Medical Certification of Death Outline PDF

**OUTLINE** I. **Introduction** II. **Verbal Autopsy** III. **Registrable Acts & Events** a. Death b. Fetal Death c. Place of Registration IV. **Who is responsible in reporting the event and preparing the certificate of death/certificate of Fetal Death (COD/COFD)?** V. **Who certifi...

**OUTLINE** I. **Introduction** II. **Verbal Autopsy** III. **Registrable Acts & Events** a. Death b. Fetal Death c. Place of Registration IV. **Who is responsible in reporting the event and preparing the certificate of death/certificate of Fetal Death (COD/COFD)?** V. **Who certifies the COD?** VI. **Who reviews the COD?** VII. **When can Registration of Death be denied?** VIII. **Delayed Registration** IX. **Uses of Certificate of Death** X. **Medical Certification** XI. **Causes of Death** a. Immediate Cause of Death b. Antecedent Cause of Death c. Underlying/ Proximate Cause of Death XII. **Mechanism of Death** XIII. **Manner of Death** XIV. **Causes of Death** XV. **General Guidelines for Completing the Medical Certificate Portion of the COD** XVI. **Guidelines for Reporting Causes of Death in Specific Groups of Conditions** +-----------------------+-----------------------+-----------------------+ | **LEGEND** | | | +=======================+=======================+=======================+ | ⭐ | 🖊️ | 📖 | | | | | | Must | Lecture | Book | | | | | | Know | *\[lec\]* | *\[bk\]* | +-----------------------+-----------------------+-----------------------+ INTRODUCTION {#introduction.TransOutline} ============ - ⭐The **Certificate of Death (CoD**) is a permanent legal record that contains an individual's death information. It provides important information and data on the circumstances surrounding the death. - It has various uses: - Settlement of claims - Inheritance - Insurance benefits - Proof of death - Burial arrangement - The information on the death certificate is coded and classified using the International Classification of Diseases (ICD) Version 10. VERBAL AUTOPSY {#verbal-autopsy.TransOutline} ============== - For the many deaths occurring in the Philippines that are not attended by a physician, the best way of ascertaining the cause of death by the local health authority is through **verbal autopsy**. - This is done by interviewing family members who are knowledgeable as to the probable cause of death. - This is the **task of the local health officer** since he or she signs the death certificate for those not medically attended. - 🖊️This method is undertaken using a standard questionnaire that asks for information on signs, symptoms, medical history, and circumstances preceding death. REGISTRABLE ACTS & EVENTS {#registrable-acts-events.TransOutline} ========================= A. DEATH {#a.-death.TransSubtopic1} -------- - Refers to the **permanent disappearance of all evidence of life** at any time after live birth has taken place or the postnatal cessation of vital functions without the capability of resuscitation. B. FETAL DEATH {#b.-fetal-death.TransSubtopic1} -------------- - **Death prior to the complete expulsion or extraction from the mother** of a product of conception, irrespective of the duration of pregnancy. - The death is indicated by the fact that after such separation the fetus does not breathe nor show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. - In cases when the fetus has an intrauterine life of less than seven months, it is not deemed born if it dies within 24 hours after its complete delivery from the maternal womb. C. PLACE OF REGISTRATION {#c.-place-of-registration.TransSubtopic1} ------------------------ - As a general rule, the place of registration is the city or municipality where the event occurs. - Except in circumstances where the place of death is not ascertained, then the place of registration is the city or municipality of usual residence of the deceased or where the deceased will be buried. +-----------------+-----------------+-----------------+-----------------+ | **Table 1. | | | | | Guide to Fetal | | | | | Death | | | | | Registration** | | | | +=================+=================+=================+=================+ | **Intrauterine | **Fetus lived | **Fetus lived | **Remarks** | | Life** | less than 24 | more than 24 | | | | hours** | hours** | | +-----------------+-----------------+-----------------+-----------------+ | Less than 7 | X | | Accomplish COLB | | months | | | and COD, two | | | | | copies each | | | | | with remarks | | | | | "For | | | | | statistical | | | | | purposes" | | | | | | | | | | (One copy each | | | | | for LCR and CRG | +-----------------+-----------------+-----------------+-----------------+ | | | X | Accomplish 4 | | | | | copies and | | | | | register (one | | | | | copy each for | | | | | registrant, | | | | | CRG, C/MCR. | | | | | Attendant at | | | | | death) | +-----------------+-----------------+-----------------+-----------------+ | More than 7 | X | X | Accomplish 4 | | months | | | copies and | | | | | register (one | | | | | copy each for | | | | | registrant, | | | | | CRG, C/MCR. | | | | | Attendant at | | | | | death | +-----------------+-----------------+-----------------+-----------------+ | **COLB -- | | | | | Certificate of | | | | | Live Birth;** | | | | | | | | | | **COLD -- | | | | | Certificate of | | | | | Live Death;** | | | | | | | | | | **COD -- | | | | | Certificate of | | | | | Death;** | | | | | | | | | | **LCR -- Local | | | | | Civil | | | | | Registry;** | | | | | | | | | | **CRG -- Civil | | | | | Registrar | | | | | General;** | | | | | | | | | | **C/MCR - | | | | | City/Municipal | | | | | Civil | | | | | Registrar** | | | | +-----------------+-----------------+-----------------+-----------------+ WHO IS RESPONSIBLE IN REPORTING THE EVENT AND PREPARING THE CERTIFICATE OF DEATH/ CERTIFICATE OF FETAL DEAHT (COD/COFD)? {#who-is-responsible-in-reporting-the-event-and-preparing-the-certificate-of-death-certificate-of-fetal-deaht-codcofd.TransOutline} ======================================================================================================================== A. FOR DEATH THAT OCCURRED IN THE HOSPITAL {#a.-for-death-that-occurred-in-the-hospital.TransSubtopic1} ------------------------------------------ - When a death occurs, **[the physician]** who last attended the deceased or the **[administrator of the hospital or clinic]** where the person died is responsible for preparing the COD and certifying the cause of death. - The certificate is forwarded, **within 48 hours after death**, to the local health officer who will review the certificate and affix his signature in the "Reviewed By" portion and direct its registration at the LCRO (Local Civil Registry Office) **within 30 days.