etc.),
even
deliberately
concealing
a
crime.
Due
to
the
aforementioned
a
significant
problem
commonly
seen
in
almost
all
countries
of
the
Americas
is
the
high
proportion
of
death
certificates
that
are
incomplete
or
contain
errors,
which
result
in
poor
data
quality
and
unusable
information
for
decision-making,
at
local
(e.g.
in
the
hospital
unit
where
the
death
certificate
was
generated),
regional
and
even
at
central
or
policy
levels,
where
national
statistics
are
produced.
This
percentage
varies
from
one
country
to
another.
Consult
Table
1
to
identify
the
value
of
quality
indicators
of
the
medical
certification
of
the
cause
of
death
in
the
countries
of
the
Americas.
9
For
these
reasons,
this
awareness
course
is
specifically
aimed
at
and
being
presented
to
practicing
physicians
in
the
Americas.
The
courses
objective
is
to
highlight
the
importance
of
death
certificates,
stressing
that
the
data
recorded
on
these
forms
must
be
complete
and
correct.
The
proper
way
to
fill
out
the
forms
is
explained
through
examples.
In
this
manner,
doubts
that
often
arise
when
filling
out
a
death
certificate
can
be
cleared
up.
Table
1.
Proportion
of
ill-defined
causes
of
death*
and
imprecise
causes
of
death**
in
the
countries
of
the
Americas,
around
2010
Proportion of causes (%):
Country
Ill-defined* Imprecise**
Anguilla 1,6 14,8
Antigua and Barbuda 1,1 21,5
Argentina 8,4 32,0
Aruba 4,6 23,3
Bahamas 1,9 15,5
Barbados 2,2 20,1
Belize 1,1 13,8
Bermuda 2,4 18,9
Bolivia (Plurinational State of)
Brazil 6,7 14,0
Canada 0,9 11,8
Chile 2,5 12,1
Colombia 2,1 12,2
Costa Rica 1,2 12,6
Cuba 0,8 10,0
Curacao
Dominica 1,9 17,4
Ecuador 9,4 17,1
El Salvador 16,3 24,4
United States of America 1,6 13,6
Granada 1,7 14,1
Guadalupe 9,4 21,2
Guatemala 7,3 17,5
French Guyana 9,4 19,1
Guyana 0,8 19,0
Haiti
Honduras
Cayman Islands 4,0 15,2
Turks and Caicos 8,2 14,5
Virgin Islands (USA) 3,6 13,8
Virgin Islands (UK) 10,0 28,4
Jamaica
Martinique 11,3 19,0
Mexico 1,8 13,6
Montserrat 0,0 16,4
10
Table
1.
Proportion
of
ill-defined
causes
of
death*
and
imprecise
causes
of
death**
in
the
countries
of
the
Americas,
around
2010
Proportion of causes (%):
Country
Ill-defined* Imprecise**
Nicaragua 1,7 14,5
Panama 3,1 18,2
Paraguay 10,4 14,8
Peru 28,3
Puerto Rico 1,0 17,3
Dominican Republic 4,3 14,4
Saint Kitts and Nevis 1,1 17,1
Saint Vincent and the Grenadines 4,3 15,5
Saint Lucia 4,6 14,9
Saint Maarten (Dutch)
Suriname 8,3 12,1
Trinidad and Tobago 1,9 12,0
Uruguay 8,4 20,5
Venezuela (Bolivarian Republic of) 0,6 14,3
Source: Regional Mortality PAHO/WHO Database
* Ill-defined causes of death: Includes Chapter XVIII of ICD-10 (Symptoms, signs and abnormal clinical and
laboratory findings, not elsewhere classified)
There are no sources in the current document.
** The selection of imprecise causes of death was based on the list published in: Naghavi, M. et al.
"Algorithms for Enhancing public health utility of national causes-of-death data". Population Health Metrics
2010, 8:9. Excludes ill-defined causes, Chapter XVIII, ICD-10
Data not available
List of imprecise and ill-defined causes
ICD Code Description
A31.1 Mycobacterium skin infection
A40-A41 Streptococcal septicemia and other septicemias
A48.0 Gas gangrene
A48.3 Toxic shock syndrome
A49.9 Unspecified bacterial infection
A59 Trichomoniasis
A60.0 Infection of the genitalia and the urogenital path due to the herpes virus [herpes simplex]
A63.0 Warts (venereal) anogenital
A71-A74 Trachoma and other diseases caused by chlamydia, except infection due to Chlamydia psittaci (A70)
B00.0 Eczema herpeticum
B07 Viral warts
B08.1 Molluscum contagiosum
B08.8 Other specified viral infections, characterized by lesions of the skin and mucous membranes
B30 Viral conjunctivitis
B35-B36 Dermatophytosis and other superficial mycoses
11
List
of
imprecise
and
ill-defined
causes
ICD
Code
Description
B83.9
Unspecified
helminthiasis
B94.8
Sequelae
of
other
specified
infectious
and
parasitic
diseases
B94.9
Sequelae
of
infectious
and
unspecified
parasitic
diseases
B99
Other
infectious
and
unspecified
diseases
C26
Malignant
neoplasm
of
other
and
ill-defined
sites
within
the
digestive
organs
C39
Malignant
neoplasms
of
other
and
ill-defined
sites
in
respiratory
system
and
intrathoracic
organs
C57.9
Malignant
neoplasms
of
other
and
unspecified
female
and
genital
organs
C76
Malignant
neoplasm
of
other
and
ill-defined
sites
C80
Malignant
neoplasm
without
specification
of
site
D00-D13
Tumors
(neoplasms)
in
situ
and
benign
tumors
of
the
mouth
and
pharynx,
salivary
glands,
colon,
rectum,
anus
and
anal
canal
and
elsewhere
and
ill-defined
digestive
system
D16-D18
Benign
neoplasm
of
the
bone
and
articular
cartilage,
benign
lipomatous
tumors
and
hemangioma
and
lymphangioma
of
any
site
D20-D24
Benign
neoplasm
of
soft
tissue
of
retroperitoneum
and
peritoneum,
connective
tissue
and
other
soft
tissue,
melanocytic
nevus,
other
benign
skin
tumors,
benign
tumor
of
the
breast
D28-D48
Benign
neoplasm
of
other
female
genital
organs
(uterus
and
ovaries
except,
D25-D26)
and
unspecified
male
genital
organs,
urinary
organs,
the
eye
and
adnexa,
meninges,
brain
and
other
parts
of
the
central
nervous
system,
of
the
thyroid
gland
and
other
endocrine
and
unspecified
glands,
of
other
sites
and
those
unspecified
and
tumors
of
uncertain
or
unknown
behavior
D65
Disseminated
intravascular
coagulation
[defibrination
syndrome]
E85.3-E85.9
Secondary
systemic
amyloidosis,
or
limited
to
an
organ
or
other
or
unspecified
E86-E87
Other
disorders
of
fluid,
electrolyte
and
acid-base
balance
E88.9
Other
metabolic
disorders
F32-F33
Major
depressive
disorder,
single
episode,
F40-F42
Phobic
anxiety
disorders,
other
anxiety
disorders
and
obsessive-compulsive
disorder
F45-F48
Somatoform
disorders
and
other
neurotic
disorders
F51-F53
Nonorganic
sleep
disorders,
sexual
dysfunction
not
caused
by
organic
disorder
or
disease
and
mental
and
behavioral
disorders
associated
with
the
puerperium,
not
elsewhere
classified
F60-F98
Disorders
of
personality
and
behavior
in
adults,
mental
retardation,
disorders
of
psychological
development
and
emotional
and
behavioral
disorders
usually
occurring
in
childhood
and
adolescence
G43-G45
Migraine
and
other
headache
syndromes
of
transient
ischemic
attacks
and
related
syndromes
G47-G52
Sleep
disorders
and
disorders
of
the
cranial
trigeminal
nerve,
facial
and
other
G54
Disorders
of
the
roots
and
nerve
plexuses
G56-G58
Mononeuropathies
from
upper,
lower
limbs
and
other
G80-G83
Cerebral
palsy
and
other
paralytic
syndromes
G91.1
Obstructive
hydrocephalus
G91.3-G91.8
Posttraumatic
hydrocephalus,
other
types
of
hydrocephalus
and
unspecified
G92
Toxic
encephalopathy
G93.1-G93.6
Anoxic
brain
damage,
not
elsewhere
classified,
benign
intracranial
hypertension,
post
viral
fatigue
syndrome,
unspecified
encephalopathy,
compression
of
the
brain
and
cerebral
edema.
H00-H04
Disorders
of
the
eyelid
and
lacrimal
apparatus
12
List
of
imprecise
and
ill-defined
causes
ICD
Code
Description
H05.2-H69
Non-inflammatory
disorders
of
the
orbit,
conjunctival
disorders,
disorders
of
the
sclera,
cornea,
iris
and
ciliary
body,
lens
disorders,
disorders
of
the
choroid
and
retina,
glaucoma,
and
vitreous
disorders
of
the
eye,
disorders
of
the
optic
nerve
and
visual
pathway
disorders
of
ocular
muscles,
binocular
movement,
the
accommodation
and
refraction,
impaired
vision
and
blindness,
other
disorders
of
the
eye
and
adnexa
(all
eye
disorders
and
their
Annexes
to
except
orbital
inflammatory
disorders);
Diseases
of
the
external
ear
and
middle
ear
disease
H71-H80
Cholesteatoma
of
the
middle
ear,
perforation
and
other
disorders
of
the
tympanic
membrane
(myringitis),
other
disorders
of
the
middle
ear
mastoid
apophysis
and
otosclerosis
H83-H93
Other
disorders
of
the
inner
ear,
conductive
and
sensorineural
hearing
loss,
other
hearing
loss,
earache
and
discharge
from
the
ear
and
other
ear
disorders
not
elsewhere
classified
I10
Essential
(primary)
hypertension
I15
Secondary
hypertension
I26
Pulmonary
embolism
I27.1
Kyphoscoliotic
heart
disease
I44
Atrioventricular
and
left
bundle-branch
block
I45-I46
Other
conduction
disorders
and
cardiac
arrest
I49-I50
Other
cardiac
arrhythmias
and
heart
failure
I51
Complications
and
ill-defined
descriptions
of
heart
disease
I70
Arteriosclerosis
I74
Embolism
and
arterial
thrombosis
I81
Portal
vein
thrombosis
I99
Other
and
unspecified
disorders
of
the
circulatory
system
J30
Allergic
and
vasomotor
rhinitis
J33
Nasal
polyps
J34.2
Deviation
of
the
nasal
septum
J35
Chronic
diseases
of
tonsils
and
adenoids
J69
Pneumonitis
due
to
solids
and
liquids
J80-J81
Adult
respiratory
distress
and
pulmonary
edema
syndrome
J86
Pyothorax
J90
Pleural
effusion,
not
elsewhere
classified
J93
Pneumothorax
J94
Other
conditions
of
the
pleura
J96
Respiratory
failure,
not
elsewhere
classified
J98.1-J98.3
Lung
collapse,
interstitial
and
compensatory
emphysema
K00-K11
Disorders
and
dental
and
gingival
diseases,
cysts
of
oral
region,
not
elsewhere
classified,
other
diseases
of
the
jaws
and
salivary
gland
diseases
K14
Diseases
of
the
tongue
K65-K66
Peritonitis
and
other
disorders
of
peritoneum
K71-K72
Toxic
liver
disease,
cirrhosis
and
other
liver
fibrosis
and
liver
failure
not
elsewhere
classified
(not
K71.7)
K75
Other
inflammatory
diseases
of
the
liver
K76.0-K76.4
Fatty
degeneration
of
the
liver,
not
elsewhere
classified,
chronic
passive
congestion
of
the
liver,
central
hemorrhagic
necrosis
of
the
liver,
liver
infarction,
and
peliosis
K92.0-K92.2
Hematemesis,
melena
and
unspecified
gastrointestinal
hemorrhage
13
List
of
imprecise
and
ill-defined
causes
ICD
Code
Description
L04-L08
Acute
lymphadenitis,
pilonidal
cyst
and
other
local
infections
of
skin
and
subcutaneous
tissue
L20-L25
Atopic,
seborrheic,
of
the
diaper,
allergic
and
irritant
to
contact
and
other
non-specified
contact
dermatitis.
