Death certification

Recognition of death¹

It is vital when certifying death, to ensure that death has indeed occurred. In the modern world of advanced intensive care techniques and potential for organ donation, this can be a challenge. In the UK at present, there is no legal definition of death and there is no international consensus, although it is generally taken to mean the irreversible loss of capacity for consciousness combined with the irreversible loss of capacity to breathe² . Guidance on the diagnosis and confirmation of death (as well as death certification) was issued in 2008 from the Academy of Medical Royal Colleges. The guidance is mainly concerned with confirmation of death in hospital and in circumstances where the diagnosis of death may be more difficult (patients on ventilators, for example).

Guidance on the diagnosis and confirmation of death from the Academy of Medical Royal Colleges

Proceed without unnecessary and distressing delay. Death may be obvious with clear signs pathognomonic of death (hypostasis, rigor mortis). If not, obvious death should be identified by "the simultaneous and irreversible onset of apnoea and unconsciousness in the absence of the circulation".

The guidance in addition advises that:

• Full and extensive attempts at reversal of any contributing cause to the cardiorespiratory arrest have been made where appropriate (for example, body temperature, endocrine, metabolic and biochemical abnormalities more relevant in hospital).

• One of the following is fulfilled:
  

  • The individual meets the criteria for not attempting cardiopulmonary resuscitation

  • Attempts at cardiopulmonary resuscitation have failed

  • Treatment aimed at sustaining life has been withdrawn because it has been decided to be of no further benefit to the patient and not in his/her best interest to continue and/or is in respect of the patient's wishes in an advance decision.

• The individual should be observed by the person responsible for confirming death, for a minimum of five minutes to establish that irreversible cardiorespiratory arrest has occurred. In primary care the absence of mechanical cardiac function is normally confirmed using a combination of the following:
  

  • Absence of a central pulse on palpation.

  • Absence of heart sounds on auscultation.

  In hospital this can be supplemented by one or more of the following:
  

  • Asystole on a continuous ECG display.

  • Absence of pulsatile flow using direct intra-arterial pressure monitoring.

  • Absence of contractile activity using echocardiography.

• Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt a further five minutes of observation from the next point of cardiorespiratory arrest.

• After five minutes of continued cardiorespiratory arrest the absence of the pupillary responses to light, of the corneal reflexes, and of any motor response to supra-orbital pressure should be confirmed

• The time of death is recorded as the time at which these criteria are fulfilled.

Verification of death

Who can verify death?

The British Medical Association (BMA) guidance is as follows³ :

UK laws

• Do not require a doctor to confirm death has occurred or that "life is extinct".

• Do not require a doctor to view the body of a deceased person.

• Do not require a doctor to report the fact that death has occurred.

• Do require the doctor who attended the deceased during the last illness to issue a certificate detailing the cause of death (unless the death is referred to a coroner or Scottish procurator fiscal).

So a doctor's legal duty is to notify the cause of death, not the fact that death has taken place. Doctors, nurses, suitably trained ambulance clinicians or community care staff may confirm that death has taken place. In the era of the COVID-19 pandemic the BMA has issued a protocol for the remote verification of death⁴ . This enables non-medically trained persons to verify death under the guidance of a doctor. The recommended method is to use a mobile phone with a camera.

There is no legal obligation on a doctor to see or examine the deceased before signing a death certificate⁵ . This is the case across the UK.

Should a GP visit?

For deaths in the community, the BMA advice was that if an expected death occurred in the community, a doctor should visit as soon as possible, whilst prioritising the urgent needs of the living. For unexpected deaths, the BMA recommended a visit by the GP with whom the patient was registered, to examine the body and confirm death, although this is not a statutory requirement. Since the COVID-19 pandemic, however, the BMA advice has changed³ . The BMA now acknowledge the concern of some doctors that "being asked to attend cases where death is clear, expected and verification could reasonably have been performed by others, either independently or with remote support, creates unnecessary risk. In doing so it draws them away from providing care to the seriously sick and creating an additional unnecessary infection risk to them, their patients or those who were caring for the deceased."

How to verify death

A thorough physical examination should be carried out to ascertain whether or not death has taken place. First inspection should reveal an extreme pallor (particularly of the face and lips) and relaxation of the facial muscles. This leads to drooping of the lower jaw and open staring eyes, unless these have been closed. Further examination should confirm:

• No palpable pulses.

• No heart sounds on auscultation (or asystole on ECG).

• No observed respiratory effort.

• No breath sounds on auscultation.

• Pupils dilated and not reactive to light.

Particularly if the death is unexpected, an external examination of the deceased and their surroundings should be made, to look for any apparent factors which may be relevant to their death (bleeding, vomit, wounds, weapons, alcohol, pills, notes, etc).

Other signs of death include:

• No response to painful stimuli.

