IMPROVING ACCURACY OF DEATH CERTIFICATES Jesse B. Barber, MD Washington, DC
Resolution 89-14, presented by the MedicoChirurgical Society of the District of Columbia, was approved by the National Medical Association (NMA) House of Delegates at the Annual 1989 meeting in Orlando, Florida. The resolution called for the NMA to fully support efforts to improve the accuracy of death certificate data. Subsequently, the NMA participated in the Workshop on Improving Cause of Death Certificates in October 1989. The conference was sponsored by the National Center for Health Statistics in cooperation with the National Committee on Vital and Health Statistics. The conference's 40 attendees generally agreed that the cause of death, even when known, may be erroneously entered on the death certificate. The mode of dying such as cardiopulmonary arrest, shock, or heart failure is sometimes entered as a cause of death despite the instruction to the contrary on the certificate. Efforts to protect other physicians or the patient's families also may be related to some errors as can a lack of knowledge. More subtle reasons for inaccuracy include the failure to consider risk factors such as poverty, -obesity, smoking, and alcoholism on the certificate. The function of the death certificate as a legal document requires prompt completion prior to burial or other disposition of the body. Late arriving laboratory data, cultures, and microscopic pathologic diagnoses are often unavailable at the time the death (burial) certificate is completed. Although amendment of the death certificate is possible, it seldom occurs. Very few incentives are provided to encourage Dr Barber is Secretary of the Council on Medical Legislation of the National Medical Association. Requests for reprints should be addressed to Dr Jesse B. Barber, Department of Neurosurgery, District of Columbia General Hospital, 19th St and Massachusetts Ave, SE, Washington, DC 20003. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
accurate completion of death certificates. It is unusual for the results of mortality review discussions or clinico-pathologic conferences to be used when a death certificate is being completed. Likewise, it is unusual that the accurate completion of death certificates is discussed or demonstrated during such conferences. The conference members noted the vital significance of the death certificate as a public health and research document and made several recommendations to improve the accurate completion of death certificates. These suggestions included: * Provide training in the accurate completion of death certificates and subsequent testing. Training should be directed primarily at first-year postgraduate trainees and medical students. Testing on completing death certificate during the third part of National Board exams and during specialty exams would provide incentives to obtain and reinforce that knowledge. * Develop quality improvement programs for death certificate completion. Mandatory on-site review of the certificate by an "expert" was recommended. Death certificate completion as a part of mortality review conferences and clinicopathology conferences also was suggested. Surveys of death certificate as a part of the activities of accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). was strongly supported. Published proceedings of clinicopathology conferences should include a completed death certificate as part of the presentation. * Revise the format of the death certificate to encourage recording significant risk factors such as poverty, obesity, smoking, and alcoholism. Mechanisms should be developed to encourage amending the certificate to enhance its utility as a public health and research document. Many other problems surfaced during the conference. The declining rate of autopsies was a major concern, 1007
GUEST EDITORIAL
especially to the Association of American Medical Colleges representative. The coroners, medical examiners, and medical records librarians noted the differences in the systems for completing death certificates in various states and counties. The problem of confidentiality of the death certificate data was raised by the
reporters in attendance. Discussions of reversing the sequence of recording the cause of death took place but no concensus was reached (currently, the immediate cause of death is listed first). Finally, practical problems in adding death certificates as an item to be surveyed by JCAHO were raised.
............................................................................................................................................................................................................................
..............
.I.I.I.I.I.............................................. ,....-..-.-.-.-.-.,.
,.-.,.-.-.-.-.-.-.,.I.I.I.I.I.I.I.-.%,.-.-.%-.-.-.-.-.%,.....-....... ............................... ............. %................... ............... ........................................................ %% ......................................................................................................................... %1.1.1............................. ... %.............................................. - .1.1. ........................... %..%.......%........ %.% ............................................................ :............................... " ..' " .,l.,.,..,.,.,.,.,.,.l.,.,., ................................ .................-.....-%. -.-.%....%..-.....%-.-.....%....-...........-.-................................................ :-:l;.;. -;.;& -.-:-, ........ ........................... ............................................................................. ..................................................................... ................................................................... ,-bil* .-:----... ................................................ ..,. ........ %............................................. ...................................... ......................................... '. :. ................................... ....................................... ....................-C -: .d&-.. " '.. ..% .-:....-.-' .. ..:. :-.-.-.-.,.,.,., ....................................................... .............. ................ %%,.,.,.,.,.. ......................................................-.-,.,-', .,.-.-.-.%,.-.-.%,.,.,.,.,.-. ......................................... v.,.,.,.,.,.,.., :... ...................... .................................... .. %% .........V.,.'........... ...... ---. .. ::I :...................%......................................................................... .: v.,.,.,.,-.,.,.,. .,.,.,.,...:-:.:.::.-:::::.-..%-.-.-.-.-.-.-.-. :........ :.-..1.1.1...V 1. -...................................................................................... ..... I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.1.1.%. %1.1.1.1- 1.1.1.1- 1. .% .....V.....%........... .. -................ .% .....-..... ....,.,...,.,......% I.I..%,..%,.......................................................... ...I -:-:-:-,:-, .,.,.,.,....'..,.:....-,-:-, V. ,.,.,..... ............................... -.-.-.-.-.-.-.-.- -......................................................,.,.,. .%,.,. %-.-.-.%-.-.-., ,., ..,.,.,.,.,.,.,.-.-.-.-...-.-.-..................................... ............... ......... V.- '........ .......................-.-.-.........:.:.: %1.1.1.1.1- :-:-:-:-:-:-:-:.:.-..1.1.1. ........................................................................... 1.1.%-.-.-.%. .."."...".. %.................................................................... ........................................................................................ .................%........................................................................................ .1.1.1.1.1.1.1.-.%,.,.,.-.-.,.,.,.,. .............................................. 1.1.-.-.-.-.%-.-.-.-.-.-.-.-. ................................................ :: ................... .... ....................................................................... k* .-.. .................................................%. .I.... ....,.-.,... ...% .:.:-:-:.:-:-:.:.:.:.:.:.:.,-, X................ .....%............ .... ................-.- ...........................