L28-L87
Lichen
simplex
chronicus
and
prurigo,
pruritus
and
other
dermatitis,
papulosquamous
disorders,
urticaria
and
erythema,
skin
disorders
and
subcutaneous
tissue
related
to
radiation,
appendages
disorders,
vitiligo,
other
pigmentation
disorders,
seborrheic
keratoses,
acanthosis
nigricans,
corns
and
calluses,
other
types
of
epidermal
thickness
and
transepidermal
elimination
disorders
L90-L92
Atrophic
skin
disorders,
skin
disorders
hypertrophic
and
granulomatous
disorder
of
the
skin
and
subcutaneous
tissue
L94
Other
localized
connective
tissue
disorders
L98.0-L98.3
Pyogenic
granuloma,
factitious
dermatitis,
febrile
neutrophilic
dermatosis
and
eosinophilic
cellulitis
L98.5-L98.9
Mucinosis
of
the
skin,
other
infiltrative
disorders
of
the
skin
and
subcutaneous
tissue,
other
specified
disorders
of
the
skin
and
subcutaneous
tissue
and
unspecified
disorder
of
the
skin
and
subcutaneous
tissue
M03
Post-infectious
and
reactive
arthropathies
in
diseases
classified
elsewhere
M07
Psoriatic
arthropathy
and
enteropathic
M09-M12
Juvenile
arthritis
in
diseases
classified
elsewhere,
gout,
other
crystal
arthropathies
and
other
specific
arthropathies
M14-M25
Arthropathy
in
other
diseases
classified
elsewhere,
osteoarthritis,
other
than
the
spine
and
other
joint
disorders,
except
the
joints
of
the
spine
M35.3
Polymyalgia
rheumatica
M40
Kyphosis
and
lordosis
M43.6- Torticollis,
other
specified
deforming
dorsopathies
of
the
spine
and
unspecified
deforming
dorsopathy
M43.9
M45
Ankylosing
spondylitis
M47-M60
Spondylosis,
other
spondylopathies,
myositis
and
other
dorsopathies
M63-M71
Disorders
of
muscle
in
diseases
classified
elsewhere,
tendon
disorders
and
synovium,
soft
tissue
disorders
related
to
the
use,
overuse
and
pressure
and
other bursopathies
M73-M79
Soft
tissue
disorders
in
diseases
classified
elsewhere,
injury
(nontraumatic)
of
the
shoulder,
enthesopathy
of
the
lower
limbs,
excluding
foot,
other
enthesopathies,
other
soft
tissue
disorders
not
elsewhere
classified
M86
Osteomyelitis
M95-M99
Other
disorders
of
the
musculoskeletal
system
and
connective
tissue
N14
Tubular
and
tubulointerstitial
disorders
induced
by
drugs
and
heavy
metals
N17-N19
Liver
failure
N39.3
Stress-induced
urinary
incontinence
N40
Prostatic
hyperplasia
N46
Male
infertility
N60
Benign
mammary
dysplasia
N84-N93
Female
genital
tract
Polyp,
other
non-inflammatory
disorders
of
the
uterus,
except
of
the
neck,
erosion
and
cervical
ectropion,
cervical
dysplasia,
other
non-inflammatory
disorders
of
the
cervix,
other
non-
inflammatory
disorders
of
the
vagina,
other
non-inflammatory
disorders
of
the
vulva
and
perineum,
absent,
scarce
or
rare
menstruation,
excessive,
frequent
and
irregular
menstruation
and
other
abnormal
uterine
and
vaginal
bleeding
N97
Female
infertility
Q10-Q18
Congenital
malformations
of
eye,
ear,
face
and
neck
14
List
of
imprecise
and
ill-defined
causes
ICD
Code
Description
Q36
Cleft
lip
Q38.1
Ankyloglossia
Q54
Hypospadias
Q65-Q74
Congenital
deformities
of
the
hip
and
toes,
congenital
musculoskeletal
deformities
of
the
head,
face,
of
the
spine
and
chest,
other
congenital
musculoskeletal
deformities,
polydactyly,
syndactyly,
reduction
anomaly
of
the
upper
limbs,
reduction
anomaly
of
the
lower
limbs,
reduction
anomalies
of
unspecified
limb
and
other
congenital
anomalies
of
the
limbs.
Q82-Q84
Other
congenital
malformations
of
the
skin
congenital
malformations
of
the
breasts
and
other
congenital
malformations
of
integument.
R00-R99
Symptoms,
signs
and
abnormal
clinical
and
laboratory
findings,
non-classified
elsewhere
X59
Exposure
to
unspecified
factors
Y10-Y34
Events
of
undetermined
intent
Y86-Y87.2
Sequelae
of
other
accidents,
intentionally
self-inflicted
injuries,
assault
and
events
of
undetermined
intent
Y89
Sequelae
of
other
external
causes.
The
on
line
version
of
the
International
Classification
of
Diseases
and
Related
Health
Problem
10th
Revision
(ICD
10)
-
2010
is
available
on
http://apps.who.int/classifications/icd10/browse/2010/en
15
2.
Death
Certificate
usefulness
What is the purpose of a death certificate?
A death certificate is a medical and legal document which also serves as a statistical record
belonging to a larger system of continuous or routine records. Its data is essential for the
following:
Legal
purposes
The
Certificate
is
mandatory
in
all
countries
in
order
to
list
the
death
in
the
Civil
Registry
therefore
authorizing
the
burial,
cremation
or
other
method
of
final
destination
of
the
remains.
Once
the
Act
of
Death
(Death
Certificate)
has
been
issued,
it
allows
continuing
with
legal
proceedings,
including,
among
others:
the
succession
of
property,
inheritance,
insurance
and
pension
claims,
civil
and
criminal
trials,
changes
on
marital
status
and
electoral
rolls.
The
death
certificate
is
a
document
or
written
record
concerning
a
death,
which
has
been
checked
firsthand
by
a
physician.
It
is
of
the
utmost
importance
that
all
data
entered
in
the
Certificate
is
factual
and
contains
no
errors
or
omissions.
No
person
or
public
official
shall
require
a
certifying
doctor
to
change
the
causes
of
death
noted
in
the
certificatei.
The
certificate
should
be
filled
out
to
register
the
death
of
any
person
born
alive,
independently
of
age
reached,
even
if
it
was
only
a
few
minutes
or
seconds,
or
born
with
a
weight
considered
less
than
viable
by
a
medical
facility.
It
is
very
important
for
the
physician
to
guide
the
family
of
the
deceased
to
go
to
the
Civil
Registrys
Administrative
Office
to
file
an
Act
of
Death
and
obtain
a
Death
Certificate.
However,
some
practices
can
vary
from
country
to
country.
Epidemiological
purposes
The
data
contained
in
the
death
certificate
is
used
to:
Notify
proper
authorities
immediately
of
diseases
subject
to
epidemiological
surveillance.
Respond
promptly
(establishing
epidemiological
fences,
rapid
tests,
intensive
vaccination
campaigns,
etc.)
to
the
onset
of
causes
of
death
that
fall
within
those
of
i
However,
statistical
health
agencies
should
be
able
to
ask
physicians
for
clarification
(objections)
regarding
the
causes
of
death
written
in
the
certificates
issued
so
as
to
clarify
what
was
meant
by
it
and
establish
more
accurately
the
underlying
cause
of
death.
This
should
not
involve
altering
the
certificate
itself,
but
only
the
modification
of
the
International
Classification
of
Diseases
in
the
deaths
database.
The
socio-demographic
variables
may
also
be
subject
to
clarification.
When
a
major
mistake
has
been
made
on
the
death
certificate,
for
example,
that
the
name
does
not
correspond
to
the
deceased,
or
the
causes
of
death
have
been
entered
incorrectly,
the
certificate
must
be
canceled
and
returned
in
full
(original
and
copies)
to
the
department
responsible
for
controlling
the
certificates
and
a
new
one
should
be
requested.
16
epidemiological
surveillance.
For
example,
if
a
high
incidence
of
deaths
from
Influenza
A/H1N1
is
registered
in
a
country,
the
action
of
Public
Health
that
should
arise
from
this
data
is
the
application
of
the
corresponding
vaccine
in
the
population
at
the
highest
risk.
Recognize
the
possible
damages
to
the
health
of
the
population.
Monitor
the
disease
patterns
(trend
and
distribution
in
time
and
space).
To
align
prevention
programs
and
support
the
assessment
and
planning
of
health
services.
This
facilitates
establishing
measures
to
prevent
premature
mortality
in
the
population
or
to
limit
the
occurrence
of
complications
of
those
diseases
responsible
for
the
largest
number
of
deaths
in
each
country.
Statistical
purposes
The
death
certificate
is
the
primary
source
for
the
production
of
mortality
statistics.
A
certificate
is
a
statistical
process
whereby
the
variables
included
in
it,
both
socio-
demographic
such
as
age,
sex,
place
of
residence
of
the
deceased
and
the
place
of
occurrence
of
the
death;
and
those
of
a
clinical
nature
such
as
the
cause
of
death,
are
validated,
encoded
and
integrated
into
information
systems
aimed
at
obtaining
relevant
statistics.
Each
of
the
variables
included
in
the
certificate
is
relevant
for
the
analysis
of
mortality
and
its
determinants.
Statistically
speaking
mortality
is
an
important
component
of
the
population
growth
behavior
as
much
as
its
inputs,
births,
deaths
and
migration.
If
mortality
is
being
affected
by
coverage
and
data
quality,
this
will
impact
in
the
measurement
of
growth
and
other
demographic
variables
in
the
country
such
as
life
expectancy
for
example.
To
facilitate
processing
and
analysis,
the
causes
of
death
that
the
physician
enters
in
the
death
certificate
are
turned
into
codes
of
the
International
Statistical
Classification
of
Diseases
and
Related
Health
Problems,
Tenth
Revision
(ICD-10)2,
through
a
manual
or
automated
process
performed
by
expert
coders
applying
the
most
stringent
selection
and
modification
rules
imposed
by
the
classification
system.
To
better
understand
the
process
of
how
mortality
statistical
information
is
generated,
please
refer
to
Figure
1
below.
17
3.
Process
for
generating
mortality
statistics
Figure
1.
Generating
mortality
statistics
Each death is certified in a standardized
format (Death Certificate) in which the most
important socio-demographic and clinical
Data variables are collected. It is therefore
collection essential for the physician to properly
record the requested data. Of note, in
some countries the physician responsibility
Responsible party: is more focused on the medical part.
Certifying doctor ponsible for all the items.
After the data has been validated, a copy of
the death certificate is processed by the
statistical department for coding of the
Coding and variables. The causes of death are turned
into ICD-10 codes and all variables are
data
added to the electronic information system
integration ii
thus yielding a mortality database , from
which reports and indicators are obtained.
