Introduction
Death is an inevitable event in every person’s life. However,
structure of the modern society has necessitated death to be authenticated
by the medical profession. Therefore the doctors have to bear and
carry out this responsibility with all fairness and pragmatism.4
Issuing a death certificates is one of the onerous duties of a General
Practitioner (GP), which can have medico-legal implications. The General
Practitioner must verify all the relevant facts before issuing a death
certificate and should not issue a death certificate under any pressure.
A doctor should do his utmost to arrive at the cause of death or at
the probable cause of death.4 The cause of death is to
be based only on clinical findings and not on extraneous factors.2
Death certificate and cause of death is to be issued only when the
treating doctor is fully satisfied as to the clinical diagnosis and
corroborative diagnostic tests, viz. electro-cardiogram in acute myocardial
infarction, cerebro-spinal fluid in meningitis, etc. A doctor may
certify death but the cause of death is to be issued only on verification
and after satisfying all facts of the cause, causing and resulting
in death.4 In case of suspicion of death due to unnatural
causes, the doctor may only certify death, and not the cause of death
and will inform police for further investigations and postmortem.
Before issuing death certificate, the doctor must verify and ascertain
the name, age, sex, religion, address of the deceased. Any correction
required later in the above-mentioned points, results in a lot of
inconvenience to the next of kin and may cause delay in finalization
of death claim, reimbursement of hospital bills,
insurance claims, obtaining probate or succession certificate, settlement
of property claims, release of gratuity and provident fund claims.4
The Maharashtra State Government Act, 1976 (Section 5(2)), stipulates
that death must be informed within 72 hours to the local municipal
authorities. Failure to do so is dealt under the Government of India
Act of 1969 relating to registration of birth and death.
Pre-requisites
Death certificate is to be issued free of charge and is not to be
withheld for pending fees payment from the relatives and friends of
the deceased.1,4 Only a single copy of the death certificate
to be issued.1,4 The doctor should always maintain a carbon
copy of the death certificate issued. The death certificate should
be issued by a registered medical practitioner who -
a) has been medical attendant of the deceased during life.
b) has attended the patient within past 14 days prior to his death.
c) is satisfied as to the cause of death.1
If necessary, only a duplicate true copy should be issued. Death certificate
is necessary even in cases of new born children who are still-born
or premature. It is desirable to view the whole body carefully before
issuing a death certificate. It should not be signed blank leaving
the details to be filled by someone else.
In partnership practice, one doctor should not certify the cause of
death of his colleague’s patient unless he too had attended
the patient during the last 14 days of his life. No certificate should
be issued in case of sudden death of a person who has not been examined
by the doctor before his/her death. No death certificate should be
issued in cases falling within the purview of the Coroner’s
Act. All the deaths which are unexpected, unexplained, unnatural,
under suspicious circumstances and of the people under custody of
police or public institutions like remand homes and asylums, and under
medical procedures should be reported to the Coroner.1
At the lower part of the certificate, the qualifications mentioned
should be those registered by the Indian or State Medical Council
and in most cases are confined to the qualifying degree and not to
a variety of post-graduate diplomas.1It is also the medical practitioner’s
responsibility to forward the D.C. to the registering authority, though
it is usually sent through a relative of the deceased, who receives
a permit to dispose of the dead body only after the death certificate
is issued.
Importance
Death certificate is an important legal document from the point of
view of the person (since deceased) and his/her next of kin. This
document (correctly filled and completed) is absolutely essential.
Cremation or Burial Pass is obtained from the municipal authorities
so that cremation and final rites of the deceased person can take
place as per his/her religion, without loss of time and any inconvenience
to relatives and friends.
Proper registration with the local municipal authorities, of all the
details of the death certificate of the deceased person, must be done
so that life insurance claim and settlement can be processed. All
legal dues like gratuity, provident fund and family pension can be
settled from the office of the deceased person if he/she was a salaried
person, distribution of movable and immovable property of the deceased
person (as per his/her last Testament or Will) can be bequeathed to
legal heirs. The executor of the Will can obtain a certified copy
of the death certificate from local municipal authorities before proceeding
to obtain probate or succession certificate from civil court. Legal
claim under personal accident benefit policy can be processed in case
of accidental death. Deletion of the deceased person’s name
from Ration Card, or from movable or immovable property extract viz.
share, house or flat, etc. will also need a certified copy of the
duly completed death certificate.4
International Format
The International Classification Diseases should be used in death
certificate whenever possible to maintain uniformity and facilitate
fast retrieval of data through computerization.4,6
The death certificate recommended by World Health Organization (WHO)
for International use, is in two parts (Fig. 1). Part I : Records
(a) the “disease or condition directly leading to death”
and (b) Antecedent causes viz. the “morbid conditions, if any,
giving rise to the cause mentioned in (a). Thus, “(a)”
must be due to “(b)” which must be due to “(c)”,
etc. (Fig. 1). The basic pathological condition is that which is mentioned
on the lower most line, and this is the one that is used for statistical
and epidemiological purposes. The symptomatology or mode of death
e.g. cardio-respiratory failure, asthenia, or asphyxia etc., should
not be recorded in the cause of death, unless explained. Part II :
Records “other significant conditions contributing to death,
but not related to the disease or condition causing it”.1,3,5
The underlying cause of death is defined as “the disease which
initiated the train of morbid events leading directly to death”.
International forms are used by various municipal authorities in our
country and are available for doctors. Doctors should necessarily
use their rubber stamp after affixing signature to death certificate.
