You are in the practice alone early one morning when you take a phone call from a local aged care facility, asking you to complete a death certificate for a patient. The manager explains they have found Mrs Jane unresponsive in her bed this morning and believe she died peacefully in her sleep. Her family are with her now and they need you to sign the death certificate urgently so they can transfer Mrs Jane to the funeral home. You remember Mrs Jane had been a long-standing patient of the practice, but you don’t recall seeing her for some time. According to the patient records, she was diagnosed with vascular dementia years ago and had a history of heart failure, but you haven’t seen her for nearly a year. What should you do about signing the death certificate?*
Completing a Medical Certificate of Cause of Death (MCCD or death certificate), frequently generates calls to Avant’s Medico-legal Advisory Service. Doctors tell us they can feel pressure from families, other health practitioners, funeral directors, or police, to sign the form, and they often call looking for guidance or reassurance.
This scenario illustrates some of the common questions we hear.
What are you required to do?
In most states and territories, the legal starting point is that you will be responsible for completing the death certificate for Mrs Jane if you:
- were responsible for the patient’s medical care immediately before her death, or
- examined her body.
The death certificate needs to be completed within 48 hours. The exceptions are if:
- the death has been reported to the coroner (whether you or someone else has reported it) or
- someone else has completed the death certificate.
In many jurisdictions this means that if you were treating the patient, or you examined the body, you need to take some steps to complete the death certificate or arrange for it to be completed. If the death certificate cannot be completed in time (for example because you are unsure about the cause of death), you may need to report the death to the coroner.
The wording, ‘responsible for the patient’s care immediately before death’ can cause confusion. Doctors sometimes ask what their options are in scenarios such as the one above, where a patient dies while under the care of a palliative care team or in an aged care facility.
There are several factors that determine what steps to take, including where in Australia this scenario takes place. In this article we discuss the issues generally - see the references at the end of this article for more specific guidance for your state or territory.
Could you complete the death certificate?
Even if you have not treated Mrs Jane recently, in most cases, you will be able to complete the death certificate if you are satisfied both:
- that there is no reason the death needs to be reported to the coroner, and
- of the probable cause of death.
Might Mrs Jane’s death need to be reported to the coroner?
If there was any reason to suspect Mrs Jane’s death had been violent or unnatural or had occurred in unusual or suspicious circumstances, it would need to be reported to the coroner and you must not sign the death certificate.
If Mrs Jane’s death resulted from an accident or injury, in most cases it would need to be reported to the coroner. However, if you are in NSW an accidental death may not need to be reported where the patient is 72 or older, and you are confident the accident is attributable to age and that it was not caused by any other person’s act or omission.
The law in each state and territory has a list of other reasons why a death would need to be reported to the coroner in that jurisdiction, including deaths after medical intervention. These vary and do change so it is important to check the requirements where you practise at the time (see the list of resources below).
Do you need to see the patient to complete the death certificate?
If you decide you are comfortable to complete the death certificate, it is not always legally necessary for you to view the body.
Again, however, that does depend on where you are practising. In some jurisdictions the death certificate must be signed by someone who was either treating the patient immediately before death, or who viewed the body of the patient, which would mean in this scenario you would be expected to view the body.
It is also important that you are certain about the cause of death. Unfortunately, there have been cases where doctors have signed a death certificate in a similar situation, then been contacted by the coroner when evidence emerged that suggested there were other factors involved in the patient’s death.
If you have any questions about the cause of death, we recommend you make every effort to examine the body. Without an examination it can be difficult to confidently determine the cause of death or assess whether it needs to be reported.
If you are unable to view the body in person, there may be an option to view the body by video. Contact Avant if you are in this situation.
How sure do you need to be about which condition caused death?
Even if you do not believe Mrs Jane’s death is reportable, you should only complete the death certificate if you are satisfied about which disease or condition directly led to her death. Non-specific causes such as ‘frailty’ or ‘old age’ should not be recorded as the only cause of death.
In the case of a patient with multiple co-morbidities, you can seek advice if you are unsure which condition to record as the cause of death. In most states you can contact the local coroner’s office who will generally be able to assist with reviewing the patient’s medical history and reaching a consensus on the most probable cause. The coroner should then be able to confirm that you can complete the death certificate, recording the cause of death as agreed. Keep a record of your discussion and the rationale for the conclusion you reached.
The Australian Bureau of Statistics Information Paper on Cause of Death Certification also provides guidance on recording deaths due to complex or non-specific causes such as frailty, natural causes and COVID.
It may be appropriate to contact the family of the deceased person to discuss the probable cause of death - if doing so, bear in mind the privacy issues as the confidentiality of health information survives a person’s death (see Avant - Medical records of deceased patients for more information).
What are the options if you’re not comfortable completing the death certificate?
If you are not satisfied as to the cause of death, you should not complete the death certificate.
As noted, you can contact the local coroner’s office for advice.
You can also contact Avant for advice.
If the death certificate cannot be completed because there is no medical practitioner who can be satisfied of the cause of death, even after consultation, the death needs to be reported to the coroner.
Resources and further reading
The rules around certifying death are different in every state, and they are contained in a range of legislation and regulations. There may also be guides and policies which are not always consistent.
All states and territories also require permits to be issued before the body of a deceased person can be cremated. The details of these requirements vary considerably between jurisdictions.
It is complicated and often confusing.
To assist members, Avant has produced some new resources – factsheets and decision guides for each jurisdiction – to help clarify some of the most common issues.
For more information or immediate medico-legal advice, call us on 1800 128 268, 24/7 in emergencies.
*This scenario is based on Avant claims experience to date. Details have been amended for privacy reasons and issues have been summarised for the sake of discussion.