Responsible party:
Encoder
and statistician
Death statistics and indicators make
possible the analyses of the behavior of
Analysis and mortality and its causes, both nationally and
use of the locally. This information is important for
information establishing health policies and tracking
prevention, curative and rehabilitative care
programs.
Responsible party:
National and local
health authorities
ii
In
a
few
countries
in
Latin
America
and
the
Caribbean
there
exist
some
systems
for
the
automated
filling
of
the
Death
Certificate,
which
however
do
not
encompass
all
of
the
deaths.
These
systems
allow
capturing
data
which
is
then
transferred
directly
to
the
mortality
database
and
enable
the
electronic
coding
of
causes
of
death.
18
4.
Definition
and
International
Form
of
Medical
Certificate
of
Cause
of
Death
4.1 International definitions related to the certification of deaths
Following are the international definitions which physicians should be acquainted to
properly certify deaths:
Live birth
Live
birth
is
the
complete
expulsion
or
extraction
from
its
mother
of
a
product
of
human
conception,
irrespective
of
the
duration
of
pregnancy,
which,
after
such
separation,
breathes
or
shows
any
other
evidence
of
life
such
as
beating
of
the
heart,
pulsation
of
the
umbilical
cord,
or
definite
movement
of
voluntary
muscles,
whether
or
not
the
umbilical
cord
has
been
cut
or
the
placenta
is
attached;
each
product
of
a
birth
that
meets
these
conditions
is
considered
a
live
birth3.
Death
Death
is
a
permanent
disappearance
of
all
evidence
of
life
at
any
time
after
live
birth
has
taken
place
(postnatal
cessation
of
vital
functions
without
capability
of
resuscitation).
(This
definition
does
not
include
fetal
deaths.)4
From
a
clinical
and
pathophysiological
point
of
view,
death
corresponds
in
all
cases
to
brain
death,
even
if
the
brain
death
was
preceded
by
terminal
cardiopulmonary
or
other
medical
episode5.
Brain
death
is
defined
as
the
irreversible
loss
due
to
known
cause,
of
brainstem
functional
activity
including
all
neurological
functions
of
the
intracranial
structures
of
both
cerebral
hemispheres6.
Fetal
death
Fetal
death
is
death
prior
to
the
complete
expulsion
or
extraction
from
its
mother
of
a
product
of
human
conception,
regardless
of
the
duration
of
pregnancy;
death
is
indicated
by
the
fact
that
after
such
separation
the
fetus
does
not
breathe
or
show
any
other
evidence
of
life
such
as
beating
of
the
heart,
pulsation
of
the
umbilical
cord,
or
definite
movement
of
voluntary
muscles7.
Therefore,
it
is
a
different
vital
fact
from
death,
as
it
occurs
in
those
not
born
alive.
Maternal
death
A
maternal
death
is
the
death
of
a
woman
while
pregnant
or
within
42
days
following
the
termination
of
pregnancy,
irrespective
of
the
duration
and
the
site
of
the
pregnancy,
from
19
any
cause
related
to
or
aggravated
by
the
pregnancy
or
its
management,
but
not
from
accidental
or
incidental
causes8.
Late
maternal
death
Late
maternal
death
is
the
death
of
a
woman
from
direct
or
indirect
obstetric
causes
more
than
42
days
but
less
than
one
year
after
the
termination
of
pregnancy9.
Death
occurring
during
the
pregnancy,
childbirth
and
puerperium
A
death
occurring
during
the
pregnancy,
childbirth
and
puerperium
is
the
death
of
a
woman
while
pregnant
or
within
42
days
of
termination
of
pregnancy,
irrespective
of
the
cause
of
death
(obstetric
and
non
obstetric)9.
Direct
obstetric
deaths
Direct
obstetric
deaths
are
those
resulting
from
obstetric
complications
of
the
pregnant
state
(pregnancy,
labor
and
puerperium),
from
interventions,
omissions,
incorrect
treatment,
or
from
a
chain
of
events
resulting
from
any
of
the
above9.
Indirect
obstetric
deaths
Indirect
obstetric
deaths
are
those
resulting
from
previous
existing
disease
or
disease
that
developed
during
pregnancy,
and
which
was
not
due
to
direct
obstetric
causes,
but
which
was
aggravated
by
physiologic
effects
of
pregnancy9.
Cause
of
death
In
1967,
the
Twentieth
World
Health
Assembly
defined
the
causes
of
death
to
be
entered
on
the
medical
certificate
of
cause
of
death
as
all
those
diseases,
morbid
conditions
or
injuries
which
either
resulted
in
or
contributed
to
death
and
the
circumstances
of
the
accident
or
violence
which
produced
any
such
injuries.
The
purpose
of
the
definition
is
to
ensure
that
all
relevant
information
is
recorded
and
that
the
certifier
does
not
select
some
conditions
for
entry
and
reject
others.
The
definition
does
not
include
symptoms
and
mode
of
dying,
such
as
heart
failure
or
respiratory
failure.10
Cause
of
death
also
excludes
illnesses
or
injuries
not
directly
involved
in
the
sequence
of
events
leading
to
death
or
that
did
not
contribute
to
it.
Underlying
cause
of
death
The underlying cause has been defined as (a) the disease or injury which initiated the train
of morbid events leading directly to death, or (b) the circumstances of the accident or
violence which produced the fatal injury.
20
It was agreed by the Sixth Decennial International Revision Conference that the cause of
death to be used for producing statistics by one cause (primary tabulation) should be
designated the underlying cause of death.
From the standpoint of prevention of death, it is necessary to break the chain of events that
is aggravating the disease or to on lineaffect a cure at some point. The most effective public
health objective is to prevent the precipitating cause from operating. For this purpose, the
underlying cause of death was defined, as seen before, the clinical conditions that initiate
the chain of events, although it has occurred many years ago.
From the information above, one can conclude that the information in the certificates has
the purpose of production mortality statistics to inform intervention health programs at
population level, which is different from other medical records, as clinical history which in
general aims to inform the diagnoses of the patient for curative or rehabilitation purposes at
individual level.
On the other hand, this means that the certifier should use the necessary reasoning for
identifying the underlying cause of death. Hence, deaths due to terminal complications of
chronic diseases, during which the patient had medical care should be certified by the
physician who was treating those diseases, who surely knows better than anyone the events
that led to the death.
The above principle can be applied uniformly by using the medical certification form
recommended by the World Health Assembly. It is the responsibility of the medical
practitioner signing the death certificate to indicate which morbid conditions led directly to
death and to state any antecedent conditions giving rise to this cause.
iii
The
term
"clinical
events"
is
used
here
as
opposed
to
the
annotation
of
anatomical
and
pathological
diagnoses
or
symptoms
or
signs,
which
should
not
be
recorded
among
the
causes
of
death.
Injuries
and
poisonings,
both
intentional
and
unintentional
that
are
part
of
this
sequence
are
considered
clinical
events
just
as
their
causes.
Immediate
or
direct
cause
of
death
Disease
or
condition
that
directly
leads
to
death.
The
physician
must
write
this
cause
on
line
(a),
Part
I
of
the
medical
death
certificate,
excluding
symptoms
and
death
circumstances11.
Antecedent,
intervening
or
intermediate
cause
of
death
This
defines
any
illness
or
condition
occurring
between
the
direct
cause
of
death
and
the
underlying
cause
of
death
and
as
a
complication
of
the
latter;
it
is
the
trigger
of
the
direct
or
immediate
cause.
If
there
is
more
than
one
cause
or
intervening
medical
history,
the
physician
must
write
21
these
down
on
lines
b)
and
c),
Part
I
of
the
Death
Certificate,
taking
care
to
indicate
a
sequential
cause11.
Morbid
conditions,
if
any,
occurred
among
direct
cause
and
the
underlying
cause
of
death.
These
causes
should
be
entered
in
lines
(b)
and
(c)
of
the
International
form
of
medical
certificate
of
cause
of
death.
Contributing
cause
of
death
Significant
condition
that
contributed
to
the
fatal
outcome,
but
was
not
related
to
the
disease
or
condition
directly
causing
death.
Part
II
of
the
certificate
is
for
reporting
any
other
significant
disease
or
condition
which
contributed
to
the
death
but
which
was
not
part
of
the
sequence
in
Part
I
4.2
International
Form
of
Medical
Certificate
of
Cause
of
Death
The
World
Health
Assembly
has
recommended
using
the
International
Form
of
Medical
Certificate
of
Cause
of
Death.
This
model
should
be
included
in
the
relevant
section
of
the
Death
Certificate
for
each
country
to
record
the
causes
of
death.
Your
country
probably
has
adopted
this
model
but
it
may
contain
some
variations.
Please
review
the
attached
documentation
or
the
corresponding
link.
Later
in
the
Guidelines
for
Certification
section
we
explain
how
to
properly
record
the
causes
of
death
in
this
document.
22
For
physicians
as
well
as
from
a
statistical
point
of
view,
this
is
the
most
important
section
of
the
Death
Certificate.
It
must
be
carefully
filled
out,
subject
to
existing
international
standards.
Physicians
should
use
their
knowledge
to
accurately
describe
the
chain
of
causal
events
leading
to
death.
The
medical
certification
form
presented
here
is
designed
to
facilitate
the
identification
of
the
underlying
cause
of
death
when
two
or
more
causes
are
recorded.
In
the
first
section,
identified
as
Part
I,
the
diseases
that
are
part
of
the
sequence
of
events
leading
directly
to
the
death
are
recorded;
while
in
Part
II
other
morbid
causes
that
contributed
to
the
death,
but
that
are
not
related
to
the
causal
sequence
leading
to
the
death
are
presented.
For
properly
filling
out
the
causes
of
death
in
the
death
certificate,
the
physician
should
attempt
to
identify
in
chronological
order
the
underlying,
subsequent
and
direct
causes
of
death11.
In
Part
I
the
succession
of
causes
and
effects
that
lead
to
the
death
should
be
indicated
in
the
corresponding
lines
a),
b),
c),
and
d).
23
The
causes
listed
here
must
be
causal
and
have
a
relationship
with
each
other,
so
that
the
pathological
condition
or
disease
noted
in
a)
occurred
because
of
what
was
noted
in
b),
that
happened
because
of
what
was
noted
in
c),
and
it
in
turn
was
a
consequence
of
what
was
recorded
in
d).
It
is
important
to
note
that
in
some
countries
of
the
region
the
death
certificate
shows
only
lines
a),
b)
and
c)
in
Part
I.
Another
important
element
of
the
International
Form
of
Medical
Certificate
of
Cause
of
Death
is
the
approximate
interval
between
the
onset
of
illness
and
death,
this
means
that
if
the
doctor
has
the
information,
it
must
be
entered
for
each
of
the
causes
of
death
recorded
in
the
death
certificate,
the
time
elapsed
from
the
start
of
each
disease
and
the
time
of
death.
This
should
be
expressed
in
the
unit
of
time
that
is
most
suitable,
ranging
from
minutes,
hours,
days,
weeks,
months
or
years.
This
section
helps
to
determine
more
adequately
the
succession
of
morbid
events
leading
to
death,
so
that
the
direct
cause
listed
on
line
I
a)
must
have
evolved
in
less
or
equal
time
to
what
was
recorded
on
line
I
b),
which
triggered
the
events
and
so
on.
Therefore,
the
underlying
cause
of
death
is
the
one
that
occurred
the
longest
time
ago;
it
should
be
noted
as
well
in
the
last
section
in
Part
I.
