The Role of Emergency Physicians in the Completion of Death Certificates

Originally approved June 2019

An emergency physician is often the last physician to see a patient alive or the first to bear witness to their death. In most cases, the encounter in question is the emergency physician’s first with the patient, and his or her knowledge of the patient may be limited depending on the circumstances of the death, the availability of medical records for the patient at the institution in question, and the presence and availability of relatives, as well as their knowledge (or lack thereof) of the decedent’s medical history.

Some cases, saliently those involving trauma, suspicious circumstances, substance use, or recent office-based surgery, among others, may be processed via the local medical examiner's or coroner's office. There are laws defining the types of cases that must be investigated by a coroner or medical examiner in most jurisdictions in the United States; in some jurisdictions, cases of decedents who do not have an “attending physician” may also be referred to the medical examiner. A common definition of “attending physician” is a (post-training) practicing doctor who has a formal relationship to a patient, either in-house while the patient is hospitalized or as a primary care provider in the community.

There are two distinct duties that are part of the death certification process, whether completed by a physician or coroner:

• Pronouncing the death (affirming that the individual died, including the date and time of death)
• Certifying the death (the manner and cause of death)

Manners of death include natural, accidental, homicide, suicide, or undetermined. Causes of death include immediate causes (eg, septic shock), intermediate causes (eg, multilobar pneumonia), and underlying causes that may have triggered the chain of events (eg, malnutrition). The approximate interval between the presumed onset of each of these conditions and the death is also recorded.

The American College of Emergency Physicians (ACEP) acknowledges that in many cases, including when patients expire just prior to, or during, an emergency department visit, the emergency physician is the ideal individual to pronounce the death and document the pronouncement.

ACEP affirms that in cases where a patient has an existing, ongoing relationship with an “attending physician” such as a primary care provider, it is ideal for that individual to certify the cause and manner of death, rather than the emergency physician who may have pronounced it. If no such attending physician relationship exists, in some jurisdictions, cases may be referred to the coroner or medical examiner for certification of the cause and manner of death. Such referrals should include the date and time death was pronounced, and a description of the acute presentation and clinical findings in the emergency department. Alternatively, the emergency physician – or other hospital-based physician responsible for the patient’s care at the time of death – may use available information and their clinical judgment to certify the death. ACEP maintains that any such physician who certifies the death to the best of their ability, shall be held harmless. If insufficient data exists to determine the cause of death, the emergency physician should not be compelled to provide that information.

ACEP recognizes that individual jurisdictions may have unique regulations in regard to the certification of death, that may include, but not be limited to, cases appropriate for referral to a coroner or medical examiner. Significant variations exist at the city, county, or state level. Emergency physicians should be cognizant of the relevant statutes that apply in the jurisdiction(s) where they practice and follow them appropriately.

ACEP believes that it is part of the health care team’s responsibility to make reasonable efforts to patients and their families to ensure that the decedent’s planned disposition, including burial or cremation, is not delayed unnecessarily.