Original Article

Death Certificates Are Not Reliable: Revivification of the Autopsy

Authors: Keyvan Ravakhah, MD, MBA, FACP

Abstract

Background: Medicine assumes that vital statistics are accurate, but they are only as good as the death certificates.


Objective: To evaluate the accuracy of death certificates in reporting vital statistics with an emphasis on cardiac deaths.


Design: A population-based retrospective study within one community hospital.


Patients: During the study period, 1,619 patients expired during hospitalization, of which 223 underwent autopsy.


Interventions: Clinical diagnoses were determined from the death certificate and autopsy results from the final pathology reports.


Measurements: Concordance of myocardial infarction as the underlying cause of death between the death certificate and the autopsy was measured. New diagnoses uncovered by the autopsy were tabulated.


Results: The death certificate missed acute myocardial infarction in 25 of 52 autopsy-proven cases (48% errors of omission). Conversely, it erroneously asserted the presence of an acute myocardial infarction in 9/36 cases (25% errors of commission). Autopsy showed these nine cases actually were pneumonia (5), sepsis with ARDS (2), cerebral hemorrhage (1), and cardiac tamponade (1). Autopsy proved 52 myocardial infarctions causing death, while death certificates accurately reported only 27. Myocardial infarction was more likely to be unsuspected in extreme ages, in women, when found in right ventricle or posterior wall, and in the presence of sepsis or ARDS. Death certificates were frequently inaccurate and in 21.5% of cases were of no value because of an inadequate diagnosis, ie, cardiopulmonary arrest, arrhythmia or respiratory failure.


Conclusion: Major discrepancies of commission and omission occur frequently between the death certificate and autopsy. 1) Death certificates are often wrong. 2) The time-honored autopsy is more valuable than ever. 3) Physicians need to write better death certificates and correct them. 4) Death certificate-based vital statistics should be corrected with autopsy results. 5) Vital statistics should note deaths confirmed by autopsy. 6) More autopsies would improve vital statistics and the practice of medicine.


Key Points


* Death certificates are not reliable.


* Autopsy reports remain valuable sources of medical information.


* Physicians need to be trained on how to complete death certificates.

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References

1. National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2000 Chart Book On Cardiovascular, Lung, and Blood Diseases., May 2000. Available at: http://www.nhlbi.nih.gov/index.htm. Accessed March 2004.
 
2. Fogelman A, Murphy F, Edwards P. Pathogenesis of atherosclerosis. In: Kelley W, ed. Kelley’s Textbook of Internal Medicine, 3rd ed. Philadelphia, Lippincott Raven, 1997, p 158.
 
3. Lee TH. Practice guidelines in cardiovascular medicine. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine, 5th ed. Philadelphia, WB Saunders, 1997, pp 1939–1940.
 
4. Kircher T, Nelson J, Burdo H. The autopsy as a measure of accuracy of the death certificate. N Engl J Med 1985;313:1263–1269.
 
5. Glasser JH. The quality and utility of the death certificate data. Am J Public Health 1981;71:231–233.
 
6. Dalen JE. The moribund autopsy: DNR or CPR? Arch Intern Med 1997;157:1633.
 
7. Blosser SA, Zimmerman HE, Stauffer JL. Do autopsies of critically ill patients reveal important findings that were clinically undetected? Crit Care Med 1998;26:1332–1336.
 
8. Hasson J, Scheiderman H. Autopsy training: to right a wrong. Arch Pathol Lab Med 1995;119:289–291.
 
9. Zaitoun AM, Fernandez C. The value of histological examination in the audit of hospital autopsies: a quantitative approach. Pathology 1998;30:100–104.
 
10. Nichols L, Aronica P, Babe C. Are autopsies obsolete? Am J Clin Pathol 1998;110:210–218.
 
11. Kumar P, Taxy J, Angst DB, et al. Autopsies in children: are they still useful? Arch Pediatr Adolesc Med 1998;152:558–563.
 
12. Hirsch L. Mortality data statistics flawed, pathologist charges. Am Med News December 1982:8–10.
 
13. Glantz SA. Primer of Biostatistics, 4th ed. New York, McGraw-Hill, 1997.
 
14. Anonymous. National Center for Health Statistics. Vital Statistics ICD-9 underlying cause of death lists for tabulating mortality statistics. Hyattsville, Md, Public Health Service, 1979.
 
15. Geller SA. Autopsy. Sci Am 1983;248:124–136.
 
16. Messite J, Stellman SD. Accuracy of death certificate completion: the need for formalized physician training. JAMA 1996;275:794–796.