A
special
case
occurs
with
respect
to
the
time
intervals
between
the
onset
of
illness
and
death
of
early
neonatal
deaths
that
result
from
maternal
or
fetal
diseases
which
began
in
utero;
these
causes
may
have
a
longer
period
than
the
very
age
of
the
deceased.
Some
countries
use
a
death
certificate
for
those
born
alive
that
subsequently
die
and
a
Certificate
of
Fetal
Death
for
those
stillborn.
See
the
format
or
formats
used
in
your
country.
However,
not
all
countries
in
the
region
annotate
the
causes
of
death
exclusively
for
legal
purposes
on
the
death
certificate.
In
some
of
them
there
are
different
forms
for
legal,
statistical
and
epidemiological
purposes
benefiting
both
mortality
statistics
and
protecting
the
confidentiality
of
clinical
and
socio-demographic
data.
In
practice
then,
the
physician
in
these
cases
fills
a
form
made
of
two
sections.
The
first
one
is
a
Death
Certificate,
which
has
a
legal
standing
to
attest
that
the
person
has
died
and
that
the
appropriate
funeral
arrangements
can
be
made,
and
a
second
one
called
a
Statistical
Report
of
Death.
The
latter
one
is
the
source
for
Cause
of
Death
Statistics
in
said
countries
as
it
is
there
where
the
Form
of
Medical
Certificate
of
Cause
of
Death
is
included.
The
contents
of
this
statistical
report
have
no
legal
value
and
cannot
be
used
by
any
court
as
evidence
as
it
is
issued
for
the
exclusive
use
of
the
statistician.
They
are
generally
protected
as
statistics
confidentially
data.
Look
again
at
the
death
certificate
form
used
in
your
country
to
verify
whether
such
legal
provision
exists.
24
4.3
Differences
between
the
recorded
diagnoses
in
the
clinical
history
and
the
causes
of
death
recorded
in
the
Medical
Certificate
of
Death
It
is
common
for
the
physician
to
use
the
same
reasoning
for
the
diagnostic
in
the
clinical
history
and
the
causes
of
death
in
the
death
certificate.
One
of
the
main
events
when
a
physician
cares
for
a
patient,
whether
this
is
for
the
first
time
or
not,
is
formulating
a
diagnosis
upon
which
treatment
to
improve
the
patients
condition
will
be
provided.
In
these
cases,
especially
when
these
occur
in
the
context
of
a
hospitalized
setting,
the
physician
seeks
to
list
all
the
diagnoses
that
has
detected
in
the
patient
without
limiting
their
number
as
the
main
purpose
is
to
cure,
improve
or
rehabilitate
a
patient.
Incorporating
all
these
diagnoses
in
health
records
is
a
sign
of
medical
excellence.
The
logic
behind
it
is
to
help
the
physician
decide
on
the
best
therapeutic
and
rehabilitation
treatment
for
the
patient.
Successfully
completing
these
records
is
one
of
the
main
tools
a
physician
has,
therefore,
physicians
have
great
interest
in
these
forms.
By
contrast,
the
purpose
of
recording
the
causes
of
death
in
a
death
certificate
is
not
medical
but
statistical.
The
record
seeks
to
integrate
the
causes
into
a
statistical
count,
which
will
later
serve
to
set
and
define
priorities
for
health
interventions
on
the
population.
(Please
see
Figure
2).
25
Figure
2.
Similarities
and
differences
between
the
correct
annotation
information
on
the
clinical
history
and
the
Medical
Certificate
of
Death,
as
instruments
of
health
activity.
Medical
History
Medical
Certificate
of
Death
Main
objective
To
enable
keeping
record
of
medical
To
produce
mortality
statistics
to
services
provided
to
an
individual
or
a
inform
policies
and
programs
for
Family
(this
last
one
as
part
of
prevention
of
priority
diseases
in
the
primary
care),
throughout
their
lives,
population.
especially
to
keep
track
of
medical
diagnosis
and
set
the
course
for
treating
illnesses.
Scope
of
work
Individual,
predominantly
curative
Populational,
exclusively
preventive
and
and
rehabilitative
with
an
individually
social.
preventive
component.
Diagnostic
As
many
as
they
can
be
identified
in
Record
of
the
sequential
causes
of
records
the
patient,
and
focusing
especially
in
death,
especially
identifying
the
the
current
reason
for
seeking
underlying
cause
of
death
that
is
the
medical
care.
Additional
signs
and
reason
that
began
the
events
excluding
symptoms
can
be
included.
the
manner
in
which
the
death
occurred,
symptoms
and
signs
and
trivial
causes
not-related
to
the
series
of
events
that
preceded
the
death.
Reasoning
Usual
clinical
reasoning
based
on:
Retrospective
reasoning
searching
and
inferred
by
the
history,
physical
examination,
tests,
identifying
the
underlying
cause
of
physician
laboratory
and
medical
visits
results
death
which
can
explain
the
succession
until
the
formulation
of
a
diagnosis.
of
clinical
events
that
lead
to
the
death.
It
is
not
always
easy
to
establish
the
diagnostics
that
must
be
recorded
in
the
Medical
Certificate
of
Death,
especially
due
to
the
lack
of
standardized
criteria
to
decide
the
cause
of
death.
A
contributing
factor
to
this
difficulty
is
the
difference
in
access
to
diagnostic
technology
and
the
lack
of
adequate
training
for
physicians
to
meet
this
obligation.
By
asking
a
physician
to
fill
out
a
death
certificate,
the
doctor
is
being
asked
to
make
to
decisions
on
the
causes
of
death:
-
The
first
one
has
to
do
with
the
data
recording
in
Part
I
of
the
certificate,
which
denotes
the
causal
events
that
lead
to
the
death
(immediate
or
direct
cause
and
antecedent
causes),
specifying
the
last
cause
that
started
the
chain
of
events
that
lead
to
the
death
(underlying
cause
of
death).
-
The
second
refers
to
the
entry
in
Part
II
of
the
certificate
of
other
events
that
contributed
to
the
process,
but
that
are
not
related
to
the
causal
sequence
leading
to
death
(contributing
causes)12.
26
4.4
Special
sections
of
the
Medical
Certificate
of
Death
for
the
registration
of
additional
data
4.4.1
Paragraph
or
section
to
fill
in
the
case
of
the
death
of
a
woman
of
reproductive
age
Women
of
childbearing
age
(15
to
49
years
of
age
or
other
age
range
that
the
country
deems
appropriate)
are
at
risk
of
dying
from
complications
of
pregnancy,
childbirth
or
puerperium.
Often
these
complications
are
not
properly
recorded
in
death
certificates
and
so
these
cases
cannot
be
classified
as
maternal
deaths
thus
inducing
an
underestimation
of
maternal
mortality.
Due
to
the
frequency
with
which
it
was
possible
to
demonstrate
a
gap
in
the
statistics
of
causes
of
death
even
in
developed
countries,
the
1990
World
Health
Assembly
adopted
a
recommendation
asking
countries
to
consider
including
in
the
death
certificate
questions
such
as:
Was
there
a
pregnancy
at
the
time
of
death,
or
had
there
been
a
pregnancy
in
the
one
year
period
preceding
the
death?.
This
would
be
done
in
order
to
investigate
whether
these
deaths
corresponded
to
maternal
deaths
and
using
this
information
to
correct
data
misclassification,
thereby
improving
the
integrity
of
information
on
maternal
deaths.
Physicians
in
those
countries
where
this
section
has
been
added
to
the
Medical
Certificate
of
Death
should
not
ignore
this
section
when
certifying
the
death
of
a
woman
of
childbearing
age.
In
many
countries
a
combination
of
detection
methods
and
search
for
maternal
deaths,
is
applied, systematically
reviewing
all
deaths
of
women
of
childbearing
age
and
verifying
the
medical
history
in
those
case
where
the
cause
of
death
as
septicemia,
anemia,
bleeding
and
others,
which
contributes
to
detecting
misclassified
cases,
which
are
then
incorporated
into
the
statistical
group
of
maternal
deaths.
However,
nothing
substitutes
for
the
precise
and
specific
data
entry
that
the
physician
should
enter
directly
onto
the
certificate.
While
the
definition
of
childbearing
traditionally
used
in
public
health
is
of
15-49
years
of
age,
due
to
changes
undergone
by
the
fertility
behavior
in
many
countries
in
the
Americas,
it
is
recommended
to
extend
this
age
group
from
10
to
54
years
of
age,
without
excluding
cases
that
could
exceed
these
limits
in
either
way.
In
section
5.10.1
Death
of
woman
of
childbearing
age,
there
are
detailed
guidelines
for
filling
out
this
section
and
an
example
is
given.
27
4.4.2 Paragraph
or
section
to
fill
in
the
event
of
death
by
accidental
or
violent
causes
The
definition
of
underlying
cause
of
death,
previously
discussed
(see
Section
4.
Definitions
and
International
Form
of
Medical
Certificate
of
Cause
of
Death),
also
refers
to
deaths
resulting
from
accidental
or
violent
events.
In
virtually
all
countries
in
the
region,
it
is
the
coroner
or
medical
examiner
who
certifies
the
cause
of
death
in
these
cases,
who
may
or
may
not
have
specialized
training
in
Pathological
Anatomy.
Because
of
this
and
due
to
the
influence
of
the
prevailing
definition
of
criminal
laws
which
constitute
the
norm
that
forensic
expertise
seek
to
meet,
forensic
physicians
tend
to
omit
partly
or
entirely,
an
adequate
description
of
the
circumstances
surrounding
the
accident
or
violent
act
that
produced
the
injury
or
intoxication
leading
to
the
death.
In
order
to
assist
physicians
in
the
identification
of
this
type
of
underlying
causes
of
death,
most
of
the
countries
include
in
the
death
certificate
a
section
with
additional
questions
on:
-
the
presumption
of
intentionality
of
the
event,
which
would
allow
classification
as
an
accident,
intentional
self-harm,
assault
or
event
of
undetermined
intent
through
the
survey.
-
the
detailed
description
of
circumstances,
violent
act
or
accident.
-
the
place
and
date
of
occurrence
of
the
accident
of
violent
death.
-
the
information
needed
to
determine
if
this
was
an
occupational
death.
The
certifying
physician
must
answer
these
questions,
when
certifying
deaths
related
to
accidents
or
violent
acts.
It
is
worth
noting
that
this
information
is
statistical
in
nature
and
does
not
make
up
part
of
the
judicial
investigation
carried
out
in
parallel
by
the
appropriate
authority.
In
section
5.10.2
Death
by
accidental
or
violent
causes,
there
are
detailed
guidelines
for
filling
out
this
section
and
an
example
is
given.
Often
the
medical
examiner
must
issue
a
death
certificate
within
the
first
24
to
48
hours
after
practicing
autopsy.
During
that
time
it
is
important
to
have
as
much
information
as
possible
about
the
circumstances
that
gave
rise
to
injuries
and
their
intentionality.
At
this
time,
the
necropsys
data
will
allow
the
examiner
to
describe
the
injuries
that
need
to
be
recorded
in
Parts
I
and
II,
and
to
identify
the
possible
external
causes.
In
countries
that
have
a
special
section
for
deaths
from
external
causes
in
the
death
certificate,
physician
must
input
in
detail
there
the
circumstances
that
caused
the
injury,
and
answer
the
question
of
presumption
of
intentionality.
