By Dr Pablo Millares Martin. GP Senior Partner. Whitehall Surgery, Wortley Ring Rd. Leeds, UK.
The Medical Certificate of Cause of Death (MCCD) is a very important legal document with dual functionality: to provide the information required for the registration of a death, but also to facilitate statistical comparisons of mortality causes, and to set priorities in public health. For these latter purposes, the accuracy of entries is paramount, but unfortunately, errors in their completion remain far too common [1, 2]. Medical training on death certification remains a challenge everywhere ; furthermore, the form in use in the UK is still in paper format and, in consequence, allows more easily inadequate entries , and it does not follow the latest recommended WHO template .
There is a need to understand the current gaps present among clinicians filling these forms. NHS England  has worked over the last few years on the role of the medical examiner as a way of improving MCCDs. The statutory medical examiner system will commence in April 2023. A new layer of bureaucracy will be added to the provision of death certification. Are we ready for it?
Another issue to reflect on is the certificate itself. Simply making the form digital, making certain only specific answers are ‘allowed’, will improve the completion and the quality of the form. Furthermore, they will be more legible . What should have been the first step? Improving the form? Improving the training? Or adding more steps in the process of certification?
An online survey was developed to gather views from primary care clinicians on training, on MCCD completion, with a few scenarios to test how comparable the forms produced would be. It was carried out in 2021, as part of an online training presentation available to General Practitioners (GPs) in Leeds, UK, on death certification. At the time, general practice was under immense pressure, the covid-19 pandemic and its sequelae being one reason why it may have had a small response rate: Twenty-six responses (out of 100 GPs who attended online training) were received. Still, there is plenty to learn from the responses received.
With regards to training, a medical school tutorial on the topic had been undertaken by 53.58% of physicians, with 65.4% receiving post-graduation tutorials and 46.2% getting further information from reading the documentation available in the MCCD booklets. Fourteen clinicians (53.9%) had the last training on the completion of MCCD over five years ago, seven (26.9%) considered themselves as not receiving formal training, and five (19.2%) had training in the previous 5 years.
“What is the underlying cause of death (UCD)?” is paramount for statistics. It represents the first step that started the series of events leading to the death. In the WHO form that is followed by many countries [3, 4] it corresponds to the lowest-used line of the first section of the MCCD. Among respondents, 73.1% answered wrongly that it is “the condition reported on the top line in section 1 (i.e. 1a)”, 23.1% responded correctly and one person admitted that they did not know.
The MCCD in England and Wales has three lines available in section 1 to indicate this chain of events. When clinicians were asked to reply on a five-point Likert scale how much the different subsections were used, from “as little as needed” to “as much as you can add” 53.9% would lean towards a small amount of information. When asked about adding time intervals (interval between the finding and the time of death, as stipulated by WHO) there was also a tendency towards not writing them (61.6%).
When questioned about section 2, which follows WHO guidelines on comorbidities that could have contributed to the death, there was a tendency to use it (65.2% of respondents).
When presented with three summaries to write death certifications, there were at least four different UCDs (underlying causes of death) in each case, a huge variability considering the number of responses.
- The purpose of the MCCD needs a clear understanding
This small survey indicated that there may be a lack of understanding of the MCCD and its purpose. There is also potential for interpreting this as merely another hoop, ie a transaction for the decedent’s significant other to deal with. But it is of much more than this; it is the basis for national and international statistics on causes of death. Without proper attention to detail, the result is poorer data, poorer statistical analysis and little benefit for public health when trying to reduce the effect of risk factors underlying the different causes of death.
- The underlying cause of death is the most important piece of information
It is not possible to assess the main causes of death if there is no understanding of the form, particularly regarding the underlying cause of death. Clinicians need to see beyond the recent care, as the process of health deterioration could have started much earlier than that, even decades ago.
- Adequate medical training is paramount
The UK government has decided that the way to tackle the problem is to have medical examiners check all of the death certifications, whether completed in hospitals or the community. It could be argued that additional training should be implemented before the medical examiners are in post. It is not about correcting poor entries but making good quality entries to start with.
We are facing a huge change in the bureaucracy related to death certification from 2023. Will it improve the quality of the certifications, or will it be a simple tick-boxing exercise, where only the most obvious anomalies will be corrected and the huge variability currently present will persist? There is a huge opportunity to improve death causes-related data. It will be a pity not to achieve that improvement. But then, time is running out to roll out training, to help users understand the form and its wider purposes and importance, and to make completing the death certificate a facilitator to improve public health. Not merely a mindless task to get out of the way as quickly as possible, just to get it over and done with.
- McGivern L, Shulman L, Carney JK, Shapiro S, Bundock E. Death certification errors and the effect on mortality statistics. Public Health Reports, 2017; 132(6): 669-75.
- Hart JD, Sorchik R, Bo KS, Chowdhury HR, Gamage S, Joshi R, Kwa V, Li H, Mahesh BP, Mclaughlin D, Mikkelsen L. Improving medical certification of cause of death: effective strategies and approaches based on experiences from the data for health initiative. BMC medicine, 2020; 18(1): 1-1.
- Millares Martin P. Death certification in England must evolve (Considering current technology). Journal of forensic and legal medicine, 2020; 69.
- Millares Martin P. Medical certificate of cause of death: Looking for a European single standard. Journal of forensic and legal medicine, 2020; 75.
- NHS England. The national medical examiner system.