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Death certificates: Cardiac arrest is not a cause of death.

Completion of a death certificate is an important and despised requirement within the medical profession. A death certificate is the official recording by the state of a death that occurred within its borders to fulfill legal obligations and to provide demographic and statistical information for prevention and health improvement programs.

The requirements for completion of death certificates by practitioners outside of the Office of the Chief Medical Examiner (OCME) apply to the certification of natural deaths. Any death in West Virginia that occurs by violence, apparent suicide, when in apparent good health, unattended by a physician, as an inmate of a public institution, from a disease that might pose a threat to public health, or in any suspicious, unusual or unnatural manner requires immediate notification to the OCME. A time limit is not applied when it comes to deaths that are a result of violence. For example, if someone became a quadriplegic through a non-natural process and died 10 years later from complications of the quadriplegia, it is still a case that must be reported to the OCME. If a practitioner has any doubt as to whether the underlying cause is natural, it is always proper to contact the OCME for advice.

A natural death is a death "due solely or nearly totally to disease and/or the aging process" as opposed to accidents (unintentional injury or toxicities), homicides (intentional injury), or suicides (intentional injury). The cause of death statement should be the provider's best informed medical opinion, within a reasonable degree of medical certainty, based on training and knowledge of the patient's medical history, presentation and course of treatment. It is neither reasonable nor expected that the cause of death statement contain the measure of clinical accuracy that could be obtained through autopsy.

In formulating a cause of death statement, one must avoid describing agonal or terminal events that are invalid as cause of death statements. Terms such as: Asystole; Cardiac Arrest; Cardiopulmonary Arrest; Multi-organ System Failure; or Respiratory Arrest are not specific to explain why a death occurred; they do not describe causative or underlying effects of the pathologic process. Everyone who dies quits breathing and their heart stops beating.

There are two main parts of the cause of death statement. In Part 1 - Statement of Cause(s) of Death, the practitioner must state the underlying disease that led to or culminated in death. There may be cases where the underlying cause of death is the only entry; however, the practitioner also has the opportunity to provide separate immediate or intermediate causes of death on the following lines.

There must always be an entry on Line A, which is the immediate cause of death that may also be the underlying cause of death. The opportunity to provide additional information on the form, when utilized, should be in sequence. Specifically, the condition on Line A was as a consequence of the older condition listed on Line B, which was a consequence of an even older condition on Line C, etc. There is not a requirement or a necessity to utilize all of the lines available. There are many causes of death that lend themselves to a single line statement cause of death, including: Alzheimer's Disease; Diabetes Mellitus; Coronary Artery Disease; COPD and several others.

Part 2 - Other Significant Conditions on the death certificate is for conditions that contribute to death but do not result in the underlying cause of death. Risk factors (i.e., tobacco use, morbid obesity, chronic alcohol use, etc.) are listed in this area of the death certificate, as are co-morbid diseases that likely contributed to death.

Practitioners certifying the cause of death should always seek to provide the highest possible level of specificity unless the underlying cause of death is uncertain. In cases of uncertainty, qualifying descriptors such as "probable," "presumed," or "suspected" may be used to qualify the practitioner's uncertainty of the natural cause. If the practitioner cannot make a qualification to a specific natural cause then, as long as all indications are the death was due to natural causes, the terms "unknown," "undetermined" or "unknown etiology" may be used to qualify that a death due to a natural cause had an unknown specific cause. The use of terminology such as "Unknown/Undetermined Natural Disease Process" is valid but should never be used as a matter of expediency.

Additionally, it is extremely important to ensure that cause of death statements make the nature of the process clear. There are some findings that indicate injury. These specific causes of death, when listed on a death certificate, will result in a request for clarification from the certifier or a referral to the OCME for investigation. These causes include: subdural hematoma; subarachnoid hemorrhage; fracture; pulmonary emboli; anoxic brain injury; sepsis; aspiration pneumonia; seizure disorder; and drug or alcohol overdose/abuse. Utilization of specific language, qualifiers and intermediate causes to ensure that the death certificate reflects the natural nature of the cause will eliminate additional inquiries and referrals.

The completion of cause of death statements is not an exact science. Practitioners who have questions or are uncertain should consult with a pathologist, the West Virginia Health Statistics Center or the OCME for guidance.


West Virginia Office of the Chief Medical Examiner: Matthew D. Izzo, BA, MS--Administrator; Allen R. Mock, MD. MS, DABP, FCAP - Chief Medical Examiner; Elizabeth R. Mooney, DO, MS - First Deputy Chief Medical Examiner; and Andrea Orvik, MD - Deputy Chief Medical Examiner

West Virginia Health Statistics Center: Gary L. Thompson--State Registrar


(1.) CDC. (2016, November 21). "Instructions for Completing the Cause of Death Section of the Death Certificate"; "Physician's Handbook on Medical Certification of Death. 2003 Rev."; and "Possible Solutions to Common Problems in Death Certification (including Uncertainty, the Elderty, and Infant deaths").

(2.) Hanzlick, D. R. (2006). Cause of Death and the Death Certificate - Important information for physicians, coroners, medical examiners, and the public. Northfield, IL: College of American Pathologists.

(3.) The National Association of Medical Examiners. (2006, November 21). "Writing Cause of Death Statements - Basic" and "Quick Tips on Writing Cause of Death Statements".


* Alzheimer's Dementia

* Adenocarcinoma of prostate

* Perforated gastric peptic ulcer

* Asthma

* Meningococcal meningitis


* Bowel obstruction

* Renal failure

* Sepsis

* Congestive heart failure

* Multi-organ failure

* Gastrointestinal hemorrhage

Cause of Death and the Death Certificate, Hanzlick, 2006

                                                     Approx. Interval
Part 1--Statement of Cause(s) of Death              between onset and
        Immediate Cause
Part 1  A. Acute Myocardial Infarct                       2 days
        B. Coronary artery thrombosis                     2 days
        C. Atherosclerotic coronary artery disease       Decades

Part 2--Other Significant Conditions--Conditions contributing to death
but not resulting in the underlying cause of death in Part 1

Part 2  Essential hypertension

Cause of Death and the Death Certificate, Hanzlick, 2006
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Title Annotation:West Virginia Bureau for Public Health / NEWS
Publication:West Virginia Medical Journal
Date:Jan 1, 2017
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