If
there
is
not
enough
information,
a
special
note
must
be
written
specifying
that
it
will
be
obtained
within
a
defined
period,
and
that
it
will
be
incorporated
into
the
coding
process.
Too
often
however,
this
information
is
never
recorded
by
the
coroner
and
a
number
of
death
certificates
involving
external
causes
are
coded
incompletely,
swelling
the
group
of
unspecified
deaths
from
external
causes
and
helping
little
to
nil
in
preventing
new
deaths.
28
5.
Guidelines
for
certification13
Physicians
should
take
into
consideration
10
guidelines
for
filling
out
death
certificates
correctly:
5.1 Verify the death and personally complete the death certificate.
5.2 Use all available information about the deceased person.
5.3 Use legible handwriting (uppercase letter or print)
5.4 Avoid abbreviations and / or acronyms.
5.5
Determine
the
logical
sequence
between
diseases,
from
the
direct
cause
leading
to
death
to
the
underlying
cause
of
death,
recording
as
possible
the
intervals
elapsed
between
the
start
of
each
disease
or
complication,
and
death.
5.6
Write
down
a
single
cause
of
death
per
line.
5.7 Record diseases and syndromes unambiguously.
5.8
Avoid
if
possible
recording
ill-defined
and
imprecise
causes,
as
the
sole
cause
or
underlying
cause
of
death.
5.9
Follow
the
guidelines
for
specific
causes
of
death.
5.10
Use
when
applicable
the
special
sections
of
the
Death
Certificate:
Death
of
woman
of
reproductive
age;
and
death
from
accidental
or
violent
causes.
29
5.1
Verify
the
death
and
personally
complete
the
death
certificate.
Before
completing
the
death
certificate,
it
is
essential
for
the
physician
to
look
at
and
explore
the
body
of
the
person
to
verify
the
death.
A
physician
should
never
fill
out
a
certificate
without
evidencing
first
the
death.
If
when
examining
the
body,
the
physician
suspects
the
involvement
of
an
external
cause,
the
physician
should
not
issue
the
certificate
but
should
instead
give
prompt
notice
to
the
competent
authority.
In
most
countries
the
law
provides
that
such
cases
be
certified
by
a
medical
examiner.
All
the
data
included
in
the
death
certificate
is
important,
from
the
socio-demographic
variables
(e.g.
name
of
the
deceased,
age,
education,
habitual
residence,
etc.),
to
those
of
a
medical
nature
(causes
of
death).
Therefore,
the
physician
should
carefully
fill
out
the
form
verifying
that
the
information
being
recorded
is
factual.
On
the
back
of
the
death
certificate
forms
there
are
usually
directions
for
the
variables,
therefore
it
is
important
for
the
physician
to
look
at
them.
If
the
country
has
a
more
extensive
instruction
manual,
the
physician
may
want
to
review
it.
It
is
important
to
note
that
by
signing
the
death
certificate
the
physician
is
responsible
for
its
contents,
therefore
it
is
important
that
before
signing,
the
physician
corroborates
that
all
data
has
been
recorded
correctly,
without
any
missing
information
and
is
consistent
with
what
the
informant
indicated.
5.2 Use all available information about the deceased person.
The certifying physician must use all the information available to fill out the death
certificate correctly.
This information may be obtained from official documents, identification or voter
registration cards, birth records or certificates or medical records (medical history), while
for other variables a respondent usually a relative or close friend of the deceased is
consulted. Causes of death are usually determined by the certifying doctor taking into
account when available, the deceased persons clinical history or information collected
from indirect questioning of relatives, and by scanning the body of the deceased.
In
the
case
of
deaths
occurring
in
medical
units,
the
clinical
notes
or
medical
records
(clinical
history)
should
be
consulted.
It
is
important
that
the
physician
explain
to
the
respondent
the
importance
of
the
death
certificate
and
remind
the
informant
of
the
need
to
provide
factual,
accurate
data.
30
Frequently
a
well-known
patient
of
a
medical
unit
dies
at
home;
therefore
all
medical
documentation
should
be
used
for
the
death
certificate.
In
in
its
absence,
it
is
recommended
that
the
informant
be
consulted
regarding
recent
clinical
documentation
that
can
be
used
such
as
laboratory
studies,
prescriptions
or
even
a
copy
of
hospital
notes,
which
can
help
in
identifying
the
causes
of
death.
Failure
to
use
the
information
available
or
to
not
question
the
informant
can
lead
to
significant
omissions.
Clear
examples
are
obstetric
deaths,
as
it
is
very
common
to
omit
in
the
death
certificate
if
the
woman
who
died
was
pregnant
or
in
puerperium.
The
deaths
of
young
women
are
sometimes
attributed
to
cerebral
hemorrhage,
pneumonia
or
infections,
when
in
fact
by
being
pregnant
these
should
have
been
certified
as
obstetric
deaths
with
cerebral
hemorrhage,
pneumonia
or
infections
respectively.
5.3
Use
legible
handwriting
(mold
or
print)
If
the
certification
of
death
is
made
on
a
paper
format
and
a
typewriter
is
not
available,
the
physician
should
ensure
legible
handwriting,
so
that
the
data
provided
can
be
processed
without
any
difficulty.
Where
handwriting
is
not
legible,
data
can
be
misinterpreted
risking
inclusion
of
misinformation
in
the
database,
or
information
that
does
not
match
what
the
physician
described
on
the
certificate.
When
using
self-copy
forms
original
death
certificate
and
copies
it
is
important
to
exert
the
necessary
pressure
to
ensure
that
all
copies
are
legible.
5.4
Avoid
abbreviations
and
/
or
acronyms.
Acronyms
are
difficult
for
interpreting
data,
especially
when
used
to
record
the
causes
of
death.
The
use
of
ARI
for
example,
could
describe
Acute
Respiratory
Infection,
or
Acute
Renal
Infection,
two
completely
different
diseases.
Therefore,
all
acronyms
should
be
avoided
when
describing
a
diagnosis,
even
when
these
seem
to
be
universally
accepted.
The
use
of
acronyms
or
abbreviations
may
lead
to
misinterpretation
and
loss
of
factual
information.
31
5.5
Determine
the
logical
sequence
between
diseases
from
the
direct
cause
leading
to
death,
to
the
underlying
cause
of
death
and
recording,
if
possible,
the
intervals
elapsed
between
the
start
of
each
disease
or
complication
and
death.
Statistically
it
is
essential
to
record
the
"underlying
cause
of
death",
which
is
the
disease
or
injury
which
initiated
the
train
of
morbid
events
leading
to
death,
or
the
circumstances
of
the
accident
or
violent
act
which
produced
the
fatal
injury.
The
Medical
Certificate
of
Cause
of
Death
can
be
filled
with
one
or
several
causes
of
death,
but
the
underlying
cause
of
death
should
always
be
noted
on
the
last
line
in
Part
I.
If
the
doctor
believes
that
a
single
cause
is
sufficient
to
explain
death,
it
should
be
entered
on
line
I
a);
if
the
physician
considers
there
are
two
causes,
the
direct
cause
should
be
recorded
on
line
I
a),
and
the
underlying
cause
of
death
on
line
I
b).
Where
three
causes
are
considered,
the
direct
cause
should
be
added
on
line
I
a),
the
antecedent
or
intervening
cause
should
be
note
don
line
I
b),
and
the
underlying
cause
of
the
death
on
line
I
c).
If
the
physician
considers
there
are
four
causes,
then
the
direct
cause
of
death
should
go
on
line
I
a),
the
antecedent
or
intervening
causes
on
line
I
b)
and
I
c),
and
the
underlying
cause
of
death
on
line
I
d).
As
previously
mentioned
Part
II
is
reserved
for
recording
contributing
causes,
for
example,
obesity,
malnutrition,
smoking
or
other
addictions;
and
when
appropriate,
pregnancy,
childbirth
or
the
puerperum
period.
When
available,
record
the
approximate
interval
between
the
onset
of
each
condition
and
death.
The
latter
helps
determine
the
logical
sequence
of
causes
leading
to
death.
32
Note
the
following
examples:
Example 1
48-year-old
man
with
a
clinical
record
indicating
an
illness
related
to
the
acquired
human
immunodeficiency
virus
diagnosed
two
years
prior.
A
week
before
his
death
the
patient
was
released
from
the
hospital
in
the
absence
of
therapeutic
alternatives
for
improvement.
At
the
request
of
the
family,
the
physician
goes
to
the
home
to
certify
the
death.
After
reviewing
the
body,
the
doctor
certifies:
48-year-old man
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Disease
by
human
immunodeficiency
virus
2
years_
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
_________________________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
_________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
__________________________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
The
filling
out
of
the
causes
in
the
death
certificate,
begins
in
Part
I
line
a)
corresponding
to
the
direct
cause
of
death.
In
this
case
the
physician
only
entered
one
cause:
disease
by
human
immunodeficiency
virus
of
2
years,
which
is
entered
in
Part
I
a)
and
which
is
also
considered
the
underlying
cause.
In
this
case,
according
to
the
physicians
criteria
a
single
condition
is
required
here
as
it
fully
explains
the
cause
of
death.
Example
2
8-hour-old
male,
born
prematurely
with
a
laceration
of
the
umbilical
cord.
From
birth
the
newborn
presented
respiratory
distress
and
hemodynamic
alterations.
Child
died
of
hypovolemic
shock
two
hours
later.
8-hour-old
male
I Approximate
33
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Hypovolemic
shock________________
2
hours_
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Laceration
of
the
umbilical
cord________
8
hours_
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
_________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
__________________________________
_______
II
Other
significant
pathologies
____ Respiratory
distress___________
contributing
to
the
death
but
not
8
hours_
related
to
the
disease
or
8
hours_
condition
causing
it
_________prematurity
___________________
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
In
this
case
the
direct
cause
of
death
was
the
hypovolemic
shock
which
is
written
on
I
a).
This
occurred
as
a
result
the
laceration
of
the
umbilical
cord
during
birth.
As
the
underlying
cause
of
the
death,
the
information
is
recorded
in
section
I
b).
Both
prematurity
and
respiratory
distress
are
considered
contributing
causes
and
logged
in
Part
II
of
the
Medical
Certificate
of
Cause
of
Death.
34
Example
3
58-year-old
woman
diagnosed
with
type
2
diabetes
mellitus
ten
years
prior.
For
three
years
patient
has
diabetic
nephropathy.
She
is
hospitalized
three
days
before
her
death
and
dies
due
to
acute
myocardial
infarction
in
the
anteroseptal
wall
which
lasts
one
hour.
58-year-old
woman
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Myocardial
infarction
of
the
anteroseptal
1
hour_
wall
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Diabetic
nephropathy________________
3
years_
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
Diabetes
mellitus
type
2______________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
__________________________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
10
years
related
to
the
disease
or
________________________________________________
______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
The
registration
of
causes
of
death
begins
in
Part
I
line
a)
corresponding
to
the
direct
cause
of
death,
in
this
case
an
acute
myocardial
infarction
of
the
anteroseptal
wall,
which
was
the
last
illness
recorded.
It
is
considered
that
the
infarction
was
due
to
diabetic
nephropathy,
which
is
recorded
in
Part
I
b);
and
this
in
turn
was
a
consequence
of
diabetes
mellitus
type
2
which
is
entered
in
Part
I
c),
and
corresponds
to
the
underlying
cause
of
death.
Note
the
available
information
on
the
evolution
for
each
of
the
diseases;
the
doctor
wrote
the
information
in
the
column
that
reads:
Approximate
interval
between
onset
of
disease
and
death.