** B. FOR DEATH IN HOSPITAL IN THE EMERGENCY ROOM (ER) {#b.-for-death-in-hospital-in-the-emergency-room-er.TransSubtopic1} --------------------------------------------------- - **Emergency room (ER) deaths** refer to deaths of patients occurring in the ER, including patients who were revived by initial resuscitative measures at the ER but eventually died there, regardless of the time of stay in the ER. - In such cases, the Certificate of Death shall be accomplished by the **[ER officer]** if he can provide a definite diagnosis. - Otherwise, the death should be referred to the **[Medico-Legal Officer]** of the hospital or the local health officer who shall cause the issuance of the Certificate of Death. C. FOR DEATH THAT OCCURRED IN THE AMBULANCE {#c.-for-death-that-occurred-in-the-ambulance.TransSubtopic1} ------------------------------------------- - When a death occurs in the ambulance while the patient is being transferred to another healthcare facility, the **[attending physician]** during the transport of the patient shall accomplish the Certificate of Death. D. FOR DEATH THAT OCCURRED OUTSIDE THE HOSPITAL {#d.-for-death-that-occurred-outside-the-hospital.TransSubtopic1} ----------------------------------------------- - If the deceased died without medical attendance, **the nearest relative or any person who has knowledge of the death** is responsible for reporting the event to the local health officer **within 48 hours.** - The Local Health Officer is the one who will prepare the COD/COFD, certify the cause(s) of death, and review and direct its registration at the Local Civil Registry Office within 30 days. - ⭐In the absence of the local health officer the death should be reported to the **mayor, or any member of the Sangguniang Bayan, or to the municipal secretary** who shall issue the Certificate of Death for burial purposes. E. SPECIAL CASES {#e.-special-cases.TransSubtopic1} ---------------- - For death that occurred in a **vehicle/vessel/airplane** - **Local Health Officer or his authorized representative**, who shall examine the deceased, prepare the COD, certify as to the cause of death, reviews and directs its registration to LCRO. - In accidents where there are **no survivors** - The **concerned Local Health Officer or his authorized representative** - When **mass death occurs**, and several persons die during calamities, accidents, or epidemics and the deceased cannot be identified - The **Local Health Officer** - The certificates must bear an annotation "Body Not Identified." - An **affidavit** by two disinterested persons must be submitted together with the Certificate of Death and should contain the following information: - Sex of the deceased - Estimated age - Distinguishing features - Date, place, and condition of the body when found - Circumstances surrounding death F. DEATH WITHOUT MEDICAL ATTENDANCE {#f.-death-without-medical-attendance.TransSubtopic1} ----------------------------------- - The **Municipal Health Office or the City Health Office** (or in some cases the Local Civil Registry Office) prepares the certificate and its local health officer will provide entries for the Medical Certificate portion of the form. - 🖊️ Entries to the Medical Certificate must be accomplished by the physician correctly and completely before causing its registration at the Local Civil Registry Office since there is a **prohibition against change or correction of entries in the Certificate of Death without a judicial order.** G. FOR DEATH OF FILIPINO MUSLIMS IN INDIGENOUS CULTURAL COMMUNITIES/INDIGENOUS PEOPLE (ICC/ICP) {#g.-for-death-of-filipino-muslims-in-indigenous-cultural-communitiesindigenous-people-iccicp.TransSubtopic1} ----------------------------------------------------------------------------------------------- - For Filipino Muslims, Indigenous Cultural Communities/Indigenous Peoples (ICCs/IPs), the dead body **may be buried even without a Certificate of Death** provided that the death shall be reported to the local health officer within 48 hours after the date of burial. - **[The Local Health Officer]** shall prepare the COD, certify the cause of death, and submit the COD to the LCR for registration. - **Reminder**: Aside from the COD/COFD, it is required to have an attachment that shall constitute the facts of the occurrence of the event. - **Municipal Form 103 (IP Form 2)** - Attachment for the death of ICCs/Indigenous Peoples (Annex 3) - **Municipal Form 103 (Muslim Form)** - Attachment for Muslim deaths (Annex 4) H. FOR DEATH UNDER MEDICO-LEGAL EXAMINATION {#h.-for-death-under-medico-legal-examination.TransSubtopic1} ------------------------------------------- - If the physician has reasons to believe or suspect that the cause of death was due to violence or crime (or that he is dealing with a medico-legal case), then he **is duty-bound to immediately report to the authorities of the Philippine National Police (PNP) or the National Bureau of Investigation (NBI).** - There is violence or crime when the cause of death was due, but not limited, to the following: - Stab wounds - Gunshot wounds - Suicide of any kind - Strangulation - Accident resulting to death - Actual physical assault inflicting injuries upon a person resulting in death - Any other acts of violence upon a person resulting in death - Sudden death of undetermined cause - When the death under medico-legal investigation has not been registered, the **head of the PNP or NBI or his authorized representative shall cause the registration** of such death through the local health officer of the city or municipality where the death occurred. - The **Medico-Legal Officer** of this investigative agency will accomplish and sign the Medical Certificate portion of the Certificate of Death. WHO CERTIFIES THE CERTIFICATE OF DEATH? {#who-certifies-the-certificate-of-death.TransOutline} ======================================= - If there is a medical attendant at death, the certifying officer is the **attendant at death.** - If there is no medical attendant at death, the certifying officer is the **local health officer.