MEDICAL CERTIFICATION OF DEATH

Jun David Diciano, MD, MPM

Ara Monica V. Ballesteros, MD, MPM
Certificate of Death
• Permanent legal record which contains the individual’s death
information
• Provided to the family member for burial arrangement
• Cause of death is certified by a doctor
• Cause of death is coded and classified using ICD-10, entered into a
database and consolidated by PSA
Certificate of Death
• Consolidated mortality statistics is the foundation of a country’s health
policies, plans and programs
• For deaths occurring that are not attended by a physician, the best
way to ascertain cause of death is through verbal autopsy
• All death certificates are to be reviewed by the local health officer,
medically attended or otherwise
Legal Mandates
• Civil Registry Law- Act No. 3753
• Philippine Statistical Act- RA No. 10625
• Civil Registration Services
• Code on Sanitation of the Philippines- PD 856
• Local Government Code- RA 7160
Fetal Death
• Death prior to the complete expulsion or extraction of a product of
conception from its mother, irrespective of duration of pregnancy
• Fetus does not breathe nor show any evidence of life:
• beating of heart, pulsation of the umbilical cord, or voluntary movement
• Less than seven months of intra-uterine life and dies within 24 hours
after complete delivery- fetus is not deemed born
Fetal Death
Place of Registration
• City or municipality where the death occurred
• If not ascertained where:
• city or municipality of usual residence of the deceased
• where the deceased will be buried
Vital Events Occurring Abroad
• For Filipinos residing abroad, vital events shall be reported to the
Philippine Foreign Service Establishment of the country where the
event occurred
• If none is located in the country, could be in the Philippine Foreign
Service Establishment of the country nearest the place of residence
Flow of Submission
• Report within 30 days to the City/ Municipal Registrar (C/MCR)
• C/MCR submits to PSA- Provincial Office within 10 days following the
month of registration
• PSA-PO compiles the report of all cities/municipalities and submits to
PSA-Central Office
Dismembered Body Parts
• Surgical pathology report signed and issued by the pathologist shall
serve as Certificate of Dismembered Body Part for burial purposes or
disposal
• Surgical removal of body parts are not considered as death of a
person, no need to issue Certificate of Death
Persons Responsible for Issuing Medical Certification of Death
• Death in the Hospital
• Physician who last attended the deceased
• Certificate is forwarded within 48 hours to the local health officer

• Death in the Hospital Emergency Room

• ER Officer
• Medico-legal Officer of the hospital or local health officer if ER Officer cannot
provide a definite diagnosis
Persons Responsible for Issuing Medical Certification of Death
• Death in the Ambulance
• Physician who attended the transport

• Death Outside the Hospital

• If without medical attendance, nearest of kin or person who has knowledge of
the death is responsible for reporting the event to the local health officer within
48 hours
• Local health officer will prepare the COD/COFD
• If no LHO, should be reported to the mayor or any member of the Sangguniang
Bayan, or municipal secretary
Persons Responsible for Issuing Medical Certification of Death
• Special Cases
• Death in vehicle/vessel/airplane- the driver/captain/pilot shall report to
concerned local health officer
• Accidents where there are no survivors- owner of the vehicle/vessel/airplane to
report to the local health officer
Persons Responsible for Issuing Medical Certification of Death
• Special Cases
• Mass death, deceased cannot be identified- MHO/CHO to issue a corresponding
number of COD and cause the registration of these deaths at the local civil
registrar
• Must bear an annotation “Body Not Identified”
• Affidavit of two disinterested persons must be submitted containing the following:
• sex of the deceased
• estimated age
• distinguishing features
• date, place and condition of the body when found
• Circumstances surrounding death
Persons Responsible for Issuing Medical Certification of Death
Death of Filipino Muslim or Indigenous Cultural Communities/
Indigenous Peoples
• The dead may be buried even without a Certificate of Death provided
that the death shall be reported to the local health officer within 48
hours after date of burial