Example 4
35
77-year-old
man
diagnosed
with
pulmonary
cancer
three
years
earlier.
It
is
now
7
months
since
developing
metastasis
of
the
kidney.
Patient
is
admitted
to
the
hospital
seven
days
prior
to
death
with
hypertension;
case
worsens
48
hours
prior
to
death
after
developing
a
brain
hemorrhage
and
dying.
Patient
received
iron
for
iron
deficiency
anemia
which
he
had
for
a
total
of
five
years.
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Cerebral
hemorrhage_____________
2
days__
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Hypertension_______________________
7
days__
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
Metastatic
Kidney___________________
7
months
condition
last
due
to
(or
as
consequence
of)
(d)
_Pulmonary
cancer___________________
3
years
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
______
related
to
the
disease
or
________________________________________________
______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
The
doctor
described
the
following
chain
of
events:
the
direct
cause
was
cerebral
hemorrhage
of
two
days
duration
which
was
recorded
on
I
a);
this
occurred
as
a
result
of
the
high
blood
pressure
which
occurred
during
seven
days
noted
on
I
b);
which
in
turn
was
a
consequence
of
a
secondary
malignant
renal
tumor,
noted
on
I
c)
which
grew
from
a
malignant
lung
tumor
that
lasted
10
years
and
was
recorded
as
the
underlying
cause
of
death
in
I
d).
Iron
deficiency
anemia
was
not
considered
by
the
physician
as
a
contributing
cause
of
death
and
therefore
was
not
recorded
in
Part
II.
36
5.6
Write
down
a
single
cause
of
death
per
line.
The
death
certificate
has
been
designed
to
record
only
one
cause
of
death
in
each
line.
This
pattern
should
be
respected
as
much
as
possible
to
avoid
confusion
and
loss
of
factual
information
on
the
causes
of
death,
when
handling
the
data.
Example:
51-year-old
man
goes
to
the
emergency
room
with
severe
abdominal
pain
and
a
compromised
state
of
health,
which
had
persisted
for
about
one
day.
Patient
is
diagnosed
with
appendicitis
complicated
by
peritonitis
and
dies
while
being
prepared
for
surgery.
The physician filled out the death certificate as follows:
51-year-old male
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Acute
appendicitis
&
peritonitis_________
_______
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
_________________________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
_________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
__________________________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
37
However
the
correct
manner
to
fill
out
this
certificate
is:
51-year-old
male
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Peritonitis_________________________
_______
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Acute
apendicitis_____________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
_________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
__________________________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
Sometimes
there
are
concurrent
conditions
or
injuries
that
cannot
be
listed
in
sequence
according
to
the
manner
in
which
they
occurred.
For
example,
acute
renal
failure
and
peripheral
vascular
complications
due
to
diabetes
mellitus
type
2,
or
when
multiple
injuries
after
an
accident
or
assault
cause
death,
for
example,
fracture
of
the
base
of
the
skull
and
ruptured
spleen
and
liver
due
to
a
fall
from
a
great
height.
38
5.7.
Record
diseases
and
syndromes
unambiguously
The
causes
of
death
listed
in
the
certificate
must
be
specified
as
best
possible.
It
is
incorrect
to
say
diabetes
mellitus
without
indicating
which
type
or
what
complication
derived
from
it
or
to
record
information
about
a
tumor
without
specifying
its
behavior
or
anatomical
site.
Specifying the diagnosis means to:
- Whenever known, specify the etiology. If the diagnosis corresponds to a communicable
disease and there is information about the causal agent, register it. For example:
meningococcal meningitis, meningitis caused by Haemophilus influenza, or meningitis due
to unspecified germ, instead of only purulent meningitis. Or pneumococcal pneumonia,
staphylococcal pneumonia or pneumonia due to unspecified germ, rather than simply
pneumonia without providing any further specification.
- This rule is also applicable to non-infectious causes, for example: spontaneous
miscarriage or induced abortion; complete or incomplete miscarriage; alcoholic liver
cirrhosis or liver cirrhosis due to contraceptive hormones.
-
Specify
the
anatomical
location
of
the
disease
or
injury.
E.g.,
pulmonary
hydatid
cyst
of
the
right
upper
lobe
or
hepatic
hydatid
cyst;
pulmonary
tuberculosis,
intestinal
tuberculosis
or
miliary
tuberculosis;
bronchogenic
adenocarcinoma
of
the
right
lung
or
prostate
adenocarcinoma.
In
the
case
of
malignant
tumors,
if
you
have
information
on
the
morphological
type
of
tumor,
it
is
then
valid
to
write
it
down
in
the
diagnosis,
but
without
skipping
notation
of
the
anatomical
site.
-
Consider
the
sequelae,
that
is
the
residual
effects
that
occur
years
or
decades
after
the
primary
disease
that
initiates
the
causal
chain
of
events
that
led
to
the
death.
For
example,
rheumatic
heart
disease
should
be
mentioned
as
the
underlying
cause
if
the
death
occurs
due
to
terminal
complications
of
it.
-
Specify
the
diagnostic
terminology
so
that
the
disease
and
its
complications
are
fully
detailed.
For
example,
in
the
case
of
diabetes
mellitus
it
must
be
specified
which
type
(1,
2
or
associated
with
malnutrition)
and
its
complications
(coma,
ketoacidosis,
kidney
failure,
peripheral
vascular,
etc.)
that
led
to
the
death.
39
5.8
Avoid
if
possible
recording
ill-defined
and
imprecise
causes,
as
the
sole
cause
or
underlying
cause
of
death.
Medical
terms
that
do
not
add
clinical
or
epidemiological
information
to
establish
strategies
for
prevention
and
control
of
diseases
are
called
ill-defined
causes.
When
certifying
a
death,
the
physician
should
be
careful
not
to
cite
as
an
underlying
cause
of
death
either
an
ill-defined
or
inaccurate
cause.
Examples
of
ill-defined
causes:
Abdominal
pain
Multiple
organ
failure
Fever
Hypotension
Acute
respiratory
failure
Respiratory
failure
Respiratory
failure
of
the
newborn
Cardiac
arrest
Cardiopulmonary
arrest
Senility
Vomiting
As
can
be
seen
in
the
examples,
ill-defined
causes
are
actually
signs,
symptoms
or
terminal
stages
of
a
disease,
therefore
they
cannot
be
considered
as
the
condition
that
initiated
the
chain
of
events
leading
to
death
(underlying
cause
of
the
death)
and
should
not
be
listed
on
the
last
section
of
Part
I
of
the
death
certificate.
Sometimes
the
doctor
doesnt
have
more
information
to
go
on
than
some
ill-defined
signs
and
symptoms
in
the
absence
of
necessary
tests
or
autopsy,
or
when
the
interrogation
of
relatives
did
not
provide
the
necessary
information.
These
are
the
only
cases,
and
should
only
be
few,
in
which
symptoms,
signs
or
ill-defined
causes
could
be
noted
as
cause
of
death,
which
is
preferable
to
inventing
a
diagnosis.
The
proportion
of
cases
with
underlying
causes
corresponding
to
an
ill-defined
cause
of
death
in
a
database
of
mortality,
in
addition
to
being
a
tracer
of
the
quality
of
mortality
data,
is
an
indicator
of
the
quality
of
medical
care
provided
a
given
population.
Imprecise
causes
are
those
that,
while
providing
information
are
not
specific
enough
to
identify
diseases
to
establish
preventive
and
control
measures
or
to
identify
the
true
underlying
cause
of
death
and
where
further
clarification
from
the
appropriate
certifying
physician
is
needed.
40
These
are
some
examples
of
imprecise
causes:
Ventricular
arrhythmia
Generalized
atherosclerosis
Unspecified
disease
Cirrhosis
Dehydration
Events
of
undetermined
intent
Heart
failure
Hepatic
Impairment
Chronic
renal
failure
Myocarditis
unspecified
Generalized
sepsis
Pulmonary
thromboembolism
Malignant
neoplasms
of
unspecified
site
Tumors
that
do
not
describe
behavior
and
anatomical
site
affected
To
see
the
proportion
of
ill-defined
and
imprecise
causes
of
death
see
Table
1
and
Graph
1.
Physicians
should
avoid
imputing
imprecise
and
ill-defined
causes
in
the
death
certificate.
This
can
be
done
in
certain
cases
NOT
as
the
underlying
cause
of
death
but
rather
as
the
chain
of
events
leading
to
death
even
if
this
means
wasting
lines
in
Part
I
and
not
registering
the
sequence
of
all
causes
of
death.
When
there
are
more
than
four
causes
to
be
listed
in
Part
I,
the
ill-defined
or
imprecise
causes
should
be
dropped.
Mathers
et
al.,14
consider
mortality
statistics
to
be
high
quality
when
the
sum
of
imprecise
and
ill-defined
causes
is
below
10%;
of
medium-quality
when
the
sum
is
between
10%
and
20%
and
low
quality
when
it
exceeds
20%.
41
Graph 1. Proportion of ill-defined and imprecise causes of death according to country
The Americas, circa 2010
El Salvador
Argentina
Virgin Islands (UK)
Guadalupe
Martinique
Uruguay
French Guyana
Peru
Aruba
Ecuador
Paraguay
Guatemala
Turks and Caicos
Antigua and Barbuda
Barbados
Bermuda
Panama
Brazil
C Suriname
Guyana
O Saint Vincent and the Grenadines
U Saint Lucia
N Dominica
T Cayman Islands
Dominican Republic
R Puerto Rico
Y Saint Kitts and Nevis
Bahamas
Virgin Island (USA)
Anguilla
Montserrat
Nicaragua
Granada
Mexico
United States of America
Belize
Venezuela (Bolivarian Republic)
Chile
Colombia
Trinidad and Tobago
Costa Rica
Canada
Cuba
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0
Proportion of cases per 100
Imprecise Ill-defined
Source:
Regional
mortality
database
PAHO/WHO
PAHOs
Project
of
Health
Information
and
Analysis
(HSD/HA)
Some
countries
lacking
data
for
this
period
were
not
included
in
the
graph
(see
Table
1).
Other
countries
lack
information
either
for
the
imprecise
or
ill-defined
causes
and
so
they
are
included
in
Figure
1
with
a
single
bar.
42
5.9
Follow
the
guidelines
for
specific
causes
of
death.
Below
is
a
list
of
causes
of
death
due
to
ill-defined
and
imprecise
reasons
which
should
be
avoided
as
the
underlying
cause
of
death,
or
if
they
are
used,
they
should
be
supplemented
by
other
information
in
accordance
with
the
instructions
detailed.
Avoid
using
terms
such
as
those
listed
on
column
A
below,
since
they
correspond
to
ill-
defined
conditions
or
terminal
complications
of
a
disease
and
not
a
primary
cause.
Instead
specify
these
in
column
B,
noting
the
cause
that
led
to
the
ill-defined
disease
or
terminal
complication.
For
example,
if
simply
recording
"sepsis"
in
the
certificate,
specify
the
sepsis
origin,
cause
or
gateway.
