The Massachusetts Standard Certificate of Death: Laws, Data and Public Health Uses

1
The Massachusetts Standard Certificate of Death
Laws, Data and Public Health Uses
Jane Purtill, M.S. Director, Statistics
Unit Registry of Vital Records and
Statistics Bureau for Health Information,
Statistics, Research and Evaluation Massachusetts
Department of Public Health
Portions of this presentation were provided
by Centers for Disease Control and
Prevention National Center for Health Statistics
2
Why do it right?

• Completion of the death certificate is the final
  act of care given to a patient and provides
  closure to the family
• The death certificate is much more than just an
  administrative document

3
Why should you care?

• Information from the death certificate, including
  the cause of death, is used to generate official
  mortality statistics such as
• Life expectancy
• Deaths and death rates by cause of death,
  geographic area and socio-demographic
  characteristics
• Leading causes of death
• Infant and maternal mortality rates

4
Why should you care?

• Mortality statistics generated from death
  certificates are used to
• Assess the general health of the population
• Examine medical problems which may be found among
  specific groups of people
• Indicate areas in which medical research may have
  the greatest impact on reducing mortality
• Allocate medical services, funding, and other
  resources

5
Who Depends on You?

• Child Fatality Review

• National Center for Health Statistics/ CDC

• National Violent Death Reporting

• Substance Abuse Bureau

• Consumer Product Safety Commission

• National Death Index

• Cancer Registry

• Genealogical Research

• Family medical histories

• Interstate Exchange

• MassCHIP

• RVRS DPH Publications

• Registry of Motor Vehicles

• Governors Highway Safety Commission

• Social Security Administration

• Insurance verifications

• Center for Birth Defects

• Medical Research Data Requests

• Maternal Mortality Review

• State Lab/Infectious Diseases

• Occupational Health Surveillance

• Emergency Medical Services

• Environmental Health Bureau

• Law Enforcement Agencies

• Hospital QA Departments

• Injury Surveillance

(and much more)
6
How is Massachusetts Different?

• Flow of information
• Pronouncer/Physician -gt (ME) -gt Funeral Director
  -gt Local Burial Agent -gt Local City/Town Clerk -gt
  State
• MA (and most other states) have not yet adopted
  the 2003 NCHS standard
• MA Death Certificates are Open Records

7
Open Records

• There are no restrictions on access to
  Massachusetts death certificates
• Certified copies from RVRS are exact photocopies
  of the death certificate
• Certified copies from cities and towns vary in
  format
• RVRS has on-site all MA death records from 1916
  to the present older records are transferred
  every five years to the State Archives

8
Massachusetts General Law

• Statutes relating to Death Registration and
  Removal Permits
• Chapter 38
• Chapter 46
• Chapter 114
• Chapter 4

9
M.G.L. Chapter 38, s.3When is the Medical
Examiner involved?

• Must Notify conditions listed on back of death
  certificate
• Notably
• Violent death
• Accidental death
• Occupational injury
• Unusual circumstances
• Under age 18

10
M.G.L. Chapter 38, s.4Jurisdiction

• The Medical Examiner will take jurisdiction in
  which the death was due to
• Violence
• Other unnatural means
• Natural causes that require further investigation

11
M.G.L. Chapter 38, s.13Physician Responsibility
to Complete a Death Certificate

• The certifying physician initiates the death
  certificate process.
• Three categories of physicians may be the
  certifier
• Attending physician
• Physician declaring an individual dead or a
  hospital medical officer (include the name of the
  attending physician when possible)
• Medical Examiner

12
M.G.L. Chapter 46, s.1

• Defines the items that should be included on the
  certificate of death
• Date of death
• Name of decedent
• Social security number
• Age
• Residence
• Occupation
• Place of death
• Place of birth
• Names and places of births of parents
• Cause of death so it can be classified under ICD
• Place and type of immediate disposition

13
M.G.L. Chapter 46, s.9

• or, if the death occurred in a hospital, a
  hospital medical officer duly appointed by the
  administrator, shall immediately, furnish for
  registration a standard certificate of death, or
  in the case of a medical examiner, a medical
  examiner's certificate of death, to an undertaker
  or other authorized person or a member of the
  family of the deceased, stating to the best of
  his knowledge and belief the name of the
  deceased, the disease of which he died, defined
  as required by section one, where the same was
  contracted, the duration of the illness from
  which he died, and the date of death.
• The foregoing provisions shall apply in the
  same manner in the event of a child dying
  immediately after birth. Both the birth and death
  of such child shall be recorded.