• Absence of corneal reflexes.

• Cloudiness of the cornea.

• Examination of the trunk may show evidence of post-mortem staining as a result of hypostasis.

• Rigor mortis may have set in (begins approximately three hours after death).

• Decreased temperature - will depend on ambient temperature but may not occur for up to eight hours.

The precise moment of death may be difficult to recognise, and for a period of time after respiration has ceased, and the heart has stopped, the patient may still potentially be resuscitated. In certain conditions a patient may appear dead if not thoroughly examined:

• Following prolonged submersion in cold water.

• Following ingestion of alcohol or drugs.

• When hypoglycaemic or in a coma.

They may recover completely, if treated appropriately. It should be remembered that hypothermia protects against hypoxic neurological damage and that children under the age of 5 are more resilient to hypoxic brain injury; therefore, resuscitation should be continued in these circumstances until normal body temperature is reached, even if the patient appears to be dead.

Practical definition of death in primary care

Remote verification of expected death

The BMA and the RCGP have drawn up a protocol to be used when a doctor is guiding a non-medical person to verify an expected death via a mobile phone and camera, viz⁴ :

If rigor mortis is not present:

1. Check pupils are dilated and do not respond to light in both eyes from pen torch or mobile phone torch.

2. Check no chest wall movements for three minutes by observing the chest (exposing the chest may be necessary). Absence of breath sounds using a stethoscope may provide further confirmation.

3. Locate site of carotid pulse (using video advice from guiding clinician if required) and check that pulse is absent for at least one minute. Absent heartbeat, using a stethoscope, may provide further confirmation. Repeat steps 1-3 after 10 minutes.

If rigor mortis is present:

Make an appropriate record of time of verification of death, name of patient, date of birth of patient, address (if known), NHS Number (if known), details of next of kin (if known), name of person in attendance, other people present, circumstances of death and name of guiding clinician.

Death certification

Certification of death will depend on:

• The circumstances of the death.

• Where it has occurred.

• Whether or not it was anticipated.

• Whether or not there is any suspicion of foul play.

Relatives and/or friends of the deceased may be very distressed and GPs attending a death should offer support where appropriate. Bereaved families may also require guidance on the procedures following a death, particularly if the death was unexpected.

Medical certificate of cause of death (MCCD)⁶

During the COVID-19 pandemic, the Coronavirus Act 2020 amended the regulations concerning the completion of the MCCD. This is viewed as a temporary change, and it is not sure when and if the guidance will revert to the original version, or indeed whether further regulations will in due course be issued.

The MCCD (more commonly known as the death certificate) fulfils a number of purposes:

• It allows the relatives of the deceased to register the death.

• It provides a permanent legal record of death

• It allows the relatives to arrange for the funeral, etc and to settle the estate of the deceased.

• It is used to provide national statistics about causes of death and trends in disease which go on to guide research, health services planning, etc.

In England, Wales, Northern Ireland and Scotland, death certification may be issued by a doctor who has provided care during the last illness and who has seen the deceased within 28 days before death. This includes video consultations. They should be confident about the cause of death. The Coronavirus Act 2020 recognises that the doctor who saw the patient during their last illness may be unable to sign the certificate or it might be impractical for them to do so - for example, if they are self isolating. In such circumstances, a doctor would need to state to the best of their knowledge and belief the cause of death. Guidance from NHS England and NHS Improvement states that a doctor intending to complete the MCCD should obtain agreement that they can do so from the coroner. It is also possible that no doctor attended the patient in the 28 days preceding death. It remains the case that if there is no doctor at all who can give a cause of death then the death will still need to be referred to the coroner in the usual way.

When to report a death to the coroner

In some circumstances, a doctor is unable to provide a death certificate and the death must be reported to the coroner (or procurator fiscal in Scotland) rather than issuing a death certificate. Such circumstances include:

• No doctor satisfies the attendance requirements for being able to certify death - eg, the only doctor who has provided care during the last illness is away on holiday, or the deceased has not been seen by a doctor within the preceding 14 days.

• If the cause of the death is unknown.

• Sudden, unexpected, suspicious, violent (homicide, suicide, accidental) or unnatural deaths.

• Deaths resulting from injury or poisoning.

• Deaths due to alcohol or drugs. (Not chronic alcohol or tobacco use.)

• Doubtful stillbirth.

• Deaths related to surgery or anaesthetic.

• Deaths within 24 hours of admission to hospital.

• Deaths in prison.

• Identity of deceased unknown.

• Death from an industrial disease.

• Death from neglect, want or exposure.

Completing the death certificate

There is detailed information at the front of the death certificate book explaining how to fill in each section. A few specific points are worth mentioning:

• Old age. Old age alone should not be used as the sole cause on a death certificate unless:

  • The deceased is 80 years of age or more.

