Death investigation in the United States is governed by a mishmash of laws that define jurisdiction and roles using a mixture of medical examiners (MEs), coroners, justices of the peace, districts, sheriff-coroners, and prosecutor-coroners working in more or less centralized systems. Coroners are elected officials with jurisdictional authority for death certification. Typically, coroners are not physicians and have few requirements for training or qualifications. By contrast, MEs are appointed positions filled by physicians with legal authority for death investigation. Many MEs are board certified by the American Board of Pathology in Forensic Pathology and can perform autopsies. In the United States there are approximately 2300 death investigation jurisdictions. 1 The majority are coroner offices, with many located in smaller, more rural counties. About one half of the US population is served by an accredited ME office; these often have jurisdiction over large cities, counties, or whole states.
Widespread local and regional variation exists regarding the statutory authority to complete death certificates. The funeral home typically begins the process, inserting demographic information provided by family members or other knowledgeable sources. 2 Community physicians, other health professionals (e.g., nurse practitioners), coroners, or MEs provide cause and manner of death and other public health information.
The death certificate has dual purposes. It is primarily a public health document, revised periodically to meet public health needs to track population mortality. Over the years, it has been expanded to include data about tobacco use and maternal mortality. In Washington State in 2020, it was updated to add fields for COVID-19 testing results. For families, though, death certificates become part of family history. And death certificates also are used for “proof of death” certification for insurance companies, the Social Security Administration, and banks. Several states have begun to address its dual purposes by issuing “short-form” certificates that exclude cause and manner of death as well as sensitive information and “long-form” certificates with access restricted to public health agencies and immediate family members.
Death certificates can sometimes fuel family and community controversy. The listed manner of death may not comport with legal definitions. In most jurisdictions, traffic fatality deaths are classified as “accidents,” although legally some are vehicular homicides. Family members may strongly object to a death classified as “suicide.” Deaths during legal intervention are scrutinized by the public and law enforcement.
The National Association of Medical Examiners has partnered with the Centers for Disease Control and Prevention on several initiatives to improve the death certificate. One is to standardize the practice of listing specific drugs or medications on the certificate to track the opioid epidemic. 3 A second is to seek better certification of deaths during hurricanes and other natural disasters. This was instituted partly because of controversy over mortality statistics in Puerto Rico after Hurricane Maria.
But MEs and coroners, most experienced with certification, complete a minority of death certificates in the United States. Indeed, in my county the ME office certifies about 12% of all deaths in the county. The focus is on unnatural deaths: homicides, suicides, and accidents. These require investigation to ascertain correct certification. By contrast, community health care providers certify natural deaths, which are the majority of deaths. However, repeated surveys of community physicians reveal inadequate training in completing death certificates. Correspondingly, studies using death certificate data find inherent problems in accuracy. 4
COVID-19 has renewed concerns about weaknesses of the death certificate process. For example, confusion about how COVID-19 comorbidities should be reported results in delay and accuracy concerns. 5 The fact that hospital physicians sign the great majority of COVID-19 death certificates underscores the need for better training of physicians in death certification as part of their medical school or residency education.
CONFLICTS OF INTEREST
The author has no conflicts of interest to declare.
REFERENCES
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