14
How Immediate is Immediate?

• Immediately after pronouncing the death the
  certifying physician (in cases where the ME has
  not taken jurisdiction) must furnish for
  registration a standard certificate of death
  (M.G.L. Ch.38, s.13, M.G.L Ch 46, s9)
• No exact definition of immediate in the
  statutes
• Case law has determined that the phrase should be
  taken in conjunction with the overall intent of
  the statute
• RVRS recommends in the case of a nursing home or
  hospital death, immediate could be defined as
  eight hours.

15
Physicians Certification Cause of Death

• Physician completes reverse and items 29-36
  38-40
• ME completes items 29-35 37-40

16
Completing the Physician portions of the death
certificateGeneral guidelines-

• Dont leave items blank if unknown, write
  unknown, if not applicable, use
  dashes (---)
• Use permanent black ink
• No strikeovers, erasures, or correction ink
• Write out dates e.g., September 9, 2007

17
Standard format for reporting cause of death
Approximate interval between onset and death
Condition which directly preceded death
18
Immediate cause of death Part I, line (a)

• The disease or complication which directly
  preceded death
• There must always be an entry on line I(a)

19
Standard format for reporting cause of death
Approximate interval between onset and death
Antecedent condition
Underlying cause
20
Antecedent causes (conditions, if any, leading
to immediate cause) Part I, lines (b), (c) and
(d)

• Reported conditions should be in a logical
  sequence in terms of time, etiology and/or
  pathology
• If more lines are needed write due to between
  conditions on the same line do not continue the
  sequence into Part II

21
Underlying Cause of Death

• Terminate the sequence with the underlying cause
  of death leave unused lines blank
• The disease that initiated the train of morbid
  events leading directly to death
• or
• The circumstances of the accident or violence
  that produced the fatal injury

22
Interval between onset and death

• For each condition reported, report the interval
  between the presumed onset of the condition (not
  the date of diagnosis) and the date of death
• General terms such as minutes, hours, days or
  years are OK
• Terms unknown or approximately are OK when
  necessary

23
Standard format for reporting cause of death
Approximate interval between onset and death
24
Other significant conditions Part II

• Other important diseases or conditions that were
  present at the time of death and that may have
  contributed to death, but were not directly
  related to the underlying cause of death should
  be reported in Part II

25
General Guidelines for Causes of Death

• The certification should represent your best
  medical opinion
• If multiple conditions are present and the
  underlying cause is uncertain, construct a
  logical sequence for part I and then list other
  conditions in part II
• Provide as much specificity and detail as can
  reasonably be determined

26
More General Guidelines (cont.)

• Avoid abbreviations
• Do not report mechanisms or modes of dying
• Cardiac or respiratory arrest
• Cardio-pulmonary or cardio-respiratory arrest
• Heart stopped
• Electromechanical dissociation

27
And

• Non-specific processes such as heart failure,
  renal failure, septicemia, hemorrhage,
  prematurity, etc. that have more than one
  possible cause, should not be reported as the
  underlying cause
• Always report the etiology of these conditions,
  if known
• Primary diagnosis and underlying cause are not
  necessarily the same

28
And

• If information with regard to specificity,
  etiology or the cause of death is unknown,
  indicate explicitly that this is the case
• Terms such as probable or presumed are OK
• Dont use vague terms such as old age,
  senescence, or infirmity

29
Manner of Death

• Must never be left blank
• Choose only one
• Use best reasonable medical certainty

30
Date, Hour of Death and Pronouncement Items

• Date and Time Pronounced Dead
• Use Exact Date (written out) and Exact Time
  (am/pm)
• Date of Death (on reverse)
• Write out
• Exact date, on or about, or Found on
• Hour of Death
• Exact time (HHMM am/pm) if known
• Appx. if necessary
• Last resort found at

31
DOAs

• Contact the attending physician
• Obtain notes from EMS personnel who were treating
  the decedent
• Talk with family members to obtain medical
  history and other pertinent information

32
Now Where?

• Originals of death records and death amendments
  with original evidence sent from community of
  occurrence to

• State Registry of Vital Records and Statistics

33
Unbound Records

• How Many?
• 57,000 deaths occur
• in Massachusetts each
• year

• Records are numbered and put into packs of 100.
• Unexamined records are shelved in unbound record
  room according to order received
• About 1100 deaths are processed each week

34
Examine Register

• Signatures
• Completeness
• Consistency
• Alterations/ authenticity/ ME stamp
• Dates spelled out
• Clerks stamp
• Related documentation