** - If there is no medical attendant at death and the local health officer is not available, the **mayor**, **any member of the Sangguniang Bayan**, or the **municipal secretary** may issue a certificate of death for burial purposes only. - In medico-legal cases, the certifying officer is the **Medico-Legal Officer.** WHO REVIEWS THE CERTIFICATE OF DEATH? {#who-reviews-the-certificate-of-death.TransOutline} ===================================== - In all cases, the medical certificate of death shall be reviewed and signed by **the Local Health Officer (Municipal/City Health Officer).** WHEN CAN REGISTRATION OF DEATH BE DENIED? {#when-can-registration-of-death-be-denied.TransOutline} ========================================= - The local civil registrar **cannot deny registration** except for insufficiency of information. The entries are essential to identify the deceased and his/her cause of death. It is important that these should be mandatorily entered in the death certificate, otherwise the document shall be considered valueless. - Application for registration of death shall not be allowed if the **entries in the full name of the deceased and the cause of death are not provided.** DELAYED REGISTRATION {#delayed-registration.TransOutline} ==================== - Registration of death beyond **30 days shall be considered for delayed registration** and shall be accepted only if the procedures and requirements are observed and complied with. - **Requirements:** - Four copies of COD were accomplished correctly and completely. - **Affidavit for delayed registration** which shall be executed by the **hospital/ clinic administrator**, if the person died in the hospital, clinic, or similar institution, or if the person died elsewhere, by the attendant at death. Otherwise, the **affidavit shall be executed by any of the nearest relatives of the deceased**, or by any person having legal charge of the deceased when he was still alive. - **Authenticated copy of the certificate of burial, cremation, or other means of corpse disposal.** - **Approval for registration** by the health officer in the box provided in the COD. - Reminder: Entries in the Medical Certificate Portion of the Certificate of Death must be accomplished by the attending physician/local health officer/medico-legal officer correctly and completely before registration since there is a prohibition against change or correction of entries without a judicial order. USES OF CERTIFICATE OF DEATH {#uses-of-certificate-of-death.TransOutline} ============================ - Prima facie evidence of death - Claim of benefits, pensions, insurance, or tax exemption - Evidence for settlement of the estate - Remarriage purpose of surviving spouse - Designation of a guardian or foster parent for a minor - Determine health priorities for the prevention of deaths due to similar causes in the future - The information is also important for family members so that they know what caused the death and are aware of conditions that may occur or could be prevented in other family members MEDICAL CERTIFICATION {#medical-certification.TransOutline} ===================== - **Death** - Refers to the permanent disappearance of all evidence of life at any time after live birth has taken place, or the postnatal cessation of vital functions without capability of resuscitation. - **Fetal death** - Death prior to the complete expulsion or extraction from the mother of a product of conception, irrespective of the duration of pregnancy. - Death is indicated by the fact that after such separation, the fetus does not breathe nor show any other evidence of life, such as the beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. A. UNDERSTANDING THE CERTIFICATE OF DEATH {#a.-understanding-the-certificate-of-death.TransSubtopic1} ----------------------------------------- - **The Certificate of Death, Municipal Form No. 103, (Annex 1)** - Conforms to the International Form of Medical Certificate recommended by the World Health Organization (WHO) with some modifications. - This certificate, which was revised in January 2007, has a change in color from blue in the January 1993 version to white in the current 2007 version. - The new version of the form also includes an **additional item, No. 19c. Maternal Condition** (if the deceased is female aged 15-49 years old), which was not present in the old form. - **The Medical Certificate portion of the Certificate of Death includes:** - Items 19b to 22 for deceased aged 8 days and above - Items 14 to 19a for deceased children aged 0 to 7 days - Entries to all of these items must be filled out by the attending physician or the local health officer if the deceased died without medical attendance. - As a certifier of death, the attending physician or local health officer must affix his signature to the last item, number 22. - The last item also includes a Reviewed By portion where the local health officer will affix his signature after a thorough evaluation and review of the certificate. **If the deceased died without medical attendance, the local health officer will affix his signature twice**, one as the certifier of death and the other as the reviewer. B. PARTS OF MEDICAL CERTIFICATE {#b.-parts-of-medical-certificate.TransSubtopic1} ------------------------------- A close-up of a certificate Description automatically generated - Figure 1: The death certificate Municipal Form No. 103 - 🖊️This slide shows items 1-13, which include the name of the deceased, date of death, date of birth, age at the time of death, place of death, religious sect, citizenship, residence at the time of death, occupation, name of father, and maiden name of mother.  