LIST OF CAUSES THAT SHOULD BE AVOIDED AS UNDERLYING CAUSE
AND REQUIRED SPECIFICATIONS TO ESTABLISH AN UNDERLYING CAUSE OF DEATH
a) Deaths due to various conditions except for accidents or violence
A. Cause of death to be B. Specification
registered
Cardiac arrhythmia Disease causing cardiac arrhythmia
Generalized arteriosclerosis Most important anatomic site of arteriosclerosis and
deadly effect
Heart block Disease that caused the heart block
Bronchopneumonia If terminal illness or complication of another primary
condition, report it including time it took to develop
Hypostatic bronchopneumonia Illness leading to admission to hospital or prolonged
stay in bed and causing the hypostatic
bronchopneumonia
Cancer Anatomical site affected and as accurately as possible
Heart disease Type of heart disease
Congenital heart disease Type of congenital heart disease
Cirrhosis Agent that caused the disease or liver cirrhosis
Seizures Disease that caused the seizures
Chronic cor pulmonale Lung disease caused chronic cor pulmonary
Quadriplegia Illness or injury that caused quadriplegia and duration
Dehydration Disease or condition that caused dehydration
Diabetes mellitus Type of diabetes mellitus (type 1, type 2, associated
with malnutrition, etc.), as well as the type of fatal
43
A.
Cause
of
death
to
be
B.
Specification
registered
complication:
coma,
acidosis,
of
the
kidney,
of
the
eye,
peripheral
vascular,
etc.
Drug
Addiction
Identify
the
drug
that
caused
the
death.
In
case
of
multiple
drugs,
determine
if
possible
which
is
the
main
culprit
for
the
death.
Acute
pulmonary
edema
Agent
that
caused
disease
or
acute
pulmonary
edema
Encephalopathy
Agent
that
caused
disease
or
encephalopathy
Toxic
encephalopathy
Toxicant
and
circumstance
how
it
occurred
Toxic
liver
disease
Toxicant
and
circumstance
how
it
occurred
Bedsores
Illness
leading
to
admission
to
hospital
or
prolonged
bed
rest
and
sores
caused
Multiple
organ
failure
Disease
that
lead
to
multiple
organ
failure
Fever
Disease
that
caused
fever
Hematemesis
Illness
or
injury
that
gave
rise
to
the
hematemesis
Hemiplegia
Illness
or
injury
that
caused
the
hemiplegia
and
duration
Gastrointestinal
bleeding
Illness
or
injury
that
caused
bleeding
Viral
hepatitis
Type
of
viral
hepatitis:
A,
B,
C,
etc.
Hydrocephalus
(hydrocephalus)
Type
of
hydrocephalus:
obstructive,
traumatic
and
other
types
Heart
failure
Disease
that
lead
to
heart
failure
Hepatic
impairment
Disease
that
lead
to
liver
failure
Chronic
renal
failure
Disease
that
gave
rise
to
chronic
renal
failure.
If
unknown,
at
least
point
to
the
stage
in
the
chronic
renal
failure
Respiratory
failure
Disease
that
caused
the
respiratory
failure
Congenital
malformation
Type
of
congenital
malformation
(affected
organ
or
body
system)
Melena
Illness
or
injury
incurred
in
the
melena
Multi-malformed
(multiple
Type
of
congenital
malformations,
define
which
of
malformations)
these
was
the
underlying
cause
of
death
Pneumonia
due
to
solid
or
liquid
Disease
or
circumstance
that
caused
aspiration
pneumonia
identifying
the
aspirated
substance
44
A.
Cause
of
death
to
be
B.
Specification
registered
Hypostatic
pneumonia
Illness
leading
to
admission
to
hospital
or
prolonged
bed
rest
and
hypostatic
pneumonia
caused
Paraplegia
Illness
or
injury
which
caused
paraplegia
and
duration
of
the
same
Cardiac
arrest
Skip
this
cause.
It
only
indicates
the
way
the
person
died.
Instead,
specify
the
illness,
injury
or
condition
that
caused
heart
failure.
Respiratory
arrest
Skip
this
cause.
It
only
indicates
the
way
the
person
died.
Instead
specify
the
illness,
injury
or
condition
that
caused
the
respiratory
arrest.
Peritonitis
Illness
or
injury
that
caused
peritonitis
Politraumatized
If
possible,
identify
the
lesion
responsible
for
the
death
and
specify
the
external
cause
Senility
Skip
this
cause.
Record
the
disease
that
actually
killed
the
person
Generalized
sepsis
or
sepsis
Origin,
cause
or
gateway
sepsis
Electrolyte
disorder
Disease
or
condition
that
causes
the
disorder
of
electrolytes
Pulmonary
thromboembolism
Disease
that
caused
the
pulmonary
embolism
Tumor
Behavior
of
the
tumor
(primary
malignant,
secondary
malignant,
benign,
in
situ)
and
affected
anatomical
site
Vomiting
Disease
that
caused
the
vomiting
b)
Defunciones
por
causas
accidentales
o
violentas
A.
Cause
of
death
B.
Specification
Traffic
accident
Type
of
vehicle
involved
(car,
motorcycle,
bus,
etc.),
type
of
accident
(collision
with
another
vehicle,
rollover),
role
of
victim(s)
in
accident
(occupant,
driver,
pedestrian,
etc.).
For
statistical
purposes
provide
as
much
information
about
the
circumstances
of
the
accident
as
possible.
Fall
Where,
how
and
when
the
fall
occurred.
As
in
traffic
accidents
and
other
external
causes,
provide
as
much
information
about
the
circumstances
as
possible.
45
A.
Cause
of
death
B.
Specification
Gunshot
wound
Identify
injury
caused
and
type
of
weapon
used
(handgun,
shotgun,
etc.),
and
intent
of
the
event.
Poisoning
Identify
the
substance
that
caused
the
poisoning
and
intentionality
of
the
event
(accidental,
aggression,
self-
inflicted).
Events
of
undetermined
intent
Is
the
intent
really
undetermined
or
is
it
feasible
to
establish
a
presumptive
medical
judgment
with
the
available
information?
Identifying
the
intent
in
the
death
certificate
is
presumptive
and
will
not
necessarily
match
the
result
of
any
possible
legal
investigation
made.
Below are some of the most common cases that result in incorrect or inaccurate records
- Cardiopulmonary arrest
- Natural Death
- Surgical procedure
- Tumors
46
Cardiopulmonary
arrest
If
writing
this
in
a
death
certificate,
without
any
other
cause,
this
definition
will
be
considered
an
ill-defined
cause
and
for
statistical
purposes
it
will
appear
as
an
unknown
cause
of
death.
Example:
67-year-old
man
is
admitted
moribund
to
Emergency
Services
and
dies
within
minutes.
He
had
a
history
of
liver
cirrhosis.
The doctor filled the Certificate as follows:
67-year-old male
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Cerebral
hemorrhage_________________
_______
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Cardiopulmonary
arrest________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
______________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
The correct manner to fill out the certificate however is:
67-year-old male
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Cardiopulmonary
arrest________________
_______
due
to
(or
as
consequence
of)
47
Antecedent
cause
of
death
(b)
Cirrosis
of
the
liver____________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
______________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
Natural
death
From
the
judicial
point
of
view,
natural
death
is
a
relevant
term
since
it
rules
out
a
violent
death,
yet
epidemiologically
it
is
not
to
be
accepted
as
cause
of
death,
nor
is
it
in
the
medical
record.
Example:
80-year-old
woman
diagnosed
with
end-stage
esophageal
cancer,
which
she
had
suffered
for
5
years.
Woman
arrives
at
hospital
in
cardiac
arrest
after
having
aspirated
vomit.
No
signs
of
violence
on
physical
examination.
The doctor filled the Certificate as follows:
Female 80-years-old
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Natural
death
________________________
_______
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
_______________________________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
______________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
_______
48
condition
causing
it
________________________________________________
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
The correct way to fill out the death certificate is:
Female 80-years-old
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Esophageal
cancer___________________
_______
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
_______________________________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
______________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
Surgical procedure
It is incorrect to record medical procedures (including surgical) on the death certificate.
Instead it should be noted the disease that requires the procedure. If surgical procedure is
entered on the certificate as cause of death without mentioning the medical condition, or
findings of the procedure, the underlying cause of death on the certificate will be
considered imprecise.
Example:
82-year-old
woman,
diagnosed
with
hypernephroma
of
the
left
kidney,
ultimately
treated
with
nephrectomy.
She
dies
from
acute
myocardial
infarction
during
the
surgical
procedure.
The
doctor
filled
the
certificate
as
follows:
49
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Acute
myocardial
infarction____________
_______
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Nephrectomy__________________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
______________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
The correct way to write down the causes in the Certificate is:
82-year-old woman
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Acute
myocardial
infarction____________
Minutes
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Hypernephroma
of
the
left
kidney______
Years
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
______________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
50
This
is
a
poorly
elaborated
certificate.
By
classifying
the
cause
of
death
only
noting
Nephrectomy
on
the
last
line,
the
underlying
cause
of
death
will
be
noted
as
unspecified
renal
disease
since
in
the
description
of
the
procedure
undertaken,
the
liver
was
indicated
as
the
affected
organ.
In
a
death
certificate
correctly
elaborated,
the
causes
have
been
recorded
in
a
correct
causal
relationship
and
the
true
underlying
cause
has
been
identified
as
hypernephroma
of
the
left
kidney.
It
is
important
to
note
that
complications
following
a
medical
procedure
can
and
should
be
noted
on
the
death
certificate;
this
constitutes
the
only
situation
in
which
it
is
correct
to
refer
to
procedures.
Tumors
When a malignant tumor is considered as the underlying cause of death it is very
important to determine the primary site, if known it should be mentioned in the
certificate, otherwise it will be classified as malignant tumor of unknown primary site,
which for purposes of prevention and control of neoplasms is insufficient.
Example:
60-year-old
man
dies
from
acute
lung
edema
due
to
pulmonary
metastatic
cancer
which
he
suffered
for
a
year,
derived
from
a
prostate
adenocarcinoma
for
which
he
had
surgery
four
years
earlier.
The doctor filled the certificate as follows:
60-year-old man
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Acute
edema
of
lung____________
1
year_
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Pulmonary
metastases_________________
________
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
______________________________________
_______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
51
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
The
correct
way
to
fill
out
the
causes
in
the
death
certificate
is:
60-year-old
man
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Acute
edema
of
lung____________
1
year
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Pulmonary
metastases_________________
1
year
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
Prostate
adenocarcinoma_____________
4
years
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
In
a
badly
elaborated
death
certificate,
where
for
example
only
pulmonary
metastasis
is
written
on
the
last
line,
the
underlying
cause
of
death
will
be
malignant
neoplasm
of
unknown
primary
site,
because
the
physician
did
not
did
not
include
the
primary
site
of
the
malignant
tumor
(adenocarcinoma
of
the
prostate).
In
a
correctly-prepared
death
certificate
the
causes
have
been
annotated
in
a
correct
causal
relationship
and
the
true
underlying
cause
of
death
has
been
identified
as
adenocarcinoma
of
the
prostate.
52
5.10
Use
when
applicable
the
special
sections
of
the
Death
Certificate:
Death
of
woman
of
reproductive
age
and
death
from
accidental
or
violent
causes.
5.10.1
Death
of
a
woman
of
childbearing
age
Sometimes due to poor completion of the death certificates, misclassifications of maternal
deaths occur. To avoid this, the death certificate must include a specific paragraph or
section, so that in the event of the death of a woman of childbearing age some questions
can be answered. These include whether the death occurred during pregnancy, childbirth
or the postpartum period including the 42 days from the date of delivery or abortion but
before one year.
Example:
38-year-old
woman
is
hospitalized
one
week
after
the
live
birth
of
one
child.
Woman
dies
on
the
third
day
after
being
hospitalized,
where
she
had
been
diagnosed
with
sepsis.
