Certification of Causes of Deaths

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Identifying and documenting the cause of death of individuals is an important part of public health procedures. It is important to keep such records in order to establish the main causes of death in a community, to track changes in death rates, and to help determine how certain causes of death can be prevented. Death record information helps to assess future preventive, corrective, of palliative actions that might be taken, such as improving car safety or emergency services, or instituting health-education programs about a certain disease. It is also important to know the age and sex of deceased persons in order to identify risks specific to age and gender, and to identify those deaths that can be classified as premature. Of course, identifying the cause of death is also important for legal reasons, especially in cases of violent death, and to help surviving friends and relatives deal with the death of a loved one.

In countries with well-developed civil and medical death registration procedures, a physician or qualified health worker registers a death on a certificate. Death certificates tend to follow a standard format. The section dealing with the cause of death is usually in two parts. Part one lists the chain of events that, in the opinion of the reporting physician, led directly to death. The immediate cause is listed first. This is the final disease, injury, or complication directly causing death, and should not be confused with the mode of death (heart failure, respiratory arrest, etc.), as often happens. The immediate cause may be followed, if appropriate, by the chain of up to four disease or injury events that led to the immediate cause of death these are known as the intermediate and underlying causes of death. Part two of the death certificate reports other significant diseases, such as diabetes, or conditions, such as heavy drinking or smoking, that contributed to death but were not listed in part one as a cause of death.

A few examples will help clarify the terminology used. Suppose a child falls off a bicycle, suffers a cranial fracture, and dies from a cerebral hemorrhage. On the death certificate the immediate cause of death is listed as a cerebral hemorrhage, due to or as a consequence of a cranial fracture (intermediate cause), which was due to or as a consequence of a fall off a bicycle (underlying cause).

Another example would be a man who died from a rupture of the heart after an acute myocardial infarction following chronic insufficiency of the blood supply to the heart. He also suffered from diabetes and was a heavy smoker. On part one of the death certificate the immediate cause of death is listed as "rupture of myocardium." The intermediate cause is "acute myocardial infarction." The underlying cause is "chronic ischemic heart disease." On part two, "diabetes" and "smoking" are listed as significant contributing conditions.

Other elements, such as the duration of each causal element, the performance of an autopsy, and the manner of death (natural, accidental, suicide, or homicide) may also be entered according to local or national requirements. The tenth revision of the International Statistical Classification of Diseases and Related Health Problems, known as ICD-10, provides standardized lists of causes of death. It also deals with special requirements for the recording of death in cases of maternal death (linked to pregnancy, childbirth, or postpartum), infant death, or accidental death.

Michel C. Thuriaux

(see also: Causes of Death; Child Mortality; Infant Mortality Rate; Mortality Rates )


World Health Organization (1993). International Statistical Classification of Diseases and Related Health Problems, 10th revision. Geneva: Author.