The accurate completion of the medical cause of death is of utmost importance for doctors in Australia. It plays a crucial role in providing vital information for public health data, research, and policy-making. This guide aims to assist doctors in understanding the process and requirements for completing the medical cause of death, ensuring accurate and reliable reporting.
As a doctor, your role in completing the medical cause of death is vital. This information serves various purposes, including epidemiological surveillance, public health planning, and the provision of mortality statistics.
By accurately documenting the cause of death, you contribute to the overall understanding of diseases, their prevalence, and their impact on the population. The death certification process is also an important safeguard against the disposal of bodies without professional scrutiny of the requirement for further investigation, particularly in relation to suspicious deaths.
Understanding the Medical Cause of Death
The medical cause of death refers to the disease or injury that directly led to a person's death. In New South Wales, the Medical Certificate of Cause of Death is the form issued by the Registry of Births, Deaths & Marriages in which a medical practitioner notifies the Registrar, Registry of Births, Deaths & Marriages of a death and the cause of that death, pursuant to legislative requirements in Section 39 of the Births, Deaths and Marriages Registration Act 1995.
When doctors are being asked to complete the death certificate, this generally refers to the Medical Certificate of Cause of Death (MCCD). However, it's crucial to distinguish the MCCD from the official death certificate issued by the Registry of Births, Deaths, and Marriages. While the MCCD confirms the cause of death, the official death certificate serves as an official record indicating that the death has been registered. The official death certificate is usually issued by the respective state's Registry of Births, Deaths, and Marriages.
It's important to understand that without a completed MCCD, it becomes difficult to arrange a funeral. The MCCD serves as an essential requirement in the funeral planning process. It provides vital information about the cause of death, which is necessary for various legal and administrative purposes.
Steps to complete the Medical Cause of Death.
Medical Certificate of Cause of Death forms generally contain demographic details of the deceased person including full name, gender, date of death, place of death, age at death, Aboriginal or Torres Strait Islander origin.
Essential steps to follow when filling out a MCCD (Medical Certificate of Cause of Death):
- In order to complete a death certificate, it is important to be confident about two things:
- Determining the cause of death.
- Ensuring that the death does not require reporting to the coroner.
- If you were involved in treating the patient shortly before their passing or if you conducted an examination of the body, you usually have a 48-hour window after the death to finalise the death certificate or the death should be reported to the coroner.
- If you feel uneasy or unable to make an informed opinion about the likely cause of death, it is advisable not to sign the death certificate. Seek guidance or advice in such situations.
In New South Wales, a death should be reported to the Coroner in the following circumstances:
- if the death was not a reasonably expected outcome of a health related/medical procedure, or healthcare caused/contributed to the death and the death was not expected by an independent person
- if the person was not attended by a medical practitioner within 6 months immediately before death.
To determine if a death should be reported to the coroner refer to NSW Health
Information Bulletin Coronial Checklist. The Coronial Checklist includes
details of how to seek advice where there is uncertainty.
Common challenges and errors.
Completing the medical cause of death can be challenging due to various factors. Here are some common challenges and errors to be aware of:
- Incomplete or inaccurate information: Limited information about the patient's medical history or circumstances surrounding their death can make it difficult to determine the accurate cause of death. It is crucial to gather as much relevant information as possible to ensure accuracy.
- Ambiguous or non-specific terminology: Using vague or ambiguous terms when documenting the cause of death can lead to confusion and inaccuracies. It is important to use precise medical terminology that clearly describes the disease or injury.
- Differentiating between immediate and underlying causes: Differentiating between the immediate cause of death and the underlying cause can sometimes be challenging. The immediate cause is the final disease or condition that directly led to death, while the underlying cause is the initiating disease or condition. Careful consideration and analysis are necessary to correctly identify these causes.
Tips for accurate completion.
To ensure accuracy when completing the medical cause of death, consider the following tips:
- Utilise proper medical terminology: Familiarise yourself with the appropriate medical terminology related to the specific diseases or injuries you encounter. Using standardised terms helps ensure consistency and clarity.
- Consult relevant medical records: Reviewing the deceased person's medical records, including diagnostic test results and consultation notes, can provide valuable insights into their health condition and contribute to accurate reporting.
- Seek assistance when uncertain: If you encounter complex cases or are unsure about the cause of death, consult with colleagues or specialists who may have more expertise in the specific area. Collaboration can help ensure accurate reporting.
The Australian Bureau of Statistics offers an information paper and a quick reference guide on the certification of the cause of death. Here are some guidelines to follow:
- Specify the specific disease, injury, or condition that directly led to the person's death, rather than simply indicating the manner of death like heart or respiratory failure.
- It is acceptable to use very brief causes of death as long as they are logical and accurately convey the main cause.
- If the direct cause of death stated in the "Cause of Death" section is a result of or linked to another disease, injury, or condition, make sure to mention this in the "Antecedent causes" section.
- Whenever the cause of death could be open to interpretation, it is important to provide an antecedent cause for clarity and accuracy.
- In the case of any type of haemorrhage or fracture, always include an antecedent cause. For example, for a fracture, you could indicate osteoporosis as the antecedent cause, and for an intracerebral haemorrhage, hypertension might be listed.
- Include only the relevant and significant information about the cause of death. The cause of death details, combined with the deceased person's identification and family information, are used to create the death certificate.
Legal Responsibilities of Medical Practitioners in New South Wales
Death certificates certify the facts and circumstances of the death of a person. According to the Births, Deaths and Marriages Registration Act 1995, the medical practitioner responsible for a person's medical care prior to their death or who examines the deceased person's body must do the following within 48 hours of the death:
a) Notify the Registrar of Births, Deaths and Marriages about the death and provide details of the cause of death.
b) If the medical practitioner believes it is not possible or advisable to provide the cause of death within that time frame, inform the Registrar about the death and express their intention to sign a death certificate with the cause of death as soon as possible thereafter.
- The Medical Certificate of Cause of Death Form is required in NSW public health organisations to notify a death.
- The form asks for the date of death or a range of dates if the exact date is unknown.
- A medical practitioner cannot provide notice based solely on the review of medical records; they must have viewed the body or have been treating the person before death.
- If another medical practitioner has already given notice or if the death has been reported to the Coroner, a medical practitioner is not required to provide repeat notice to the Registrar.
- A medical practitioner can only certify the cause of death if a diagnosis can be made. If the cause of death is uncertain, reasonable steps must be taken to gather sufficient information, such as reviewing medical records or contacting other healthcare professionals involved in the deceased person's recent care.
- If the medical practitioner is unable to determine the cause of death, the matter must be referred to the Coroner.
- If the medical practitioner is a relative of the deceased, they should not complete the certificate unless they are the only medical practitioner in a remote area. They should also disclose any anticipated benefits from the death, such as property or financial gains.
Resources and support for doctors.
Several resources and support systems are available to assist doctors in accurately completing the medical cause of death:
- Guidelines and Resources: Familiarise yourself with the guidelines provided by relevant authorities, such as the Australian Bureau of Statistics or state health departments. These guidelines outline the recommended procedures and standards for completing the MCCD.
- Training and Education: Attend workshops, seminars, or online courses that provide training on completing the medical cause of death. Continuing medical education programs often offer sessions on this topic.
Final thoughts on completing an MCCD in New South Wales.
Accurately completing the medical cause of death is an essential responsibility for doctors in New South Wales. By following a structured approach, utilising proper medical terminology, and seeking assistance when needed, you can ensure accurate reporting. Timely and accurate reporting contributes to public health data, research, and policy-making, ultimately benefiting the overall understanding and improvement of population health.