.....................................................................
..........
.:-:-:-:-:-:-:-:-:-:-:-:-,-,-,-,---,-,-,-,-1-1.1-I.-I-1-1-1.1-1.1
.........::::::::::-,:-:-:-:-,-,%%.%.:.,.%.:.: ::-...:.%..-.-.-.-.
-- :-:-:-B-,.w "'.11gr
..& ..,:....
.:.::::::::::::..........................................................................................................................
'i
.::,.. :-:-,.,
"..."l-l-I.I........ .........
.%-.-
.....------
:-:-:---------..... .......: .:' ..........
:%:::::::
:, 'M ... -:::-:-:-:-:-:::-:::::-:::bhw 1 .'.'-.;. .! .'
.....................:-:-:-:-:.:.:-:.:.:.:.:.-.-.-.-.-.-.-.-.-.-.-.-...
!i
-:-:-:= -:-:-,-:.. .............................. e-.-, ..
::
..-.-..
1: e.:.:-:-
..
.-.lw-:-.-:Ai-
XlLiff :-
....
.-.-.-.-.-.-.-.-.-.-.-.:.%
I.... ni ..".-.W.
...:::::::::l
.,.,.,.,.
..................
............... ............
........X...
................ ,.,.,.,.%,.,. ............................... ....X....................e :.% .......................... .%% ..... .......... ...... -.-.-.%%-.-. -..-.-' ..% .. .............................. ............... .................. ................. ............................... ..%.1 -......................... -:-, X :.:.:.:.:.%............................... ............ .-.-.-.-.-.-.-.%-.-.-.-.-.-.%...,.,.,.,-..-..- ..-.... .:.:.:.:. ............................... :-:-:-:-:-:-:-:.:. .-.%-.-.-.-.-.-.
-.-.%-.-.-.%-.-.-.-.-.-.-.-.:-:-:-:-:-%:.:-:-:.:.,%....,:
-:-,.:::-%,.:-,.:-:-.-...:-:.:-:-:-
.-.,-,.'-,-'.'-'-'-'-'-'. ................................................ ...............................:.:.:.:-:-% .,.:-:.:-:-:-:-:-.-:-:%-.-.-.-.-.-.-...............%................................................................ .... ............ ...... ....%........
.... .................x-x.-
: : ,.
................,.
-.,.
:.:-,:::::.::-:-.-:::::...:.:-:.:-:-:.:-:-:-:.:-:-:.:-:.,.-.-.-.........-.....-.. .%
::::: , -: -* .....%*-:-:-:-:-;,-,
.......... .........'.%'.
,I.
..................
1.
.................
..........
....................................................................................:............. ..................................................
I.:.:-::::::.:::::::b::::..:::..:-:.:.:.:.:.:::: .::.:-:.:.:..:,:.:.:.:.:.:..:.:.:.- ;,.' .:.-::. .:. :.:.:.:-:.:-:. ...... C ",,-,,,,-,,,,,,,,,,,,,-,,,-,,,,,,-,.,-,.,.,.,-,.-.,.,-'-'-'-'-' ::::; .4f%,-" ::: .41;0%1 ..:lm :-:-:-:..-.-.-.......-.-.....-.-.-...m lo ..t -X ----,,--,,---................ -'.t-. ::: .................. ....... .eV: :1.W.V ".. :: :"-.,..: .X. . .. t A .--....e. .: n-, -c--. :., -t;:.................,......,.,...,.,.,.........%-.-.-.................................................................................................................................................................................................................................. .%,.,.,.,.,.,.%....% .................... .
...
:.: *'. '.
C-.:rN
..............................
re
"'U
::.a -s,...--, t
"..
..
.s..............................
::::,. .....................................-.-.-.-.-.-.-....................................... ............... ................................................................................................................................................. .% .................................................................... :-:-:-%,................:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-,-,-,-,-,-,---,-.1-,-,.,-,-,.,-,-,.,-,.'-' .................... ...... X.....-11-11,11,11111-1111,-111,111,11I ..............I..:d.:-:-*-..,.,.,..,..-.-.............................................................................................. ... ... ::::::::,-,:-- ...... -*....................................................................................................................... ::::::::::::::::::::::::::::......-.......-.-.-.........-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.......-...-.-.----......................................... .,. -u:. ........................................................................... .. .:-,:...:.:-. .'-'.'.'.'-'.'.'.'-'.'.'-'-'-'.'.--'.'.,.,-1-1.1--.,:.:.:.:.:. ................................................................................................................................................ .'....... .l...,......,. .l..............................................................................................-...-...-.,.,...,............. ....:........ ......................-.-....-.-...............-........-.-............................................................................................. ................. .................% ........................... .......................... ..... ::::::::::::: ::::::::::::::::::::::::::::::: ...................................................... ::: ..................................................................................................................................................-. ........................................................................................................ --................................................................................................................... :::::::::::::::%.:.,::::::::::::: .......-.-.%,.-.-.,................................................ ..............,.........................................%... ..........V ...