  • You have personally cared for the deceased over a long period (years or many months).

  • You have observed a gradual decline in your patient's general health and functioning.

  • You are not aware of any identifiable disease or injury that contributed to the death.

  • You are certain that there is no reason that the death should be reported to the coroner.

  • You have considered checking with relatives that they are satisfied with this explanation for the cause of death.

• Organ failure. Avoid organ failure alone as the cause of death. Specify the condition which led to organ failure below.

• Mode of dying or terminal events. These cannot be used as the cause of death (eg, cardiac arrest or shock).

• Abbreviations. Do not use abbreviations on a death certificate.

• Diabetes. Specify type 1 or type 2 and give the complication which led to death.

• COVID-19. COVID-19 is now an acceptable 'direct' or 'underlying' cause of death for the purposes of the MCCD and although COVID-19 is a notifiable disease, this does not mean that deaths from COVID must be reported to the coroner (or procurator fiscal in Scotland). In Scotland the guidance has clarified that the terms COVID-19 disease and SARS-CoV-2 infection are acceptable if the disease is suspected but not confirmed. You may write 'Presumed COVID-19 disease' on the MCCD. In both cases, the hazards box on the form must be ticked and the public health department informed.

The Coronavirus Act 2020 allows for the death to be registered without automatically having to refer the death to the coroner (as was the case previously) provided the deceased has been seen by a doctor within the last 28 days. Even where the deceased has not been seen within the last 28 days, if the coroner agrees that a doctor can complete an MCCD then the relatives should be able to register the death. Registrars will now accept scanned or photographed copies of the MCCD forwarded from a secure email account (such as nhs.net). An original, signed MCCD should be securely retained for delivery to the registrar as soon as circumstances allow.

If the Registrar decides that the death does not need reporting to the Coroner they will issue:

• A Certificate for Burial or Cremation.

• A Certificate of Registration of Death (for Social Security purposes).

• (On request), certified copies of the Death Register (at least two copies advisable because banks and insurance companies expect to see them).

If the body is to be buried in England, there are no further formalities. If the burial is to be outside of England, an Out of England Order is needed from the Coroner. If the burial is to be at sea, and Out of England Order and a licence from the Ministry of Agriculture, Food and Fisheries is needed, and the District Inspector of Fisheries should be notified.

Cremation certificate and forms

The Coronavirus Act 2020 has amended the current regulations. There is no no longer a need to complete a confirmatory medical certificate (form 5) for cremations. The existing form 4 (medical certificate) is still required and this should be completed as normal.

If the doctor who attended the patient (either by remote video consultation or in person) within the last 28 days is unable to complete the form or it is impractical for them to do so, then any medical practitioner is able to complete a form 4. However they can only do so when the MCCD was completed on the basis that the deceased was attended within 28 days of the death or where a medical practitioner has viewed the body after death, even if only for the purpose of verification.

Examination of the body after death is not required if the deceased was either seen after death by a medical practitioner or attended (in person or by video consultation) within the last 28 days.

If a doctor completing form 4 did not attend the patient during their last illness, question 5 can be completed with 'certifying doctor' as an acceptable 'medical role'. Question 9 should be completed with the name, GMC number and role of the medical practitioner who attended the deceased.

It is acceptable to answer question 8 (which asks the date and time that the body of the deceased and the examination that was made) with 'not applicable' if another medical practitioner attended the patient within 28 days before death or saw the body of the deceased, even if only to verify the death. The date and time and nature of that examination should be set out in the answer to question 9 (which asks for an explanation from the medical notes, the doctor's own observations and that of others about how the cause of death conclusions were elucidated).

Changes introduced in 2008 already allowed cremation forms to be sent to the crematorium's registrar by email.

Summary: what to do when called to a death in primary care

• Be sensitive and supportive towards bereaved and/or shocked relatives.

• Verify that death has taken place as in the section above.

• Document the time death was verified.

• In an expected death, provide a death certificate as soon as possible. If you are not the regular GP, establish whether the regular GP is likely to be able to issue a certificate (if they have seen the deceased in the preceding 28 days). If this is the case, notify the regular GP as soon as possible. If it appears likely a certificate can be issued, the relatives may contact a funeral service to arrange removal of the body.

• In an unexpected death, document anything on or around the body which may point towards a cause of death. Explain to the relatives it may not be possible to issue a certificate until a cause of death has been established, and to do this you will need to refer the death to the coroner or procurator fiscal. Explain that the coroner will then ascertain if further investigation is required, or if a certificate can be issued. Phone the coroner or police and explain to the relatives that the coroner or police officer will advise about moving the body.

• If cremation forms are required, the funeral service will contact you and ask you to complete Form 4.

• Where relevant, follow up with ongoing offers of support to the family.