Figure 2: The death certificate Municipal Form No. 103 - 🖊️ Item number 14 is for children aged 0-7 days. It includes the age of the mother, method of delivery, length of pregnancy, type of birth (single, twin, triplets), multiple births (the child was first, second, third), and the medical certificate which includes your 19a item -- main disease, other diseases, main maternal disease, and other relevant circumstances. A medical certificate with a medical record Description automatically generated with medium confidence Figure 3: The death certificate Municipal Form No. 103 - 🖊️ As we continue with the medical certificate for ages 0-7 days, item number 19b will indicate the causes of death. Here you will see the immediate cause of death, antecedent cause of death, underlying cause of death, and other significant conditions contributing to death. - 🖊️ You also have to put entries that indicate the interval between onset and death. For example, there is acute myocardial infarction, 1 hour or 2 hours interval. - 🖊️ 19c refers to a maternal condition. - 🖊️ Death by external causes is 19d where it indicates manner of death. Whether it is natural death, homicide, suicide, or accidental death. Place where the death occurs. - 🖊️ Item no. 20 will indicate if an autopsy was conducted or not. - 🖊️ 21a will indicate if there was an attending physician. - 🖊️ 22 will indicate the place where the certifier of death will be signing the death certificate and also the reviewer. ITEMS THAT MUST BE FILLED OUT BY THE CERTIFIER OF DEATH WHEN COMPLETING THE MEDICAL CERTIFICATE PORTION OF THE CERTIFICATE OF DEATH {#items-that-must-be-filled-out-by-the-certifier-of-death-when-completing-the-medical-certificate-portion-of-the-certificate-of-death.TransSub-subtopic2} ----------------------------------------------------------------------------------------------------------------------------------- - 19b. **Causes of death** entry containing three lines marked (a), (b), and (c) with the corresponding lines for the entry of interval between onset and death, and a line for other significant conditions contributing to death. - 19c. **Maternal condition** if the deceased is female aged 15 to 49 years old. - 19d. **Death by external causes** which include manner of death and place of occurrence of external cause, when applicable. - 20\. **Autopsy**, whether done or not. - 21a. **Attendant before death**, whether cared for by a private physician, public health officer, hospital authority, none, or others (specify). - 21b. **Dates for the duration of time of attendance** if the deceased was attended to or cared for by a health worker before death. - 22\. **Certification of death** containing the time of death and whether the deceased was attended or not; signature, name, position, and address of the certifier and the date signed; and name and signature of local health officer as reviewer and the date signed. **Figure 4.** Death Certificate Municipal Form No. 103 - 🖊️As we continue with the **municipal form no. 103, item no. 26** indicates the certification of the informant, the one who will provide information on the entries that will be placed on the death certificate the one who will receive the information, and the **one who prepared the death certificate.** A close-up of a certificate Description automatically generated**Figure 5.** Death Certificate Municipal Form No. 103 - 🖊️ At the back of the municipal form no. 103, there is a heading, the postmortem certificate of death. I hereby certify that I have performed an autopsy upon the body of the deceased and that the cause of death was. This is the part where the body was examined or autopsied **by MELO either from the PNP, NBI, or municipal health officer. ** CAUSES OF DEATH {#causes-of-death.TransOutline} =============== - Any injury, disease, or combination of both, responsible for **initiating the trend or physiological disturbance**, brief or prolonged, which produced the fatal termination. - It may be: - Immediate or Primary Cause of death - Proximate or Secondary Cause of death - Antecedent Cause of death A. IMMEDIATE CAUSE OF DEATH {#a.-immediate-cause-of-death.TransSubtopic1} --------------------------- - Cause that **directly leads to death** - Trauma or disease kills quickly - Ex. Brain laceration due to VA B. ANTECEDENT CAUSE OF DEATH {#b.-antecedent-cause-of-death.TransSubtopic1} ---------------------------- - Intervening cause/s between the underlying cause of death. C. UNDERLYING/PROXIMATE CAUSE OF DEATH {#c.-underlyingproximate-cause-of-death.TransSubtopic1} -------------------------------------- - Injury or disease survived for a prolonged period of time, which permitted the **development of complications.** - Ex. Peritonitis from stab wound of abdomen - Disease or injury that **initiated the series of morbid events leading to death.** - Circumstances of the accident or violence which produced the fatal injury. MECHANISM OF DEATH {#mechanism-of-death.TransOutline} ================== - Include p**hysiological derangement or biochemical disturbance incompatible** with life which is initiated by the cause of death. - Ex. Hemorrhagic shock, metabolic disturbance, respiratory depression, toxemic condition, cardiac arrest, tamponade, etc. - Hemorrhage - Sepsis/septicemia - DIC - Electrolyte imbalance - Acid-base abnormalities MANNER OF DEATH {#manner-of-death.TransOutline} =============== - Is the **explanation** of how the cause of death came about - Generally categorized as: - Natural death - Violent or unnatural death - Homicide - Suicide - Accident - Undetermined CAUSE OF DEATH {#cause-of-death.TransOutline} ============== - The causes of death, which must be filled out in item number 19b of the Medical Certificate, refer to all those diseases, morbid conditions, or injuries that either resulted in or contributed to death and the circumstances of the accident or violence that produced any such injuries. - Parts: - **Part I**, which has three lines, marked (a), (b), and (c), for **reporting the causes of death**. The three lines in Part I are labeled accordingly as the Immediate cause, Antecedent cause, and Underlying cause. - **Part II** includes other **significant conditions contributing to death**. There is one other part in item 19b of the Medical Certificate which must always be filled out by the certifier. This is the time interval between the onset of cause and death. Medical Certificate portion of the Certificate of Death showing Parts I and II of item 19b and the column marked, Interval Between Onset and Death. A. PART I OF THE MEDICAL CERTIFICATE PORTION OF THE CERTIFICATE OF DEATH {#a.