..........
.........
%.:.-.-.-:::,-,:-,-:::
.:-:-:-,-:-:.:-:-:-:-:-:-:-:-:-:-:-:-%::::,-".,,..,:.: - .......l.........%.......... .,.-.-.%-.-.-.-.-.-.-.%-. .,.%, ............-.1.-I..... .........................::.:-:.:.:-:-.-:-:.:-:-:.: ...
.,:,. . .: : : : : : :-,: .-
...............
%
..................................................
:-:-:-:-:-:-:-:-:-:-:.:-:.:.:-:.,.,.,.,".."..,..,.,",""",-"'.,'I."""'l-"'."""""-'-'-".."".".",",.,"-'-""'.".",.'-'-"."....,.".-""""""""""'--l-I."",.,.""."."""'-"'-'-'-"""'I"'-'-'-""""""........................................................................................................... :.....-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.....-...-.-...-.-.........-..........---............-.-.-.....-.-.-.-...-.-...-...-.-.....-.-.-.....-.........-.-.-...-.---...-......-.......-.-...-.-...-.-....---.........-.-...-.....-.-...............-...........-.............-.....-.-...-.............-
...'...'....................
...... .............................%........... %.. ............................................................................,.........." ................. .......................................... ........................................................... %..%....%-...%..-.-. ............................... %.........., ...........-i-v ".... ........%......................................................" ......................... %-....:..., "....." ..................................................................................................... .,.,.,.-.,.,.-.-.,.,.I., ............... .... ......... ...................... ................................. ... .................. ............ ........................................ .. % .. % .... :, ,..,. .................. -.... .;&W -.'. ...... ............................................................. ..% ..................... :-X-. ......%.....................--..,.,..:.: :.................. .......: .................... ... .. .1-1.1-1-1.1-1---,.-.-.1-1---,.,.,--.-.,-,-1-1.1-1-1-1-1-1-1-1 -11 ...... .... -..... ....,.,.,.,.....,...........:.... .'...... ..:.... % ............................................ :....... ..... ..... ............................................................................................ .:-:.:.:.:-:-: .............'........... -.-.-.-.-.-.-.......,...,.,...... ..... ...... .............................................................................. ........ ............................................................................................. .U...,.,..... ... .,. ............ .. .% .................... ......... .:" i .... -.-.-.-.-.%-.%-. '............................................................................ .......... .................................................................................... ,................................,.....,...,.,...,.....,.,.,...........................,.,.,..........,................. .............................................................,... .................................. ................................................................. ..........:.:.:.:.:.:-:-:.:-:.:.:-:.:.:-:-":-:-:--.,---,--" .................................................................................. .......................- ................................................
::::::::........A..:::::: .:.:.:.::::::::::::::: :.:.%,: ,-,::::% :%,:% .............:.-,.,-,.,-,..................................:-:.:.......-....-...-:-:::::::::::::::::::,.:,.
.................................................................
...
.I -,
.-'- ID
..
..........:::::::::................,..................................................................................................,.,...,...,............................................................................................................................................................................................. .:::%.:-:-:.:.:.:-:.:-.-..:-:-:-:-,-:-:-:-:-:-:-:-:-:-:-:-:-:-:.:.,.'-'.'.'--.'.,-'-'..'.'.'-'.'.'.'.--'.-.'-'..'.'.'.'.'.'.'.,.-.'.'---,.,.---.,.I.-I.I.-.,.1-1-1.1---,---,.,.,.,.1-1.1-1-1.1-1.1-1-1.1-1.1-1-1-1----.--,.,.,.l.-.-.--,---1.1---,.-.-.,.,.,.,.,.-.,.,.-.,.,.,.-.,.,.,.1-1-1.1-1.1--.,.,.,.,.-.-.,.-.,.,.-.,.-.-.-.,.,.,.,.-.,.I.I.I.I.I.I.............................-...........-.-.-.-...-.-.-.-...-. ..................................................................................................................................................................................................................................................................................... ...................... .:-:.:-:-:.,.,.,-,.,..-.-.......-...........-.-...-....-.------.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-...-.-.-... .:.:.:.:.:.:-:.:-:.: ..........%.................................................................................................................................................................................... ..............................................................
.............%........
.......................... X-1 ......,.,.%..-.-.-.-.-.....%,.,.-. X.:.:.:.
11-1 ...... ... 11 ... -
%, :.:.:.:-:-:-...:::::::::::::,.,...... ..:.....-.-.-.-.-.,.,.-.,.,........ :.:-:-:.:.:.:.:.:.:..-.-.,...:.:.,.,...,,,,.-,,,,,, ..-.,.-X%::::::::,--%-.-...%-.-.%-.-.-.-.-...-,::::-,-.%..:: ::..:.,.......x ..
--
.................................... .......................... ............................... ...................................................... ............................
................................................................ ........................................................ ................................................................ ......................................................... ................................................................ ................................................................ ................................................................ ................................................................ ................................................................
......
..........:.:.:..-..'.-.-.'.............................% ,.......,..........%......-.-.-.-.-.-.-.-.,.-.-.-.-. .....................%..........%%......%..........%-. ...................................%..........%..........
................................................................