• Local health officer to certify the cause of death

• Attach the following:
• Municipal Form 103- attachment for Muslim Death
• IP Form 2- attachment for death of ICCs/ Indigenous Peoples
Persons Responsible for Issuing Medical Certification of Death
• Death under Medico-Legal Examination
• Physician to determine whether death is reportable or not
• Determine if another physician is more qualified to complete the certificate
• If death is due to violence or crime, the doctor is duty-bound to report immediately to the PNP
or NBI
• Stab wounds
• Gunshot wounds
• Suicide of any kind
• Strangulation
• Accident resulting to death
• Actual physical assault inflicting injuries upon a person resulting to death
• Any other acts of violence upon a person resulting to death
• Sudden death of undetermined cause
Persons Responsible for Issuing Medical Certification of Death
• Death under Medico-Legal Examination
• If death is not registered, the head of PNP or NBI or his authorized representative shall cause
the registration of such death through the MHO
• The Medico-legal officer pf the investigative agency will accomplish and sign the medical
certificate portion of the Certificate of Death
Who certifies the Certificate of Death?
• Attendant at death
• Local health officer
• Medico-legal officer
Who reviews the Certificate of Death?
• Local health officer
When can registration of death be denied?
• The local civil registrar cannot deny registration except for
insufficiency of information
• Full name of the deceased and cause of death are required
Delayed Registration
• Registration beyond the 30-day period
• Shall be accepted once with the following requirements:
• Four copies of COD accomplished correctly and completely
• Affidavit for delayed registration executed by hospital/clinic/attendant at
death/nearest relative/legal charge
• Affidavit should state name of deceased, facts of death, date and place of burial
or cremation and circumstances why death was not reported for registration
within 30 days
• Authenticated copy of certificate of burial, cremation or other means of corpse
disposal
• Approval for registration by the health officer in the box provided in the COD
Uses of Certificate of Death
Relevant Entries to be Filled Out
Relevant Entries to be Filled Out
Relevant Entries to be Filled Out
General Guidelines
• Do not make alterations or erasures. Obvious changes may be rejected by the
Local Civil Registrar
• Verify the accuracy of identification data, including the correct spelling of the
name of the deceased
• Do not use abbreviations or medical symbols.
• Record only one cause per line in the cause of death portion. Line (a) must always
have an entry
• Never report signs and symptoms or abnormal clinical and laboratory findings as
causes of death
• If organ failure is reported as a cause of death, the underlying condition
responsible for failure should be reported (liver failure due to hepatitis B
infection)
General Guidelines
• Mechanistic terminal events should never be reported as one of the causes of
death
• If there is uncertainty in the entries, it is acceptable to use qualifying terms such as
“probable” or “presumed”
• For deaths without medical attendance, a verbal autopsy may be conducted to
determine cause
• Complete each item legibly using a computer printer with high resolution or
typewriter with a black ribbon, or print with pen using permanent black ink
• For signatures, use pen with permanent black ink. Rubber stamps or facsimile are
not acceptable.
• Reproductions or duplicates are not acceptable.
• Avoid use of terms such as “senility, old age, senescence and advanced age”- use
undetermined natural cause instead.
 Medical Certification

Underlying cause of death

• Disease or injury which initiated the train of morbid events leading to death,
circumstances of accident or violence which produced the fatal injury
• The most important entry in the certificate
 Medical Certification

Immediate cause of death

• Most recent condition written on top line of the certificate that leads directly to
death

