It is amusing for me when I see death certificates mentioning the cause of death as cardio-respiratory arrest. During my internal medicine residency at AIIMS, New Delhi one of the first things my seniors taught me was to how to document a death certificate. My Professors periodically used to check the death certificate during the Mortality and Morbidity (M&M) meetings.

Unfortunately training on death certificate documentation is sparse because it is filled in after death and teachers even during an M&M meeting focus on treatment gaps.

In this blog, let me explain how to document a logical and rational death certificate.

1. What is the importance of death certificate?

• Death certificate is an important document that will help government to understand which diseases are causing deaths for the public.
• This data obtained at local, regional and national level will help tailor the public health policy.
• In the COVID 19 era an accurate death certificate is essential because it is a pandemic and a public health emergency.
• If this data is faulty, government cannot institute appropriate public health policies.
• Biggest challenge is training on how to prepare a quality death certificate is lacking in India.

2. Can we label cardiac arrest – respiratory arrest – cardio respiratory arrest as cause of death?

One cannot list cardiac arrest and respiratory arrest etc. as cause of death because these terms are synonymous with death. This is mentioned on the form itself.

3. What is cause of death?

Let me exemplify this, for example, a 73 year lady presents with fever and cough of 3 days duration and for the past one week she has fever. In the past she has diabetes and congestive heart failure for which she is taking medicines and is in stable condition.

She has been admitted in the hospital and succumbs within the next 24 hours. Just before her death the diagnosis of COVID 19 is confirmed by the RT PCR test report.

In a case like this one should not mention cardiac arrest as cause of death because cardiac arrest itself means death.

One should not mention diabetes or Congestive Heart Failure as these are co-morbidities and are not cause of death. They contribute to death and not cause death.

4. What are the components of a death summary?

Death summary has two parts.

Part I deals with the immediate cause for death and what disease/s caused this problem.

Part II deals with the underlying medical conditions that are not directly responsible to the disease causing death but could contribute for the same.

Part I a. IMMEDIATE CAUSE (final disease or condition resulting in death)	a. Bronchopneumonia -------------------------------------- Due to (or as a consequence of)	3 days
b. Sequentially list conditions if any leading to the cause listed on line (a).	b. Novel corona virus 2019(COVID-19) respiratory infection --------------------------------------- Due to (or as a consequence of)	7 days
Enter the UNDERLYING CAUSE (disease or	c. -------------------------------------- Due to (or as a consequence of)
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I. Diabetes Congestive Heart Failure
MANNER OF DEATH (natural, homicide, accident, suicide, undetermined) (specify) Natural

5. Can we modify the death certificate at a later date?

Yes for sure because let us assume that the cause of bronchopneumonia in this lady is not established as SARS CoV2 virus infection as the report did not arrive before her death. In such circumstances if the report arrives after death the death certificate needs to be modified to include COVID 19 infection.

6. Why is death summary important in COVID era?

Death certificate is valuable information that determines public health. Unless there is uniformity in death certificate, in a pandemic the deaths cannot be quickly tracked and classified. The cause of death statement must contain the underlying medical disease and any contributing comorbidities listed in part II.

No death summary is 100% accurate but it should be well reasoned and detailed. Documentation on death certificates needs to be uniform and logical so that it allows local, national, and worldwide public health agencies to gather timely and accurate data during the COVID-19 pandemic.