%,.-.,.,.-.-.-...........:-:-:-:-:-:-:-:---
:-:-:-:-:-:-:-:-:-:-:.:.:.:.:.,.,...,-,.,-'-'.'.'-'., .,.,.,.,.,....................................
%%.
.............................................................. 41 ol 40 ::::::::::::::::::::-%--. .............................................................. % ..............................................................: .-................................................................ ::-:.:.:-:-:-:.:.:.:.:-:-.-: ............................................................... .:.:-:-:.:.:.:-:-:-:-:-:-:..:: ................................................................ '...... .... ................................................................ ..........X ...I..... :::::::,.-........ .......... ......................................................................................................................................................................................................................................................................................................... .. ",",""""",.",..".""..",." ,.....,.,...,.,.," .................................................................................................................................................................................................................................,.,.,.,.,..................................... ....... ........ :.:,.::.-.::: .....::::::::::,::,:. ." .......... .::..,:, .... ...,.,.,.,.,."."...,.....,.,.,........:-:.:.:.:.,-, .'-'-'-'.. '..'.'.'.'.'.'.'.'.'.'..'.'.'..'.:-:.:.:-:-:.:-:-:.:.:-:-:.:.:-:.:.:.:-:.:.:.:.:.:.:.:.:.:.:.:.:-:.:-:-:.:-:.:-:-:-:-:-:-:.:.:.:-:.:-:-:-:-:-:-:.:.,.,..-'-'-", .-.-.-.-.-.-. -::::::::::::::::::::::::::::::::-:-:-:.:.:.:.:.:-:.:.:.:.:.:.: ::::,., -:-:-:-:-% .....-.-:-:-:-:-:-:-:-:-% ...,.,.,.,.-.,........ ............................. ........................................... :-:-:%.:-:-.%,..........% ................... ....................................................................... .....-................. :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-.-,.,.....'.'.'.'-'-'-'.'.'.'.'-, "'.....%X ...... :-,..,.:.:-:.:.:.. -:-. .. 1.1.1.1.-.-.-.-.%%-.,... ...X ... ,...,.............,........................................................................................ . . i. ............ .. ...'...." .:..., .............. --..--..-.. k k..:::::::::: ..... -A:.....:" :. -:- .... :.:-:-:-:-:-:-:-:-:-:-:-:-:.:-,-.-,.,..-,...l.-.,.--,-,--.,-,-,. 1-............... ... ............ ::::::::::::::::::::....... ..................,................'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.','.'.'.'.'.-.'.'.:-:-:-:-:-:-:-:-."%,....:-.-,: -:.:.................................................................................... ,.-.-.,.:.-.-.-.-.-.-A .:.:.:-:.:' M ..." ...... I.Y ......... :.,.6 .-- -.-.-.-.-. ................:-:-:-:-:-:-:-:-:-:-:.:.:.:.:..,.,...-,..,.---..,..,.,....,..-.-,.,.-'.-'..,.'.-,.-..,. .......:. ...........X.:.:.:.:,M ..........:::::::::::::::-............................................................................................ .........X -:-:-:-:--:-:-. .%..... '.... .................................................................................:............:.:.:.:.:.:-:-:-:.:-:.:-:-:-:----...,...,-,..'..'-'.'.'.-,.,.,.-.-.,.----.........................-.-.--.l--.,.,.-.,.,.-.-.,.,.-.1-1-1.1-1.1.I.I.I.I.-.-.I...............%,.-.,.,.-.-.,.-.-.,.,.,.-.,.,.-.-.,.-.,.,.-.-.-.-.-.-.-...-.....-.-.................................................. ....................%....'. .............. %-.-.-....................................................... .,.....,.................................................................................................................: ...,.......,........................................................................................................................................................................ ........................... :-:-:-:-:-:-:-:-:-:-:-:.:.:.:.:..,-..,...,.1-1.--,.,.,.,.,.,.,.I.I.I.I.I.,.,-,........................................................................................ ... ........................................... ::::::: ..................................................................................................................................... :-:-:-:-:-:-:-:--................................................... :::::::::::::::::::::::::::::::,-,...-,........................................................ ................................................................................... ................. ...,.,.,.,.,.-.-.--'-'-'-'-'-,.:::::::::-.. -, .................................................................................................................. ..-.,.,.,.,.,.%,.............................. ...................................................................................................... -::::::::: :: .."...." ....- ....................... .....% .................... %..'.......'........... .,.:::::::::::::::::::::::::::.?,.:::::::::::::::::#::::::::::I.l::::::::::::::::::::::::: ................................ l-:*:::-:::::::-:::::::-*.-:, ........................................ .%%-.-.,., ............................. :.. .", :::: n..v,-"%: -&.,,g-e " ::: f ::m r.%:-,-,-----,-,-,-,-,-,-----,-,-,--,., X,&L ,j :'IS.-G -.... ... .. U.%--: %..:re X., :: -v ::-::: 1:14 T.::0-T-1, .............. ....... ..................'.'. ..................: .................
....,..
............%.
.I. . . .
..
..... '............. -.-.-.-.-.,.,., %.
. . . . . . . . . . . . . . . . ,.....,.,. .,,. . . . . . . . . . . . . . . . . . . . . .,,. . . 'U . . . . . . . . . ....-..-..r..:.: t.-. .. .. . . . . . . . . . . . .:0-I..:-t:.-'-'-'- -'-'-'- -'- . -. - -.-,
..........................................................................................
.:.:.:.:-:-:-.-.-.-.-.-.-.- -.:,.:..
