Cause of Death, Autopsies, and Health Statistics
Daniel T. McClurkin
I grew up in the shadow of my family’s funeral home. My grandmother lived in the apartment above the funeral parlor, so I would walk to the funeral home to visit her regardless of whether or not there were calling hours going on. When I turned 16, I began to go to the funeral home to work. I started out as an assistant funeral director—which just meant I walked around and refilled water pitchers and met friends of my father. Eventually, I moved to the back office where I would take donations for the family or for masses to be held in the name of the deceased at local churches. This began my paper work days where I started to help my father fill out forms, edit obituaries, and pick up or deliver death certificates. The death certificates were always the most tedious bit of paperwork to fill out. The funeral director would fill out all of the information except cause of death; in fact, you need funeral director and embalmer signature before the document could be computerized. This was just a practical issue to make sure that the body had actually arrived and everything was on the up and up. We, however, could not fill out the cause of death: that, technically, is the job of a doctor. Even if somebody didn’t die in a hospital, a medical doctor would still have to sign off on the cause of death. If the deceased has a number of pre-existing illnesses, that would usually be considered probable cause and the doctor would just sign off on that. We had to file these death certificates to be filed within 10 workings days as per Ohio state law. We would file the certificate in the county in which the deceased passed, and then the counties would send that information to the state for statistical and bookkeeping purposes.
So, as you might imagine, it could be a major hassle to make sure the forms were all filled out correctly, the right people signed the right sections, and the county got it before the 10 working days were up. The biographical information was usually pretty easy to fill out. What was most difficult, and what required the most review, was the actual cause of death.
On death certificates, the cause of death is always recorded as a serious of events that lead to the final incident that ultimately killed the deceased. Ideally, the cause of death should read like a casual chronology of illness
a. John Doe was killed by a rupture of the myocardium that lasted for minutes, caused by
b. An acute myocardial infarction that lasted for 6 days, caused by
c. Coronary artery thrombosis that lasted 5 years, caused by
d. an Atherosclerotic coronary artery disease that lasted 7 years.
Then in the final section, any other “significant conditions” are recorded such as whether or not the deceased smoked tobacco or was a diabetic. In the example presented above, John Doe essentially died from a rupture in his heart caused by a heart attack. John Doe’s death would then be added to the number of deaths attributed to heart disease nationally.
The death certificate, in this way, is one of the most important tools for collecting mortality statistics. It’s the death certificate that tells us why someone died and the events that led to their death. Death certificates create logical narratives of the events leading up to death; smoking tobacco leads to heart problems which lead to heart attacks which lead to death. Now, when it’s unclear as to the exact cause of death, then a medical examiner or coroner performs an autopsy…potentially.
Before we go any further, it is worth noting that there are two forms of autopsy performed in the U.S.: the clinical autopsy, which I’ll be talking about mostly from now on, and medicolegal autopsies. Medicolegal autopsies are ordered in extraordinary death circumstances that require the attention of law officials—think homicide or suicide. Clinical autopsies are ordered by the family of the deceased or by physicians to “clarify cause of death or assess care” (Wood MJ, Guha AK, 2001). So, if a patient dies suddnely due to a standard medical procedure, or if there is some suspicion that the disease succumbed to factors other than their diagnosed disorder, an autopsy may be requested. If the autopsy may be relevant to some legal procedure or outcomes, the autopsy may be required depending on the state. At first glance, it’s a little hard to see why accurate cause of death reports are so important. Sure, it’s nice for the family to have some closure—some final, official say as to the cause of death. But where the cause of death becomes a larger social concern is when these death certificates are turned into death statistics.
Take for example the fact hat in 2014, 133,103 people died from cerebrovascular diseases resulting in some kind of stroke. 147,101 deaths are attributable to chronic lung diseases; 591,699 to complications due to cancer; and 614,348 to heart disease. Together, these causes of death account for more than half of the 2,626,418 American deaths in 2014 and, comparatively, heart disease has claimed the most American lives. At least, in 2014.
All of those statistics come from Centers for Disease Control and Prevention, or the CDC for short, in accordance with their mission to provide “health information that protects our nation against expensive and dangerous health threats, and responds when these arise” (mission statement of the CDC). In other words, by collecting mortality statistics, the CDC determines the major diseases—whether they be chronic, acute, preventable or otherwise—that kill Americans. The CDC’s health statistics helps “identify public health problems, to monitor progress in public health, to allocate research funds, and to conduct scientific research. For these reasons, good reporting of the circumstances of death on death certificates is very important” (Hoyert et al. 2003).
Primarily, the CDC collects its data from Death Certificates, filed through counties and reported by individual states. Death Certificates record biographic information—such as one’s name, ethnicity, occupation, and place of residence—as well as the place, date, and cause of their death. The form is filed by the funeral director and signed by a physician or coroner, depending on the circumstances of the death.
Autopsies are usually the best and most accurate way to approximate the exact event that killed the deceased. Even as more advanced screening technologies are developed, that autopsy has remained the definitive “double check” for in-hospital complications that result in death. In a series of case studies published by the CDC in 2001, Dr. Donna Hoyert of the CDC clarifies that “from both the scientific and practical viewpoints, the autopsy remains a useful tool to ‘see things for one’s self,’” with “ recent reports of large numbers of in-hospital deaths due to complications of diagnostic and therapeutic procedures” (Hoyert 2001), it seems that now, as more and more people are living out their last days in hospitals that autopsies should have steadily increased with the rate of in-hospital deaths. How, then, should we account for the fact that autopsy rates for in-hospital deaths have dropped by more than 50% in the last several years from 19.3% in 1972 to 8.5% in 2007 (Hoyert 2011)?
Now, Dr. Donna Hoyert attributes this change to a 1971 decision form the Joint Commission on Accreditation of Hospitals that stated hospitals no longer needed to perform a set percentage of autopsies per year to maintain accreditation. Before 1971, hospitals were required to autopsy 20-25% of in-hospital deaths; after 1971 that standard vanished. This change in accreditation standards arose from the development and implementation of effective predictive technologies. Due to this increase in predictive technologies, physicians can be more certain than ever before that what they report the cause of death to be is actually, probably, the cause of death. That being said, a substantial number of in-hospital deaths, somewhere around 25%, when autopsied, reveal a cause of death different than what’s officially recorded on the death certificate. These discrepancies wouldn’t be enough to skyrocket some rarely diagnosed disease to the number one killer of Americans, but it does mean that mortality statistics need to be taken with a grain of salt. Of course, autopsies aren’t perfect. But they remain the most accurate way to determine cause of death, not to mention how useful tool for medical education. It has never been the case that 100% of corpses are autopsied: that’s unfeasible and unnecessary. But if we are to continue to use national mortality statistic to allocate funding for medical research, then those statistics ought to be as exact a measurement of reality as possible. And despite their waning popularity in American hospitals, the autopsy stands as an effective tool for making sure what’s recorded on the death certificates is, in fact, the cause of death. Or is, at least, as close as possible to the cause of death.
Works Cited
Hoyert D. The Autopsy, Medicine, and Mortality Statistics. National Center for Health Statistics. Vital Health Stat 3(32). 2001.
—— Kung HC, Xu J. Autopsy patterns in 2003. National Center for Health Statistics. Vital Health Stat 20(32). 2007.
—— The changing profile of autopsied deaths in the United States, 1972–2007. NCHS data brief, no 67. Hyattsville, MD: National Center for Health Statistics. 2011.
Wood MJ, Guha AK. Declining clinical autopsy rates versus increasing medicolegal autopsy rates in Halifax, Nova Scotia. Arch Pathol Lab Med 125(7):924–30. 2001.