35
Accepted Registered

• Volume assigned
• Returned to unbound record room until data
  entered bound
• Separated into volumes of 500 after data entry
• Backup documentation stored in separate volumes
  with same state certificate number
• Open volumes for late additions
• Special cases are pulled

36
Demographic Coding

• In preparation for data entry, RVRS staff code
• Hospital
• Place of death
• Hispanic Origin/ Race
• Age if under 1 year
• Place of injury
• Out of state residence code

37
Data Entry

• Records are data entered by DPH IT
• Shipments tracked - separate demographic
  medical
• Index created
• Statistical database merged on mainframe
• Upon return, volumes readied for binding

38
Cause of Death Coding

• Trained nosologists
• SuperMICAR
• Underlying cause of death
• ICD-10 in 1999

39
Publications and Statistics

• The Registrys PD1 (Annual Report of Vital
  Statistics) is the oldest continuously published
  public document in the U.S.
• RVRS has a full set of PD1s from 1842 to the most
  recent

40
Massachusetts Deaths 2000-2006Occurrence Totals
Source Massachusetts Department of Public
Health, Registry of Vital Records and Statistics
41
DOA by CertifierSaint Anne's Hospital 2000-2006
Source Massachusetts Department of Public
Health, Registry of Vital Records and Statistics
42
DOA by CertifierCharlton Memorial Hospital
2000-2006
Source Massachusetts Department of Public
Health, Registry of Vital Records and Statistics
43
Causes of Death Massachusetts 1842-2006
Source Massachusetts Department of Public
Health, Bureau of Health Information, Statistics,
Research and Evaluation
44
Leading Causes of Death Massachusetts 2006
Other 22.5
Cancer 25
Septicemia 1.7
Diabetes 2.1
Nephritis 2.6
Heart Disease 24
Alzheimers 2.9
Pneumonia Influenza 3.3

• In 2006
• 13,375 cancer deaths
• 12,891 heart disease deaths

Chronic Lower Respiratory Disease 4.7
Stroke 5.4
Injury 5.5
Source Massachusetts Department of Public
Health, Bureau of Health Information, Statistics,
Research and Evaluation
45
Ranking of Leading Causes of Death by Race and
EthnicityMassachusetts 2006
1 Non-Hispanic, 2 Chronic Lower Respiratory
Disease
Note The lower the number the higher the rank
Source Massachusetts Department of Public
Health, Bureau of Health Information, Statistics,
Research and Evaluation
46
Leading Causes of Death by Age Massachusetts
2006
of Total in Total
Age Leading Cause Age Group
Deaths 1-14 Injuries 33 124 15-24
Injuries 69 471 25-44 Injuries 44
1,953 45-64 Cancer 38
8,660 65-74 Cancer 40
7,572 75-84 Cancer 27 15,333
85 Heart Disease 31 18,811
Source Massachusetts Department of Public
Health, Bureau of Health Information, Statistics,
Research and Evaluation
47
Changes in Mortality RatesMassachusetts 2000
and 2006
Statistically higher than 2000 rate
(plt0.05) Statistically lower than 2000 rate
(plt0.05)
Rates are per 100,000 population. Age-adjusted
to the 2000 US standard population. Source
Massachusetts Department of Public Health, Bureau
of Health Information, Statistics, Research and
Evaluation
48
Causes of Injury Deaths Massachusetts 2006
Total Injuries 2,910
Other 18
Firearm 7
Suffocation Hanging or Strangulation
10
Motor Vehicle-related 16
Falls 15
Source Massachusetts Department of Public
Health, Bureau of Health Information, Statistics,
Research and Evaluation
49
A wealth of public health information

• Vital Records computer files date back to 1969.
• In total, RVRS maintains files of
• 3,500,000 birth records (6,000 bytes/record)
• 2,000,000 death records (1,600 bytes/record)
• 1,500,000 marriages records (120 bytes/record)
• 500,000 divorce records (90 bytes/record)
• 13,500 fetal death records (3,500 bytes/record)
• 20,400 abortion reports (500 bytes/record)
• Linked infant death/birth and other misc. files
• 15,000,000 backup records

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Registry of Vital Records and Statistics150
Mount Vernon Street, 1st FloorDorchester, MA
02125

• Preparation and Registration
• June Deloney, Supervisor of Registration
• [phone]
• june.deloney_at_state.ma.us
• Statistics/ Cause of Death
• Jane Purtill, M.S., Director, Statistics Unit
• [phone]
• jane.purtill_at_state.ma.us
• Administration Policy
• Karin Barrett, Assistant Registrar
• [phone]
• karin.barrett_at_state.ma.us