............................
i 2:
Resolution 89-14, presented by the MedicoChirurgical Society of the District of Columbia, was approved by the National Medical Association (NMA) House of Delegates at the Annual 1989 meeting in Orlando, Florida. The resolution called for the NMA to fully support efforts to improve the accuracy of death certificate data. Subsequently, the NMA participated in the Workshop on Improving Cause of Death Certificates in October 1989. The conference was sponsored by the National Center for Health Statistics in cooperation with the National Committee on Vital and Health Statistics. The conference's 40 attendees generally agreed that the cause of death, even when known, may be erroneously entered on the death certificate. The mode of dying such as cardiopulmonary arrest, shock, or heart failure is sometimes entered as a cause of death despite the instruction to the contrary on the certificate. Efforts to protect other physicians or the patient's families also may be related to some errors as can a lack of knowledge. More subtle reasons for inaccuracy include the failure to consider risk factors such as poverty, -obesity, smoking, and alcoholism on the certificate. The function of the death certificate as a legal document requires prompt completion prior to burial or other disposition of the body. Late arriving laboratory data, cultures, and microscopic pathologic diagnoses are often unavailable at the time the death (burial) certificate is completed. Although amendment of the death certificate is possible, it seldom occurs. Very few incentives are provided to encourage Dr Barber is Secretary of the Council on Medical Legislation of the National Medical Association. Requests for reprints should be addressed to Dr Jesse B. Barber, Department of Neurosurgery, District of Columbia General Hospital, 19th St and Massachusetts Ave, SE, Washington, DC 20003. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 12
accurate completion of death certificates. It is unusual for the results of mortality review discussions or clinico-pathologic conferences to be used when a death certificate is being completed. Likewise, it is unusual that the accurate completion of death certificates is discussed or demonstrated during such conferences. The conference members noted the vital significance of the death certificate as a public health and research document and made several recommendations to improve the accurate completion of death certificates. These suggestions included: * Provide training in the accurate completion of death certificates and subsequent testing. Training should be directed primarily at first-year postgraduate trainees and medical students. Testing on completing death certificate during the third part of National Board exams and during specialty exams would provide incentives to obtain and reinforce that knowledge. * Develop quality improvement programs for death certificate completion. Mandatory on-site review of the certificate by an "expert" was recommended. Death certificate completion as a part of mortality review conferences and clinicopathology conferences also was suggested. Surveys of death certificate as a part of the activities of accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). was strongly supported. Published proceedings of clinicopathology conferences should include a completed death certificate as part of the presentation. * Revise the format of the death certificate to encourage recording significant risk factors such as poverty, obesity, smoking, and alcoholism. Mechanisms should be developed to encourage amending the certificate to enhance its utility as a public health and research document. Many other problems surfaced during the conference. The declining rate of autopsies was a major concern, 1007
GUEST EDITORIAL
especially to the Association of American Medical Colleges representative. The coroners, medical examiners, and medical records librarians noted the differences in the systems for completing death certificates in various states and counties. The problem of confidentiality of the death certificate data was raised by the
reporters in attendance. Discussions of reversing the sequence of recording the cause of death took place but no concensus was reached (currently, the immediate cause of death is listed first). Finally, practical problems in adding death certificates as an item to be surveyed by JCAHO were raised.
............................................................................................................................................................................................................................
..............
.I.I.I.I.I.............................................. ,....-..-.-.-.-.-.,.
,.-.,.-.-.-.-.-.-.,.I.I.I.I.I.I.I.-.%,.-.-.%-.-.-.-.-.%,.....-....... ............................... ............. %................... ............... ........................................................ %% ......................................................................................................................... %1.1.1............................. ... %.............................................. - .1.1. ........................... %..%.......%........ %.% ............................................................ :............................... " ..' " .,l.,.,..,.,.,.,.,.,.l.,.,., ................................ .................-.....-%. -.-.%....%..-.....%-.-.....%....-...........-.-................................................ :-:l;.;. -;.;& -.-:-, ........ ........................... ............................................................................. ..................................................................... ................................................................... ,-bil* .-:----... ................................................ ..,. ........ %............................................. ...................................... ......................................... '. :. ................................... ....................................... ....................-C -: .d&-.. " '.. ..% .-:....-.-' .. ..:. :-.-.-.-.,.,.,., ....................................................... .............. ................ %%,.,.,.,.,.. ......................................................-.-,.,-', .,.-.-.-.%,.-.-.%,.,.,.,.,.-. ......................................... v.,.,.,.,.,.,.., :... ...................... .................................... .. %% .........V.,.'........... ...... ---. .. ::I :...................%......................................................................... .: v.,.,.,.,-.,.,.,. .,.,.,.,...:-:.:.::.-:::::.-..%-.-.-.-.-.-.-.-. :........ :.-..1.1.1...V 1. -...................................................................................... ..... I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.1.1.%. %1.1.1.1- 1.1.1.1- 1. .% .....V.....%........... .. -................ .% .....-..... ....,.,...,.,......% I.I..%,..%,.......................................................... ...I -:-:-:-,:-, .,.,.,.,....'..,.:....-,-:-, V. ,.,.,..... ............................... -.-.-.-.-.-.-.-.- -......................................................,.,.,. .%,.,. %-.-.-.%-.-.-., ,., ..,.,.,.,.,.,.,.-.-.-.-...-.-.-..................................... ............... ......... V.- '........ .......................-.-.-.........:.:.: %1.1.1.1.1- :-:-:-:-:-:-:-:.:.-..1.1.1. ........................................................................... 1.1.%-.-.-.%. .."."...".. %.................................................................... ........................................................................................ .................%........................................................................................ .1.1.1.1.1.1.1.-.%,.,.,.-.-.,.,.,.,. .............................................. 1.1.-.-.-.-.%-.-.-.-.-.-.-.-. ................................................ :: ................... .... ....................................................................... k* .-.. .................................................%. .I.... ....,.-.,... ...% .:.:-:-:.:-:-:.:.:.:.:.:.:.,-, X................ .....%............ .... ................-.- ...........................