-part-i-of-the-medical-certificate-portion-of-the-certificate-of-death.TransSubtopic1} ------------------------------------------------------------------------ - Part I of the Medical Certificate has three lines for reporting the sequence of events leading to death; these are labeled (a), (b), and (c). Entries to these lines must show a sequence of events leading to death reported in causal order, one cause per line, starting with the most recent condition or event on the top line and going backward in time on progressively lower lines until the underlying cause is reported on the lowest line. UNDERLYING CAUSE OF DEATH {#underlying-cause-of-death.TransSub-subtopic2} ------------------------- - The disease or injury **which initiated the train of morbid events leading to death**, or the circumstances of the accident or violence which produced the fatal injury. It is the **most important entry** in the certificate since mortality statistics are based on this underlying cause. All certification of death must include an underlying cause in Part I. IMMEDIATE CAUSE OF DEATH {#immediate-cause-of-death.TransSub-subtopic2} ------------------------ - The **most recent condition** is written on the top line of the certificate that directly **leads to death**. ANTECEDENT CAUSE OF DEATH {#antecedent-cause-of-death.TransSub-subtopic2} ------------------------- - Other intervening causes (or causes) of death occur **between the underlying and immediate causes.** - Depending on the number of entries or causes of death reported in the Medical Certificate portion of the Certificate of - Death can be one or more than one reported antecedent cause of death. - It is even possible not to have an intervening cause at all if only one line (immediate cause) or two lines (immediate and underlying cause) are filled out. #### CASE SAMPLE 1. WHEN THERE IS ONLY ONE REPORTED CAUSE OF DEATH IN THE CERTIFICATE {#case-sample-1.-when-there-is-only-one-reported-cause-of-death-in-the-certificate.TransSub-subtopic3}  **Figure 6.** Case Sample - A 56-year-old man dies from acute myocardial infarction within 3 hours of its onset. He did not have any other illnesses. - While it is rare to only have one event leading to death, it does occur. In these cases, the cause of death would be reported at 19b I.a and it would also form the underlying cause of death. - As a rule, when the certificate has only one entry as the cause of death, that entry is both the immediate cause of death and the underlying cause at the same time. - When the certificate has two causes of death, enter one each in lines (a) and (b), the entry in line (a) is the immediate cause and the one in line (b) is the underlying cause. - When there are three reported causes, line (a) is the immediate cause, line (b) is the antecedent cause, and line (c) is the underlying cause. - **Comment:** In the case sample above, acute myocardial infarction is the immediate and underlying cause at the same time. There is no intervening cause reported. #### CASE SAMPLE 2. WHEN THERE ARE ONLY TWO REPORTED CAUSES OF DEATH IN THE CERTIFICATE {#case-sample-2.-when-there-are-only-two-reported-causes-of-death-in-the-certificate.TransSub-subtopic3} A purple screen with white text Description automatically generated - A 56-year-old person died from an abscess of the lung, which resulted from lobar pneumonia of the left lung.  - When there are two causes of death reported, these are written below.  - **Comment:** When there are only two reported causes of death as illustrated above, the first entry which is lung abscess corresponds to the immediate cause of death, while the second reported cause which is lobar pneumonia left lung does not necessarily correspond to the antecedent cause even that word is already written to its left.  - As a rule, the last entry is always the underlying cause, whether there are two, three, or four reported causes of death. In the case above, lobar pneumonia left lung is the underlying cause, and we simply disregard the word antecedent cause found to its left. #### CASE SAMPLE 3. WHEN THERE ARE THREE CAUSES OF DEATH REPORTED {#case-sample-3.-when-there-are-three-causes-of-death-reported.TransSub-subtopic3}  **Figure 8.** Case Sample -  A 32-year-old man died from hypovolemic shock after sustaining multiple fractures when he was hit by a truck. - **Comment:** In the case sample above, the reported causes   - of death namely, hypovolemic shock, multiple fractures, and a pedestrian hit by a truck, respectively corresponds to the immediate cause, antecedent cause, and underlying cause as is written on the left side of the Medical Certificate portion of the Certificate of Death.  #### CASE SAMPLE 4. WHEN THERE ARE MORE THAN THREE REPORTED CAUSES OF DEATH {#case-sample-4.-when-there-are-more-than-three-reported-causes-of-death.TransSub-subtopic3} A screenshot of a computer Description automatically generated **Figure 9.** Case Sample - A 10-year-old boy with a past medical history of Thalassemia for the past 4 years developed severe anemia leading to high-output cardiac failure 2 weeks ago. Three (3) days prior to admission, he developed cough and dyspnea with a respiratory rate of 44/minute. Chest x-ray showed lobar pneumonia. Despite antibiotic coverage and blood transfusion, his condition deteriorated, and he died the next day.   - **Comment**: A certifier of death always has the option to add additional lines when there are more than three causes of death to report in the certificate. In this case, lobar pneumonia is the immediate cause and both high-output cardiac failure and severe anemia are antecedent causes, while Thalassemia, the last entry, is the underlying cause.  However, since there are two antecedent causes and only one line for such, it is recommended that the two antecedent causes be entered side by side separated by "due to" or "secondary to" or a semi-colon (;).  B. PART II OF THE MEDICAL CERTIFICATE PORTION OF THE CERTIFICATE OF DEATH {#b.-part-ii-of-the-medical-certificate-portion-of-the-certificate-of-death.TransSubtopic1} ------------------------------------------------------------------------- - Includes **all other significant or contributory co-existing or pre-existing diseases or conditions that contributed to death** but do not directly lead to the underlying cause of death listed in Part I (See case sample 5 below).  #### CASE SAMPLE 5. WHEN THERE IS REPORTED CONDITION CONTRIBUTING TO DEATH {#case-sample-5.-when-there-is-reported-condition-contributing-to-death.TransSub-subtopic3}  **Figure 10.** Case Sample  - Comment: When a significant condition contributed to death as in the case of diabetes above, that condition must be indicated in Part II of item 19b of the certificate. Diabetes mellitus is only a contributory cause of death since in this case, it did not cause lobar pneumonia.  C. \[2025\] INTERVAL BETWEEN ONSET AND DEATH {#c.