Printed forms are made available by the municipal authorities to doctors
and hospitals for issuing death certificate.
The basis of mortality
data is the Death Certificate.3 For ensuring national and
international comparability, it is very necessary to have a uniform
and standardized system of recording and classifying deaths.
According to the recommendations of the Brodrick Committee, a doctor
should not be allowed to issue a death certificate, unless he has
attended to the deceased at least once during the seven days preceding
death, and that the standard of accuracy of a death certificate should
be raised from the present level of "to the best of knowledge
and belief” to one of “confidence”.5
Post-mortem Examination
Earlier, it was a dictum that in case of a patient dying within 24
hours after admission to a hospital, postmortem was ordered to establish
the exact cause of death. In view of the tremendous advances of technological
developments in imaging, electronic and laboratory equipment, 4 to
6 hours are enough to diagnose most of the cases admitted to a hospital
in emergency. Thus, diagnosis can be established before death and
the need of doing postmortem is obviated wherever death is due to
disease or natural illness. However, in case of death under suspicious
condition, medico-legal postmortem is mandatory to ascertain the exact
cause of death.4
It was an earlier practice to send all bodies, where deaths occurred
in medico-legal cases for medico-legal postmortem. With advancement
in technological and scientific knowledge, accurate diagnosis is possible
in a given case. So, wherever possible, the death certificate and
cause of death may be issued in a medico-legal case. However, it must
be noted that the death certificate must be handed over to police
along with the dead body for final ‘Panchanama’. The police
authorities have the final say in this matter. If the police authorities
still want a postmortem they can order so accordingly. In cases registered
under Indian Penal Code (Sec. 498-A), due precautions must be taken
before issuing the cause of death.4,5
Social Issues
Death certificate is a predicament in any doctor’s practice.
Every doctor has faced a situation where he/she has been in a dilemma
- whether or not to issue a death certificate. The relatives of the
deceased may plead, persuade, pressurize, even offer a price and at
times, even threaten the doctor. He/she may be tempted to issue a
death certificate in doubtful situations; purely on humanitarian grounds
or for the fear of losing clientele.4 But the doctor is
advised to apply great caution while issuing a death certificate as
the final certificate may unwittingly help in destroying evidence
of a crime. Once the body is cremated, the evidence is lost. In such
a situation, the doctor may find himself in trouble with the law.4
In India, a General Practitioner (G.P.) is usually considered a family
physician and has a regular clientele. Whenever required, these patients
attend the GP’s clinic. If a regularly visiting patient, who
has not been examined recently by the doctor dies suddenly, then the
doctor is in a dilemma, about whether or not to issue the death certificate.
A similar situation is often experienced by the G.P. when called to
attend a critically ill, unknown patient who is staying as a visitor/guest
in the house of his acquaintance/regular patient. If such a patient
dies, before receiving any treatment from the doctor, social pressure
may be brought on the G.P. to issue a death certificate.4
If the G.P. has seen and treated the patient in the last 14 days,
he is justified in issuing the D.C. Otherwise, he may land-up with
a legal problem.4 The G.P. is advised to properly explain
the situation to his family patient or acquaintance and politely decline
to yield under pressure. He/she is further advised to guide the family
on further procedures to obtain the D.C. The patients usually appreciate
such steps and there is less chance of losing one’s clientele.4
The Code of Medical Ethics permits overriding the rule of confidentiality
and disclosure of the fact that the deceased was suffering from HIV/AIDS
infection.4 This exception to the Code of Medical Ethics
is permitted in public interest and overrides confidentiality.4
Errors in Death Certificate
It is often noticed that some rectification may be required in the
death certificate. If any such irregularity is noticed in D.C. by
relatives of the deceased, it is possible for the doctor issuing the
D.C. to correct it before the cremation/burial pass is obtained from
the Municipal Authorities. But, later on, correction in the extract
of a D.C. involves a long legal process. The next of kin has to struggle
a lot to get even minor corrections done in D.C. and for lack of such
rectifications, Insurance claims, gratuity, provident fund, etc. remain
unsettled, causing a lot of inconvenience to members of the bereaved
family.
Therefore, the doctor should be very careful in filling up details
in D.C. like name, age, sex, religion and address and the cause of
death.
References
1. Kapoor OP. “Kapoor’s Guide for General Practitioners”
Part-II. 4th Edition. 1996. SS Publishers, Mumbai. Pages 181-2.
2. Government of Maharashtra: “Hospital Administration Manual”.
June 1976. Reprinted in 1991, page 149.
3. Park K. “Park’s Text Book of Preventive and Social
Medicine”. 16th Edition. Banarsidas Bhanot, Jabalpur. 2000,
pages 46-47.
4. Bokil PV. “Death certificate”. QPMPA Journal of Medical
Sciences 2002;16 (3) : 84-6.
5. Subrahamanyam BV. “Modi’s Text Book of Medical Jurisprudence
and Toxicology”. 22nd edition. 1999. Butterworths India, New
Delhi. Page 15.
6. World Health Organization: “International Statistical Classification
of Diseases and Related Health Problems - Tenth Revision (ICD-10)”
Volume 2. Instruction Manual. World Health Organization, Geneva. 1993.
Pages 30-32.
*Lecturer;
**Acting Professor and Head; Department of Preventive and Social Medicine,
Rajiv Gandhi Medical College, Kalwa, Thane - 400 605, Maharashtra.