.....................................................................
..........
.:-:-:-:-:-:-:-:-:-:-:-:-,-,-,-,---,-,-,-,-1-1.1-I.-I-1-1-1.1-1.1
.........::::::::::-,:-:-:-:-,-,%%.%.:.,.%.:.: ::-...:.%..-.-.-.-.
-- :-:-:-B-,.w "'.11gr
..& ..,:....
.:.::::::::::::..........................................................................................................................
'i
.::,.. :-:-,.,
"..."l-l-I.I........ .........
.%-.-
.....------
:-:-:---------..... .......: .:' ..........
:%:::::::
:, 'M ... -:::-:-:-:-:-:::-:::::-:::bhw 1 .'.'-.;. .! .'
.....................:-:-:-:-:.:.:-:.:.:.:.:.-.-.-.-.-.-.-.-.-.-.-.-...
!i
-:-:-:= -:-:-,-:.. .............................. e-.-, ..
::
..-.-..
1: e.:.:-:-
..
.-.lw-:-.-:Ai-
XlLiff :-
....
.-.-.-.-.-.-.-.-.-.-.-.:.%
I.... ni ..".-.W.
...:::::::::l
.,.,.,.,.
..................
............... ............
........X...
................ ,.,.,.,.%,.,. ............................... ....X....................e :.% .......................... .%% ..... .......... ...... -.-.-.%%-.-. -..-.-' ..% .. .............................. ............... .................. ................. ............................... ..%.1 -......................... -:-, X :.:.:.:.:.%............................... ............ .-.-.-.-.-.-.-.%-.-.-.-.-.-.%...,.,.,.,-..-..- ..-.... .:.:.:.:. ............................... :-:-:-:-:-:-:-:.:. .-.%-.-.-.-.-.-.
-.-.%-.-.-.%-.-.-.-.-.-.-.-.:-:-:-:-:-%:.:-:-:.:.,%....,:
-:-,.:::-%,.:-,.:-:-.-...:-:.:-:-:-
.-.,-,.'-,-'.'-'-'-'-'-'. ................................................ ...............................:.:.:.:-:-% .,.:-:.:-:-:-:-:-.-:-:%-.-.-.-.-.-.-...............%................................................................ .... ............ ...... ....%........
.... .................x-x.-
: : ,.
................,.
-.,.
:.:-,:::::.::-:-.-:::::...:.:-:.:-:-:.:-:-:-:.:-:-:.:-:.,.-.-.-.........-.....-.. .%
::::: , -: -* .....%*-:-:-:-:-;,-,
.......... .........'.%'.
,I.
..................
1.
.................
..........
....................................................................................:............. ..................................................
I.:.:-::::::.:::::::b::::..:::..:-:.:.:.:.:.:::: .::.:-:.:.:..:,:.:.:.:.:.:..:.:.:.- ;,.' .:.-::. .:. :.:.:.:-:.:-:. ...... C ",,-,,,,-,,,,,,,,,,,,,-,,,-,,,,,,-,.,-,.,.,.,-,.-.,.,-'-'-'-'-' ::::; .4f%,-" ::: .41;0%1 ..:lm :-:-:-:..-.-.-.......-.-.....-.-.-...m lo ..t -X ----,,--,,---................ -'.t-. ::: .................. ....... .eV: :1.W.V ".. :: :"-.,..: .X. . .. t A .--....e. .: n-, -c--. :., -t;:.................,......,.,...,.,.,.........%-.-.-.................................................................................................................................................................................................................................. .%,.,.,.,.,.,.%....% .................... .
...
:.: *'. '.
C-.:rN
..............................
re
"'U
::.a -s,...--, t
"..
..
.s..............................
::::,. .....................................-.-.-.-.-.-.-....................................... ............... ................................................................................................................................................. .% .................................................................... :-:-:-%,................:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-,-,-,-,-,-,---,-.1-,-,.,-,-,.,-,-,.,-,.'-' .................... ...... X.....-11-11,11,11111-1111,-111,111,11I ..............I..:d.:-:-*-..,.,.,..,..-.-.............................................................................................. ... ... ::::::::,-,:-- ...... -*....................................................................................................................... ::::::::::::::::::::::::::::......-.......-.-.-.........-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.......-...-.-.----......................................... .,. -u:. ........................................................................... .. .:-,:...:.:-. .'-'.'.'.'-'.'.'.'-'.'.'-'-'-'.'.--'.'.,.,-1-1.1--.,:.:.:.:.:. ................................................................................................................................................ .'....... .l...,......,. .l..............................................................................................-...-...-.,.,...,............. ....:........ ......................-.-....-.-...............-........-.-............................................................................................. ................. .................% ........................... .......................... ..... ::::::::::::: ::::::::::::::::::::::::::::::: ...................................................... ::: ..................................................................................................................................................-. ........................................................................................................ --................................................................................................................... :::::::::::::::%.:.,::::::::::::: .......-.-.%,.-.-.,................................................ ..............,.........................................%... ..........V ...