-2025-interval-between-onset-and-death.TransSubtopic1} -------------------------------------------- - The **time interval** should always be filled out as accurately as possible by the certifier based on assessment and available information for all causes reported on the medical certificate. - The interval will have to be estimated and it is acceptable to list the interval as "Unknown" or "Approximately" if such is the case.  - General intervals such as seconds, minutes, hours, days, weeks, months, and several years are also acceptable. A range such as seconds to minutes, minutes to hours, or terms such as "known for five (5) years" may be used.  - The stated interval between the onset of cause and death helps to check that the cause of death is in the correct sequence - the underlying cause leading to antecedent cause, leading to immediate cause.  - A 65-year-old man has a long history of on and off hemoptysis and weight loss, has been diagnosed to have advanced pulmonary tuberculosis for six years. After a bout of massive hemoptysis while working in the farm, the patient died at home 6 hours later.  **Figure 11.** Case Sample D. ILL-DEFINED OR NONSPECIFIC CAUSES OF DEATH {#d.-ill-defined-or-nonspecific-causes-of-death.TransSubtopic1} --------------------------------------------- - The ill-defined causes of death under ICD-10 are vague categories and conditions that **include signs and symptoms and abnormal clinical and laboratory findings.  ** - Deaths assigned to ill-defined causes are insufficiently detailed to be of value for public health purposes.  - Hence, as a rule, ill-defined conditions should **NEVER** be entered as an underlying cause of death on the Certificate of Death unless nothing else is known about the deceased. The term **septicemia** in the absence of a more specific condition is also ill-defined and should not be reported as the underlying cause. +-----------------------+-----------------------+-----------------------+ | **Table 2. Terms that | | | | imply mode of dying | | | | rather than cause of | | | | death** | | | +=======================+=======================+=======================+ | **TERMS THAT IMPLY | | | | MODE OF DYING RATHER | | | | THAN THE CAUSE OF | | | | DEATH** | | | +-----------------------+-----------------------+-----------------------+ | Asphyxia | Exhaustion | Shock | | | | | | Asthenia  | Heart failure  | Syncope  | | | | | | Brain failure  | Hepatic failure  | Uremia  | | | | | | Cachexia  | Hepatorenal failure | Vagal inhibition  | | | Kidney failure  | | | Cardiac failure  | | Vasovagal attack  | | | Renal failure  | | | Coma  | | Ventricular failure | | | Respiratory failure | | | Debility | | | +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ **Table 3. Garbage codes and the corresponding ill-defined conditions ICD-10** -------------------------------------------------------------------------------- ------------------------------------------------------------------------------ **CODE** **CAUSE** R00-R99 Deaths classified as ill-defined *(except R95)* A40-A41  Streptococcal and other septicemia C76, C80, C97  Ill-defined cancer sites D65  Disseminated intravascular coagulation E86 Volume depletion I10  Essential hypertension I269  Pulmonary embolism without mention of acute cor pulmonale I469  Cardiac arrest I472  Ventricular tachycardia I490 Ventricular fibrillation and flutter I50  Heart failure I514 Myocarditis, unspecified I515 Myocardial degeneration I516 Cardiovascular disease, unspecified I519  Heart disease, unspecified I709  Generalized and unspecified atherosclerosis I959 Hypotension, unspecified I99  Other and unspecified disorders of circulatory system J81  Pulmonary edema J960 Respiratory failure, not elsewhere classified J969 Respiratory failure, unspecified K72 Hepatic failure, not elsewhere specified N17 Acute renal failure N18  Chronic renal failure N19 Unspecified renal failure P285  Respiratory failure of newborn Y10-Y34, Y872  External cause of death not specified as accidentally or purposely inflicted E. MECHANISTIC TERMINAL EVENTS {#e.-mechanistic-terminal-events.TransSubtopic1} ------------------------------ - These are terminal pathophysiologic or biochemical derangements that are **common final pathways that explain how a cause of death exerts its lethal effect. ** - Mechanistic terminal events include the following: - Respiratory arrest  - Cardiac arrest - Asystole  - Ventricular fibrillation  - Electromechanical dissociation  - Cardiopulmonary arrest   - 🖊️In general, mechanistic terminal events have an almost limitless differential diagnosis and **should never be reported in the Certificate of Death as one of the causes of death.**  They are extremely nonspecific and are of little value for mortality statistics that are derived from death certificates.  V. GENERAL GUIDELINES FOR COMPLETING THE MEDICAL CERTIFICATE PORTION OF THE CERTIFICATE OF DEATH {#v.-general-guidelines-for-completing-the-medical-certificate-portion-of-the-certificate-of-death.TransOutline} ================================================================================================ 1. Use the **current form of Certificate of Death** (Municipal Form No. 103, Revised January 2007) or **Certificate of Fetal Death** (Municipal Form No. 103A, Revised January 2007)  2. For the death of individuals:   - **For those aged 0-7 days**, accomplish item 14-19a at the back of the Certificate of Death (Municipal Form No. 103) - **For ages 8 days and above**, accomplish items 19b-22 3. For **fetal deaths**, accomplish items 19b-22 of the Certificate of Fetal Death  4. For **deaths without medical attendance**, a verbal autopsy may be conducted   5. Complete each item legibly using a computer printer with high resolution or typewriter with black ribbon, or print with a pen using **permanent black ink**  6. Use the **"X"** mark when filling in appropriate boxes or spaces (e.g., x).  7. Verify the accuracy of the identification data, including the correct spelling of the name of the deceased  8. Do NOT make **alterations or erasures  ** 9. Do NOT use **abbreviations or medical symbols** 10. NEVER report **signs and symptoms** or **abnormal clinical and laboratory findings** as causes of death  11. NEVER report **mechanistic terminal events** (e.g, cardiopulmonary arrest) as one of the causes of death 12. Record **only one cause per line in the cause-of-death portion ** - Line (a) must always have an entry.  - If the condition in line (a) resulted from another condition, put this other condition in line (b).   - Never skip lines.  - Additional lines may be added if necessary.   - If an organ failure (e.g., congestive heart failure) is reported as a cause of death, the underlying condition responsible for the failure should also be reported (e.g., liver failure due to hepatitis B infection)  13. If there is **uncertainty** in the entries for causes of death, it is acceptable to use **qualifying terms** such as **"probable"** or **"presumed" ** 14. **Complete all relevant portions** of the Certificate of Death 15. For all **signatures**, use a pen with permanent **black ink ** 16. File original copies of the **Certificate of Death with the Local   Civil Registry Office.** Reproductions or duplicates are NOT acceptable   GUIDELINES FOR REPORTING CAUSES OF DEATH IN SPECIFIC GROUPS OF CONDITIONS {#guidelines-for-reporting-causes-of-death-in-specific-groups-of-conditions.TransOutline} ========================================================================= A. DEATH INVOLVING WOMEN OF CHILD-BEARING AGE {#a.-death-involving-women-of-child-bearing-age.TransSubtopic1} --------------------------------------------- - In the revised Certificate of Death, there is a new item **(19c)**, labeled Maternal Condition, which must be filled out by the certifier for all deaths involving females **aged 15 to 49 years, whether pregnant or not.  ** - The fact that a woman died during pregnancy or within 42 days of the termination of pregnancy should be clearly indicated under Maternal Condition.  - A **[maternal death]** refers to the "death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes."   - **The top causes of maternal death are:  ** - Postpartum bleeding  - Complications from unsafe abortion  - Hypertensive disorders of pregnancy   - Postpartum infections; obstructed labor   #### CASE SAMPLE 6. {#case-sample-6..TransSub-subtopic3} - A 36-year-old G5P3A1 woman who delivered a full-term baby boy at home was brought to the Emergency Room because of placental retention. The woman apparently had severe bleeding and was hypotensive on her arrival at the ER. She was transfused whole blood and manual extraction of the placenta was performed. However, the woman died four hours after delivery.    **Figure 12.** Case Sample - 19c **MATERNAL CONDITION** (if the deceased is female aged 15-49 years old) put an "X" on the corresponding entry \_a. pregnant not in labor \_\_b. pregnant in labor [\_**X** ]**c. less than 42 days after delivery** \_\_d. 42 days to 1 year after delivery \_\_e. none of the choices   COMPLICATIONS AND ASSOCIATED COMMON UNDERLYING CAUSE {#complications-and-associated-common-underlying-cause.TransSub-subtopic2} ---------------------------------------------------- +-----------------------------------+-----------------------------------+ | **Table 4. Complications and | | | associated common underlying | | | cause** | | +===================================+===================================+ | **COMPLICATION** | **COMMON UNDERLYING CAUSE** | +-----------------------------------+-----------------------------------+ | PNEUMONIA | CVD, Pulmonary disease, cardiac | | | disease, dementia, other | | | neurologic or neuromuscular | | | disorder | +-----------------------------------+-----------------------------------+ | SEPSIS | Urinary tract infection, | | | decubitus | | | | | | ulcer, pneumonia | +-----------------------------------+-----------------------------------+ | UTI | Neurologic disease and other | | | | | | debilitating disease and chronic | | | | | | catheterization | +-----------------------------------+-----------------------------------+ | MALNUTRITION | Tuberculosis, neoplasia, other | | | | | | underlying systemic disease | +-----------------------------------+-----------------------------------+ | CHRONIC BEDRIDDEN STATE | Usually due to some identifiable | | | | | | underlying condition | +-----------------------------------+-----------------------------------+ | DECUBITUS ULCER | Underlying debilitating, | | | neurologic, or systemic disease | | | process | +-----------------------------------+-----------------------------------+ B. INFANT DEATH {#b.-infant-death.TransSubtopic1} --------------- For deaths involving **infants aged 0 to 7 days**, the same form of Certificate of Death (Municipal Form No. 103) is used as in other deaths from the general population except that the **Medical Certificate** portion (item 19a) found at the **back of the form** **is filled out** instead of the one in front. 🖊️The single most important or main disease/condition in the infant is entered in Line (a) and the remainder, if any, in Line (b). The mode of dying (asphyxia, heart failure, anoxia) including prematurity, is not entered in line (a) unless it is a known condition. #### SPECIAL CASE: INFANT DEATH {#special-case-infant-death.TransSub-subtopic3} Age 0-7 days The mode of dying (asphyxia, heart failure, anoxia, including prematurity) is not entered in line (a) unless it is the only known condition. A list of medical records Description automatically generated with medium confidence **Figure 13.** Special Case 🖊️A 38-year-old G3P0A2 was admitted to a birthing facility while 24 weeks pregnant. She had been having premature labor for 6 hours and subsequently delivered a 700g infant who was treated at the intensive neonatal care unit but subsequently died after 24 hours. Chest x-ray shows dense lung fields consistent with severe hyaline membrane disease. C. DEATH FROM INFECTIOUS DISEASE {#c.-death-from-infectious-disease.TransSubtopic1} -------------------------------- The certifier has to report the: Manifestation or body site: Pneumonia Pyelonephritis Hepatitis Meningitis Causative agent, if known. If not, write "cause unknown". Source and route of infection, if known Food poisoning Contaminated blood product Healthcare-associated infection Any underlying disease that may have suppressed the patient's immunity that made him susceptible to the infection that led to his death. #### SPECIAL CASE: INFECTIOUS DISEASES {#special-case-infectious-diseases.TransSub-subtopic3}  **Figure 14.** Special Case D. COVID-19 CASES {#d.-covid-19-cases.TransSubtopic1} ----------------- A medical certificate with a black text Description automatically generated **Figure 15.** Case Sample  **Figure 16.** Case Sample E. DEATH FROM NEOPLASMS {#e.-death-from-neoplasms.TransSubtopic1} ----------------------- The certifier must always indicate: The site of the neoplasm, including primary site (whether known or unknown) Laterality, if applicable Behavior of tumor -- benign/malignant Nature or histological type, if known A close up of a form Description automatically generated **Figure 17.