Antecedent cause of death

• Other intervening cause of death between underlying and immediate cause
• Can be more than one or none at all
Sample Case 1
• A 56 year old man dies from acute myocardial infarction within 3 hours of its
onset. He did not have any other illnesses.
Sample Case 2
• A 56 year old man dies from abscess of the lung, which resulted from lobar
pneumonia of the left lung.
Sample Case 3
• A 32 year old man dies from hypovolemic shock after sustaining multiple fractures
when he was hit by a truck.
Sample Case 4
• A 10 year old boy with a past medical history of Thalassemia for the past 4 years
develops severe anemia leading to high output cardiac failure 2 weeks ago. Three
days prior to admission, he developed cough and dyspnea with a respiratory rate
of 44/minute. Chest X-ray showed lobar pneumonia. Despite antibiotic coverage
and blood transfusion his condition deteriorated and he died the next day.
Sample Case 5
Sample Case 6
• A 36 year-old G5P3 woman who delivered a full—term baby boy at home was
brought to the Emergency Room because of placental retention. The woman
apparently had severe bleeding and was hypotensive on her arrival at ER. She was
transfused with whole blood and manual extraction of the placenta was
performed. However, the woman died four hours after delivery.
Sample Case 7
• A 95 year old man was found dead on bed by his wife. He had chronic mild
hypertension controlled by medication. His previous chest X-ray shows mild
cardiomegaly, consistent with chronic hypertension. There was no suspicion or
evidence of foul play. No specific cause of death could be identified.
Common Complications and Their Causes in the Elderly
Sample Case 8
• A 38-year old G3P2 was admitted at a birthing facility while 34 weeks pregnant.
After six hours of premature labor, she delivered a stillborn baby boy with cord
around his neck. The fetus is cyanotic with no gross fetal movement and no
heartbeat.
Interval Between Onset and Death
• Time interval should always be filled out as accurately as possible
• Acceptable to list the interval as “unknown” or “approximately”, “known for five
years”
• To check that the causes of death are written in correct sequence
Modes of Dying (Not Cause of Death!)
Ill-Defined or
Nonspecific Causes of
Death
The proportion of deaths
coded to ill-defined
categories should not
exceed 10% of all deaths in
the age group 65 years and
over

Must be <5% of deaths

occurring in those under 65
years of age
Ill-Defined or
Nonspecific Causes of
Death
The proportion of deaths
coded to ill-defined
categories should not
exceed 10% of all deaths in
the age group 65 years and
over

Must be <5% of deaths

occurring in those under 65
years of age
Verbal Autopsy
• Diagnosing causes of death based on the response of reliable family members and
caregivers
• Describe the causes of death at the community level or population level where
civil registration and death certification systems are weak, and some people die at
home without having to contact the health system
• Assumptions:
• Each death has a distinct pattern of signs, symptoms, severity and other characteristics
• The signs and symptoms experienced by the deceased can be recognized, remembered and
reported by lay respondents
• It is possible to correctly diagnose deaths based on reported information and to categorize
them into groups of causes of death
Verbal Autopsy
• 2 Stages
• Stage 1- interviewer visits household, record responses using a pre-designed questionnaire
• Stage 2- pattern of responses reviewed by a physician to determine the probable cause of death
based on the signs and symptoms reported by the respondents
Reviewing the Death Certificate
• RA 3753 Sec. 6., Circular No. 4, Series of 1973
• In all cases of death or fetal death even with medical attendance, the death or fetal death
certificate must be reviewed and signed in any vacant space below the certificate by the local
health officer before it shall be accepted for registration
Reviewing the Death Certificate
• The MHO must assure completeness, correctness, consistency and clarity of
information (especially in the Medical Certificate portion)

• All blanks should be filled out except in the cause of death when there is only one
or two entries. N/A or Not applicable can be used for items that do not need filling
out.

• No mechanistic terminal events must be used, no abbreviations, no ill-defined

causes of death

• Signatures must be original

Reviewing the Death Certificate
• Check or compare items 1 and 2, 4 and 5, 5 and 19c, 21a and 22

• Check if the causes of death are legibly written. Advantageous if typewritten

• MHO can verify the authenticity of information from the informant or from the
attending physician especially if there are inconsistencies or incorrectness
THANK YOU!