..........
.........
%.:.-.-.-:::,-,:-,-:::
.:-:-:-,-:-:.:-:-:-:-:-:-:-:-:-:-:-:-%::::,-".,,..,:.: - .......l.........%.......... .,.-.-.%-.-.-.-.-.-.-.%-. .,.%, ............-.1.-I..... .........................::.:-:.:.:-:-.-:-:.:-:-:.: ...
.,:,. . .: : : : : : :-,: .-
...............
%
..................................................
:-:-:-:-:-:-:-:-:-:-:.:-:.:.:-:.,.,.,.,".."..,..,.,",""",-"'.,'I."""'l-"'."""""-'-'-".."".".",",.,"-'-""'.".",.'-'-"."....,.".-""""""""""'--l-I."",.,.""."."""'-"'-'-'-"""'I"'-'-'-""""""........................................................................................................... :.....-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.....-...-.-...-.-.........-..........---............-.-.-.....-.-.-.-...-.-...-...-.-.....-.-.-.....-.........-.-.-...-.---...-......-.......-.-...-.-...-.-....---.........-.-...-.....-.-...............-...........-.............-.....-.-...-.............-
...'...'....................
...... .............................%........... %.. ............................................................................,.........." ................. .......................................... ........................................................... %..%....%-...%..-.-. ............................... %.........., ...........-i-v ".... ........%......................................................" ......................... %-....:..., "....." ..................................................................................................... .,.,.,.-.,.,.-.-.,.,.I., ............... .... ......... ...................... ................................. ... .................. ............ ........................................ .. % .. % .... :, ,..,. .................. -.... .;&W -.'. ...... ............................................................. ..% ..................... :-X-. ......%.....................--..,.,..:.: :.................. .......: .................... ... .. .1-1.1-1-1.1-1---,.-.-.1-1---,.,.,--.-.,-,-1-1.1-1-1-1-1-1-1-1 -11 ...... .... -..... ....,.,.,.,.....,...........:.... .'...... ..:.... % ............................................ :....... ..... ..... ............................................................................................ .:-:.:.:.:-:-: .............'........... -.-.-.-.-.-.-.......,...,.,...... ..... ...... .............................................................................. ........ ............................................................................................. .U...,.,..... ... .,. ............ .. .% .................... ......... .:" i .... -.-.-.-.-.%-.%-. '............................................................................ .......... .................................................................................... ,................................,.....,...,.,...,.....,.,.,...........................,.,.,..........,................. .............................................................,... .................................. ................................................................. ..........:.:.:.:.:.:-:-:.:-:.:.:-:.:.:-:-":-:-:--.,---,--" .................................................................................. .......................- ................................................
::::::::........A..:::::: .:.:.:.::::::::::::::: :.:.%,: ,-,::::% :%,:% .............:.-,.,-,.,-,..................................:-:.:.......-....-...-:-:::::::::::::::::::,.:,.
.................................................................
...
.I -,
.-'- ID
..
..........:::::::::................,..................................................................................................,.,...,...,............................................................................................................................................................................................. .:::%.:-:-:.:.:.:-:.:-.-..:-:-:-:-,-:-:-:-:-:-:-:-:-:-:-:-:-:-:.:.,.'-'.'.'--.'.,-'-'..'.'.'-'.'.'.'.--'.-.'-'..'.'.'.'.'.'.'.,.-.'.'---,.,.---.,.I.-I.I.-.,.1-1-1.1---,---,.,.,.,.1-1.1-1-1.1-1.1-1-1.1-1.1-1-1-1----.--,.,.,.l.-.-.--,---1.1---,.-.-.,.,.,.,.,.-.,.,.-.,.,.,.-.,.,.,.1-1-1.1-1.1--.,.,.,.,.-.-.,.-.,.,.-.,.-.-.-.,.,.,.,.-.,.I.I.I.I.I.I.............................-...........-.-.-.-...-.-.-.-...-. ..................................................................................................................................................................................................................................................................................... ...................... .:-:.:-:-:.,.,.,-,.,..-.-.......-...........-.-...-....-.------.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-...-.-.-... .:.:.:.:.:.:-:.:-:.: ..........%.................................................................................................................................................................................... ..............................................................
.............%........
.......................... X-1 ......,.,.%..-.-.-.-.-.....%,.,.-. X.:.:.:.
11-1 ...... ... 11 ... -
%, :.:.:.:-:-:-...:::::::::::::,.,...... ..:.....-.-.-.-.-.,.,.-.,.,........ :.:-:-:.:.:.:.:.:.:..-.-.,...:.:.,.,...,,,,.-,,,,,, ..-.,.-X%::::::::,--%-.-...%-.-.%-.-.-.-.-...-,::::-,-.%..:: ::..:.,.......x ..
--
.................................... .......................... ............................... ...................................................... ............................
................................................................ ........................................................ ................................................................ ......................................................... ................................................................ ................................................................ ................................................................ ................................................................ ................................................................
......
..........:.:.:..-..'.-.-.'.............................% ,.......,..........%......-.-.-.-.-.-.-.-.,.-.-.-.-. .....................%..........%%......%..........%-. ...................................%..........%..........
................................................................