** Case Sample F. FETAL DEATH {#f.-fetal-death.TransSubtopic1} -------------- Use Certificate of Fetal Death (Municipal Form no. 103A) From **aged 20 weeks AOG & above** #### SPECIAL CASE: FETAL DEATH {#special-case-fetal-death.TransSub-subtopic3}  **Figure 18.** Special Case #### CASE 7. \[2025\] {#case-7.-2025.TransSub-subtopic3} A 38--year--old G3P2 was admitted to a birthing facility while 34 weeks pregnant. After 6 hours of premature labor, she delivered a stillborn baby boy with a cord around his neck. The fetus is cyanotic with no gross fetal movement and no heartbeat. A close-up of a purple card Description automatically generated **Figure 19.** Case Sample G. PERIPROCEDURAL DEATH {#g.-periprocedural-death.TransSubtopic1} ----------------------- Refers to **"death that is known or suspected as having resulted in whole or in part from diagnostic, therapeutic or anesthetic procedures"** Synonyms: Therapeutic misadventures Iatrogenic Errors and accidents in medical care CATEGORIES {#categories.TransSub-subtopic2} ---------- **Peridiagnostic** - related to a diagnostic agent, procedure or device; **Perianesthetic** - related to an anesthetic agent, procedure, device; **Peritherapeutic** - related to a therapeutic agent, procedure, or device; **Perioperative**- related to a surgical procedure or device and may be further subcategorized as **intraoperative or postoperative** #### SPECIAL CASE: PERIPROCEDURAL DEATH {#special-case-periprocedural-death.TransSub-subtopic3} Include the appropriate category of periprocedural death  **Figure 20.** Case Sample **\-\-\-\-\-\-\-\-\-\-\-\-\-- The following are not included in the 2026 lecture\-\-\-\-\-\-\-\--** A purple screen with white text Description automatically generated **Figure 21.** Case Sample 🖊️Comment: Note that the term INTRAOPERATIVE is used here to indicate the periprocedural nature of death.  **Figure 22.** Case Sample 🖊️Comment: Note that the term PERITHERAPEUTIC is used here to indicate the periprocedural nature of death. #### CASE 8. {#case-8..TransSub-subtopic3} Accidental Periprocedural Death is considered accidental if death would not have occurred in the procedure's absence Ex. A healthy young man who underwent an elective cholecystectomy but died of peritonitis several days later because of surgical gauze left in the peritoneum. H. ELDERLY DECEDENT {#h.-elderly-decedent.TransSubtopic1} ------------------- The use of terms such as senility, old age, senescence and advanced age as entries for cause of death in elderly must be avoided since they have little value in public health planning and research. To be useful, the cause of death entry must have specific, clear and distinct etiological sequence. If there is uncertainty in the entries for causes of death, it is always acceptable to use qualifying terms such as "Probable" or "Presumed"; If the cause of death cannot be determined with reasonable medical probability but seems to be due solely to a natural cause, the certifier may report "Undetermined Natural Cause" as entry in the cause of death statement in the Medical Certificate. #### CASE 9. {#case-9..TransSub-subtopic3} A 95 year old man was found dead on bed by his wife. He had chronic mild hypertension, controlled medication. His previous chest X-ray shows mild cardiomegaly, consistent with chronic hypertension. There was no suspicion or evidence of foul play. No specific cause of death could be identified. A purple rectangle with white text Description automatically generated **Figure 23.** Case Sample The certifier must also be aware of common complications that may cause one to overlook and fail to report the underlying cause in elderly decedent. Whenever one of these complications is provided by the informant as a possible cause of death, always attempt to identify and report the **Associated Underlying Cause of Death** which caused the complications. I. DEATH INVOLVING EXTERNAL INJURIES {#i.-death-involving-external-injuries.TransSubtopic1} ------------------------------------ The approach to writing causes of death involving external injuries is to report the external cause or events as the underlying cause and identify the bodily trauma caused by the external event and report it as antecedent cause and lastly report the fatal derangement resulting from the bodily trauma as the immediate cause. External event Refers to external agent or force, usually physical or chemical in nature that causes trauma. Trauma An injury or damage to bodily tissues or its functions. The trauma in turn may result in anatomic or functional fatal derangement that causes death.  **Figure 24.** Case Sample 19d. DEATH BY EXTERNAL CAUSES a. Manner of Death (Homicide, Accident, Legal Intervention, etc.) \_\_\_\_\_\_\_\_\_\_\_\_ b\. Place of Occurrence of External Cause (e.g. home, factory, street, etc.) \_\_\_\_\_\_\_\_\_\_ **External event** Refers to external agent or force, usually physical or chemical in nature that causes trauma; **Trauma** An injury or damage to bodily tissues or its functions; **Anatomic/ Functional Fatal Derangement** Result of trauma that causes death #### CASE 10. {#case-10..TransSub-subtopic3} A purple screen with white text Description automatically generated **Figure 25.** Case Sample 19d. DEATH BY EXTERNAL CAUSES a. Manner of Death (Homicide, Accident, Legal Intervention, etc.) Presumed accident b. Place of Occurrence of External Cause (e.g. home, factory, street, etc.) Home **20. Autopsy** (Yes/No) No #### CASE 11. {#case-11..TransSub-subtopic3}  **Figure 26.** Case Sample 19d. DEATH BY EXTERNAL CAUSES a. Manner of Death (Homicide, Accident, Legal Intervention, etc.) Accident b. Place of Occurrence of External Cause (e.g. home, factory, street, etc.) Highway **20. Autopsy** (Yes/No) No #### CASE 12. {#case-12..TransSub-subtopic3} A screenshot of a purple screen Description automatically generated **Figure 27.** Case Sample 19d. DEATH BY EXTERNAL CAUSES a. Manner of Death (Homicide, Accident, Legal Intervention, etc.) Accident b. Place of Occurrence of External Cause (e.g. home, factory, street, etc.) Farm **20. Autopsy** (Yes/No) No REFERENCES {#references.TransOutline} ========== - PowerPoint: Villasenor, V. (2024). Medical Certification of Death. - Previous Trans: Batch 2025 lecture transcription. APPENDIX ======== - No appendices