The physician filled the certificate as follows:
38-year-old woman
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Sepsis______________________________
3
days
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
______________________________________
______
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
___________________________________
______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
In
the
section
on
Death
of
woman
of
childbearing
age,
the
doctor
failed
to
indicate
that
the
death
occurred
during
the
postpartum
period.
53
Death
of
woman
of
childbearing
age
Write
down
if
the
death
occurred
during:
Pregnancy
(
)
Childbirth
(
)
Postpartum
(
)
43
days
-
11
months
after
delivery
or
abortion
(
)
Woman
was
not
pregnant
(
)
In
view
of
the
above,
the
event
is
misclassified
and
the
underlying
cause
of
death
recorded
as
sepsis,
without
even
considering
that
it
was
a
maternal
death.
The correct way to write down the causes in the certificate is:
38-year-old woman
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Puerperal
sepsis____________________
3
days
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
______________________________________
______
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
___________________________________
______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
In
the
section
Death
of
woman
of
childbearing
age,
the
doctor
said
the
death
occurred
during
the
puerperium.
Death of woman of childbearing age
Write down if the death occurred during:
Pregnancy ( ) Childbirth ( ) Postpartum (X )
43 days - 11 months after delivery or abortion ( ) Woman was not pregnant ( )
The basic cause of death is puerperal sepsis and the event is classified as a maternal
death.
54
5.10.2
Death
by
accidental
or
violent
causes
When
the
death
is
the
result
of
an
accident,
an
assault
or
a
self-inflicted
injury,
what
matters
for
the
purposes
of
prevention
is
the
type
of
accident
or
violent
act
that
caused
the
death.
So,
in
case
of
an
accident
it
is
necessary
to
know
what
kind
of
accident
it
was
(e.g.
motorcycle
accident).
It
is
important
to
first
determine
the
presumed
intention
of
the
fact
(if
it
was
an
accident,
aggression
or
self-injury).
For
this,
it
is
recommended
that
the
death
certificate
have
a
specific
paragraph
or
section
so
should
it
be
an
accidental
or
violent
death,
the
event
can
be
correctly
described
and
classified
as:
- Accident
- Intentional self-harm
- Assault
- Event of undetermined intent
It
should
also
include
a
space
to
describe
the
circumstances
in
which
the
event
occurred.
For
example
in
the
case
of
a
transit
accident,
the
type
of
vehicle
or
transport
involved
should
be
indicated
(horse,
wagon,
bicycle,
motorcycle,
car,
truck,
van,
bus,
truck,
train,
etc.),
and
whether
the
victim
was
a
driver,
passenger
or
other
participant
(passenger,
traveling
next
to
the
driver,
traveling
outside
the
vehicle,
etc.).
In
case
of
a
collision
with
another
vehicle,
it
should
be
noted
what
type
of
accident
it
was,
or
if
whether
it
hit
a
fixed
object
such
as
a
fence
or
a
pole.
If
there
was
no
collision,
it
should
be
noted
if
the
vehicle
overturned.
Other
types
of
accidents
should
also
be
fully
described,
for
example
in
case
of
a
fall
(detail
how
and
where
the
person
fell),
or
in
the
case
of
accidental
poisoning,
identify
if
it
was
ingested,
snorted
or
through
contact.
In
relation
to
assaults,
the
circumstances
surrounding
the
violent
act
should
be
clearly
indicated.
For
example,
the
type
of
weapon
or
object
involved,
or
how
the
aggression
occurred.
In
the
case
of
suicides
it
is
also
important
to
detail
the
circumstances
surrounding
the
self-
injury.
In
this
section
further
information
such
as
date
and
place
of
occurrence
of
the
accident
or
violent
act
is
requested.
55
In
the
case
of
accidental
deaths,
it
is
of
primary
importance
to
identify
whether
the
event
corresponds
to
a
workplace
accident
or
if
it
occurred
in
the
course
of
going
home
to
the
workplace
or
from
home
to
the
workplace.
For
all
cases
it
is
necessary
to
specify
the
nature
of
the
lesion(s)
resulting
from
the
action
of
the
external
cause
noted
in
Part
I
of
the
death
certificate,
as
either
direct
causes
or
antecedents;
the
last
line
should
be
used
to
precisely
specify
the
external
cause.
Although there is no section designed to specifically describe the circumstances of the
external cause of injury, they may be listed as part of the underlying cause on the last line
of Part I of the death certificate.
Example:
26-year-old
man
with
head
trauma
after
the
motorcycle
he
was
driving
rolled-over
on
the
freeway.
Thirty
minutes
after
the
accident,
the
man
was
transferred
to
the
nearest
hospital
where
he
suffered
a
deep
intracerebral
hemorrhage
and
died.
The physician noted the following causes in the death certificate:
26-year-old man
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Deep
intracerebral
hemorrhage_________
60
minutes
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Traumatic
head
injury_________________
90
minutes
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
___________________________________
______
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
56
In
the
sequence
of
causes
reported
in
Part
I
and
in
the
section
on
Death
by
accident
or
violent
causes,
the
doctor
failed
to
indicate
that
the
event
was
an
accident
and
that
the
deceased
was
driving
a
motorcycle
on
the
highway
and
overturned
his
vehicle.
In
view
of
the
above,
the
event
is
misclassified
and
the
underlying
cause
of
death
is
classified
as
traumatic
brain
injury,
however,
the
external
cause
that
caused
is
not
identified
and
is
classified
instead
as
unspecified
accident
of
unspecified
cause.
The
correct
way
to
record
the
cause
of
death
is
as
follows:
26-year-old man
I
Approximate
Disease
or
condition
directly
interval
between
leading
to
death*
onset
and
death
(a)
Deep
intracerebral
hemorrhage_________
60
minutes
due
to
(or
as
consequence
of)
Antecedent
cause
of
death
(b)
Traumatic
head
injury_________________
90
minutes
Morbid
conditions,
if
any,
due
to
(or
as
consequence
of)
giving
rise
to
the
above
cause,
stating
the
underlying
(c)
Motorcycle
driver
rollover
on
highway__
90
minutes
condition
last
due
to
(or
as
consequence
of)
(d)
________________
___________________
_______
II
Other
significant
pathologies
___________________________________________
contributing
to
the
death
but
not
_______
related
to
the
disease
or
________________________________________________
_______
condition
causing
it
*This
does
not
mean
the
mode
of
dying,
e.g.,
heart
failure,
respiratory
failure.
It
means
the
disease,
injury
or
complication
that
caused
death.
In the section on "Death by accidental or violent causes" the doctor indicates:
Death by accident or violent causes
Write down if death is a result of a suspected:
Accident () Aggression ( ) Self-inflicted injury ( )
Event of undetermined intent ( )
Place of occurrence of death by accident or violent causes
Housing () Residential Institution () School or administrative area ()
Street or road () Trade or service area ()
Industrial area or building () House () Another Place ()
57
Location
not
specified
()
Description
of
the
circumstances
of
the
accident
or
violent
act
A
person
driving
his
motorcycle
at
excessive
speed
on
the
road,
lost
control
and
overturned
his
vehicle.
The
accident
occurred
on
the
way
from
his
house
to
his
workplace.
In
case
of
accidental
death,
did
the
death
occur
in
the
workplace
or
in
transit
to
or
from
work?
Yes
()
No
(
)
In
view
of
the
above,
the
underlying
cause
of
death
is
the
overturning
of
his
motorcycle
on
the
highway.
58
6.
Bibliography
1
On
the
estimation
of
mortality
rates
for
countries
of
the
Americas
(by
J.
Silvi).
Epidemiological
Bulletin
PAHO,
Vol.
24
No.
4,
December
2003.
2
PAHO/WHOs
International
statistical
classification
of
diseases,
10th
revision.
2008
Edition,
Scientific
Publication
554,
Washington,
D.C.
3
PAHO/WHOS
International
Statistical
Classification
of
Diseases
and
Related
Health
Problems,
Tenth
Revision.
2008
Edition,
Volume
2,
Users
Manual,
Scientific
Publication
No.
554,
Washington,
D.C.,
183
pp.,
p.
142
4
United
Nations
Department
of
Economic
and
Social
Affairs,
Statistics
Division.
Principles
and
Recommendations
for
a
Vital
Statistics
System,
Revision
2.
Economic
and
Social
Affairs,
Statistics
Division,
United
Nations.
New
York:
United
Nations,
2003.
page
184,
Manual.
ST/ESA/STAT/SER.M/19/Rev.2.
5
Daz
T.,
V.
Department
of
Neurology
and
Neurosurgery:
Brain
death
or
encephalic
death:
death
is
only
one.
Rev
Hosp
Cln
Univ
Chile
2009;
20:
263.
6
Ministry
of
Health
of
Mexico:
Diagnosis
of
an
encephalic
death.
Clinical
Practice
Guideline.
Master
Catalog
of
Clinical
Practice
Guidelines:
SSA-488-11.
7
Ibd.
3
8
PAHO/WHOs
International
Statistical
Classification
of
Diseases
and
Related
Health
Problems,
Tenth
Revision.
2008
Edition,
Volume
2,
User
Manual,
Scientific
Publication
No.
554,
Washington,
D.C.,
183
pp.,
p.
147-148.
9
Ibd.
8,
p.
148.
10
PAHO/WHOS
International
Statistical
Classification
of
Diseases
and
Related
Health
Problems,
Tenth
Revision.
2008
Edition,
Volume
2,
Users
Manual,
Scientific
Publication
No.
554,
Washington,
D.C.,
183
pp.,
p.
32.
11
Zacca
PE,
Martnez
MA.
How
to
fill
out
a
medical
death
certificate?
Reflections
and
instructions
regarding
a
correct
filling.
Cuba,
Virtual
University
of
Health
(Supercourse);
2006.
12
Conde
Vinacur,
J.
The
contribution
of
the
physician
in
understanding
the
communitys
health
problems
beginning
with
the
correct
certification
of
the
causes
of
death.
Physician
participation
in
the
mortality
statistics.
Argentina:
Statistical
Health
System,
Vital
Statistics
Subsystem,
National
Bureau
of
Statistics
and
Health
Information,
Ministry
of
Health
and
Environment.
Available
at:
http://www.deis.gov.ar/Capacitacion/contribucion.htm
13
Ministry
of
Public
Health
of
Uruguay.
Death
Certificate.
Guide
for
the
correct
completion
of
the
manual
and
electronic
certificate.
Distance
Learning
Course
2012
14
Mathers
CD,
Fat
DM,
Inoue
M,
Rao
C,
Lopez
AD.
Counting
the
dead
and
what
they
died
from:
an
assessment
of
the
global
status
of
cause
of
death
data.
World
Health
Organization
Bulletin.
2005
Mar;
83(3):171-177.
7. Acknowledgements
RELACSIS
Secretariat:
Alejandro
Giusti,
Beatriz
Plaza,
Patricia
Ruz
59
Authors
Danuta
Rajs
Grzebien,
Humberto
Rocha
Snchez
Reviewers:
Patricia
Nilda
Soliz
Snchez,
Elida
Marconi,
Aline
P.
Jimnez
Romero,
Luis
Manuel
Torres
Palacios,
Giselle
Tomasso
Content
digitization:
Alicia
Escard
Vgh,
Manuel
Yez
Hernndez
English
version:
Vilma
Gawryszewski
(PAHO/CHA/HA),
Ivey
Marsha
(CARPHA),
Patricia
Soliz
(PAHO/CHA/HA),
Donna
L.
Hoyert
(CDC/OPHSS/NCHS)
60
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