%,.-.,.,.-.-.-...........:-:-:-:-:-:-:-:---
:-:-:-:-:-:-:-:-:-:-:.:.:.:.:.,.,...,-,.,-'-'.'.'-'., .,.,.,.,.,....................................
%%.
.............................................................. 41 ol 40 ::::::::::::::::::::-%--. .............................................................. % ..............................................................: .-................................................................ ::-:.:.:-:-:-:.:.:.:.:-:-.-: ............................................................... .:.:-:-:.:.:.:-:-:-:-:-:-:..:: ................................................................ '...... .... ................................................................ ..........X ...I..... :::::::,.-........ .......... ......................................................................................................................................................................................................................................................................................................... .. ",",""""",.",..".""..",." ,.....,.,...,.,.," .................................................................................................................................................................................................................................,.,.,.,.,..................................... ....... ........ :.:,.::.-.::: .....::::::::::,::,:. ." .......... .::..,:, .... ...,.,.,.,.,."."...,.....,.,.,........:-:.:.:.:.,-, .'-'-'-'.. '..'.'.'.'.'.'.'.'.'.'..'.'.'..'.:-:.:.:-:-:.:-:-:.:.:-:-:.:.:-:.:.:.:-:.:.:.:.:.:.:.:.:.:.:.:.:-:.:-:-:.:-:.:-:-:-:-:-:-:.:.:.:-:.:-:-:-:-:-:-:.:.,.,..-'-'-", .-.-.-.-.-.-. -::::::::::::::::::::::::::::::::-:-:-:.:.:.:.:.:-:.:.:.:.:.:.: ::::,., -:-:-:-:-% .....-.-:-:-:-:-:-:-:-:-% ...,.,.,.,.-.,........ ............................. ........................................... :-:-:%.:-:-.%,..........% ................... ....................................................................... .....-................. :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-.-,.,.....'.'.'.'-'-'-'.'.'.'.'-, "'.....%X ...... :-,..,.:.:-:.:.:.. -:-. .. 1.1.1.1.-.-.-.-.%%-.,... ...X ... ,...,.............,........................................................................................ . . i. ............ .. ...'...." .:..., .............. --..--..-.. k k..:::::::::: ..... -A:.....:" :. -:- .... :.:-:-:-:-:-:-:-:-:-:-:-:-:.:-,-.-,.,..-,...l.-.,.--,-,--.,-,-,. 1-............... ... ............ ::::::::::::::::::::....... ..................,................'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.','.'.'.'.'.-.'.'.:-:-:-:-:-:-:-:-."%,....:-.-,: -:.:.................................................................................... ,.-.-.,.:.-.-.-.-.-.-A .:.:.:-:.:' M ..." ...... I.Y ......... :.,.6 .-- -.-.-.-.-. ................:-:-:-:-:-:-:-:-:-:-:.:.:.:.:..,.,...-,..,.---..,..,.,....,..-.-,.,.-'.-'..,.'.-,.-..,. .......:. ...........X.:.:.:.:,M ..........:::::::::::::::-............................................................................................ .........X -:-:-:-:--:-:-. .%..... '.... .................................................................................:............:.:.:.:.:.:-:-:-:.:-:.:-:-:-:----...,...,-,..'..'-'.'.'.-,.,.,.-.-.,.----.........................-.-.--.l--.,.,.-.,.,.-.-.,.,.-.1-1-1.1-1.1.I.I.I.I.-.-.I...............%,.-.,.,.-.-.,.-.-.,.,.,.-.,.,.-.-.,.-.,.,.-.-.-.-.-.-.-...-.....-.-.................................................. ....................%....'. .............. %-.-.-....................................................... .,.....,.................................................................................................................: ...,.......,........................................................................................................................................................................ ........................... :-:-:-:-:-:-:-:-:-:-:-:.:.:.:.:..,-..,...,.1-1.--,.,.,.,.,.,.,.I.I.I.I.I.,.,-,........................................................................................ ... ........................................... ::::::: ..................................................................................................................................... :-:-:-:-:-:-:-:--................................................... :::::::::::::::::::::::::::::::,-,...-,........................................................ ................................................................................... ................. ...,.,.,.,.,.-.-.--'-'-'-'-'-,.:::::::::-.. -, .................................................................................................................. ..-.,.,.,.,.,.%,.............................. ...................................................................................................... -::::::::: :: .."...." ....- ....................... .....% .................... %..'.......'........... .,.:::::::::::::::::::::::::::.?,.:::::::::::::::::#::::::::::I.l::::::::::::::::::::::::: ................................ l-:*:::-:::::::-:::::::-*.-:, ........................................ .%%-.-.,., ............................. :.. .", :::: n..v,-"%: -&.,,g-e " ::: f ::m r.%:-,-,-----,-,-,-,-,-,-----,-,-,--,., X,&L ,j :'IS.-G -.... ... .. U.%--: %..:re X., :: -v ::-::: 1:14 T.::0-T-1, .............. ....... ..................'.'. ..................: .................
....,..
............%.
.I. . . .
..
..... '............. -.-.-.-.-.,.,., %.
. . . . . . . . . . . . . . . . ,.....,.,. .,,. . . . . . . . . . . . . . . . . . . . . .,,. . . 'U . . . . . . . . . ....-..-..r..:.: t.-. .. .. . . . . . . . . . . . .:0-I..:-t:.-'-'-'- -'-'-'- -'- . -. - -.-,
..........................................................................................
.:.:.:.:-:-:-.-.-.-.-.-.-.- -.:,.:..
............................
i 2:
