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Context: Alcohol can contribute to various manners of death by acute intoxication that places a person at risk for fatal injury, acute fatal alcohol poisoning, or the various fatal complications of chronic abuse with or without superimposed acute intoxication. The reporting of alcohol use on the death certificate may vary with office policy or procedure, certifier judgment, and the timing of information received during investigation., Objective: To determine the number of deaths including mention of alcohol use in the investigative case file, the number of death certificates on which alcohol use is reported, the number of discrepancies between the 2, and the possible reasons for observed discrepancies., Design, Setting, and Participants: Retrospective case review of all deaths where alcohol use was mentioned in the investigative case file and/or on the death certificate for deaths investigated by the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between January 1, 2004, and December 31, 2004., Main Outcome Measures: Percentage of deaths with alcohol use reported on the death certificate, tabulation of where and how alcohol use is reported on the death certificate, and tabulation of the differences between the investigative case file and death certificate regarding alcohol's possible role in causing death., Results: Among the 1324 deaths certified by the office, 105 (8%) had alcohol use reported on the death certificate. The majority (67%) of these cases were natural deaths. Sixty-nine (5%) deaths had mention of alcohol use in the investigative case notes but did not include it on the death certificate. Twenty-five (2%) deaths had mention of alcohol on the death certificate but did not have mention of it in the investigative case file based on our search criteria. However, subsequent review of additional case follow-up information disclosed a history of alcohol use or acute intoxication in each case., Conclusions: The data show that more natural deaths are considered to be directly caused by alcohol than other manners of death. For the unnatural manners of death (excluding acute alcohol poisoning), alcohol use is often viewed by medical examiners as an incidental, associated finding or risk factor surrounding the circumstances of death rather than being an actual cause of death. In such cases, alcohol use is often omitted from the death certificate. For deaths directly caused by alcohol, the proportion of cases involving possible underreporting or overreporting of alcohol involvement was relatively small and usually involved the omission of chronic alcohol use from the death certificate. Researchers need to be aware of potential limitations of death certificate data for studying alcohol-related deaths.

Background: Although quality assurance programs for medical examiners are required by the National Association of Medical Examiners' Inspection and Accreditation Checklist, quality assurance programs specifically targeting death certificate completion have not been addressed. The Fulton County Medical Examiner, Atlanta, GA, has implemented a pilot quality assurance program for death certificate information, and this report contains information about 1 year's experience with the program., Methods: All death certificates are reviewed by the case medical examiner(s) and chief medical examiner prior to their release to funeral homes. Death certificates with errors are retained for quality assurance and review purposes, and needed corrections are made before death certificates are released. During a 1-year period, death certificates with errors were collected and then reviewed and tabulated by type of error., Results: Between May 26, 2003, and May 25, 2004, the Fulton County Medical Examiner certified 1267 deaths. Of these, 47 (4%) were found to contain errors that were corrected and an additional 52 (4%) had been amended for various reasons. The most common errors were misspellings in causes of death or poor or incomplete wording in injury-related information. Forty-seven percent of errors involved omitted, incomplete, or incorrect information that was potentially significant. The most common reason for amended certificates was unexpected detection of acute intoxications among people with significant cardiovascular disease., Conclusions: Quality assurance review of death certificates can assist in preventing the release of death certificates with incomplete, erroneous, or omitted information and may also be useful as an educational forum regarding completion of the death certificate.

More than 700 physician medical examiner/coroners (ME/Cs) were surveyed to assess differences in manner of death classifications for typical but often controversial death scenarios: 198 physicians participated by choosing the manner of death (homicide, suicide, accident, natural, undetermined) for 23 such scenarios. Sixteen questions related to death certificate training, work location, and manner of death issues were also asked. The classification of manner of death by ME/Cs was highly variable. For some challenging death scenarios, majority agreement was lacking. Agreement was > or = 80% for only 11 of the 23 scenarios and was 100% for only 1. Manner of death classification method was not influenced by forensic pathology board certification status, by whether or not the physician actually completed death certificates, or by previous threats of lawsuits over manner of death classification. However, there were some differences by state. No textbook or individual was widely recognized as authoritative on manner of death issues. Few ME/Cs had formal death certification training in medical school or residency. The data lend credence to the practice of the National Center for Health Statistics (NCHS) of classifying manner of death for statistical purposes by using coding and classification rules and selection criteria rather than solely on the basis of the classification of manner chosen by ME/Cs. The data also indicate that caution is in order when one compares manner of death statistics of one ME/C with those of another Published guidelines and more uniform training are needed so that ME/Cs may become more consistent in their manner of death classifications. Further information is presented in Part I (history of manner of death classification) and in Part III (individual death scenarios and their analysis) companion articles in this issue of the Journal.

A data base search through Westlaw was conducted to ascertain lawsuits in which a medical examiner or coroner (ME/C) was sued because of the cause or manner of death stated on the death certificate. Sixteen reported cases were found between 1948 and 1995, with 10 of the cases occurring since 1985. The frequency of reported cases is approximately 1/400,000 ME/C death certificates, but based on certain assumptions, the actual frequency may be estimated at 1/40,000 ME/C death certificates. Nine cases involved plaintiffs who contested when the manner of death was indicated as suicide. In 15 of the 16 cases, the lower court decision favored the ME/C viewpoint. Five of the 15 decisions were ultimately reversed by a higher court, but the ultimate outcomes of these cases were not available. Overall, it appears that most courts and decisions have recognized ME/C actions as discretionary or immune and that ME/Cs have been at low risk for such suits to date. This seems especially true if the ME/C position is defensible and the ME/C has acted in accordance with statute and without evidence of corruption, incompetence, arbitrariness, capriciousness, abuse of discretion, or outrageous conduct.

Objective: To develop principles and refined definitions designed to improve the content of cause-of-death statements regarding inclusion or exclusion of so-called mechanisms of death., Data Sources: Survey of readily available instruction manuals and other literature regarding mechanisms of death and instructions for death certificate completion., Data Synthesis: Definitions and principles contained in the information sources were reviewed, and a set of specific principles, criteria, and definitions were written. These principles are consistent with, but are more extensive and practically applicable than, those found in each of the information sources surveyed and may be used to decide which conditions to report in cause-of-death statements., Conclusions: Mechanisms of death include a defined list of terminal events (such as asystole) and a larger group of nonspecific physiologic derangements (such as portal hypertension) and are differentiated by definition from nonspecific anatomic processes (such as cirrhosis). Three principles may be applied in individual cases. Principle 1 states that terminal events are not reported in cause-of-death statements. Principle 2 states that a nonspecific physiologic derangement or a nonspecific anatomic process should be reported if (1) it is a recognized, potentially fatal complication of the underlying cause of death; (2) it constitutes part of the sequence of conditions that led to the death of the patient in question; (3) it is not a symptom or sign; (4) its existence in the patient would not be apparent unless included and explicitly stated in the cause-of-death statement; (5) its inclusion does not constitute an oversimplification of the facts; and (6) an etiologically specific underlying cause of death is also reported. Principle 3 states that if the existence of the complication is obvious based on the underlying cause of death or another reported complication, it need not be reported.

This article includes a brief discussion of the evolution death registration as it changed from records of church burial ceremonies to the recording of vital events by government in defined registration areas; today's death registration system in the United States; classification and coding procedures; limitations of data derived from death registration; educational materials; legal issues involving death certificates; and the re-engineering of the death registration process.

A cause-of-death statement may result in a query by the vital records registrar to clarify cause of death information or to educate the certifier of death in recommended death certification procedures. The level of querying depends on local need and resources, and is usually conducted at one of six query priority levels. When applying International Classification of Disease (ICD) coding to cause-of-death information, nosologists use a General Rule and 12 additional rules, as needed, to identify an underlying cause of death for statistical purposes. Incorrectly or poorly written cause-of-death statements, and even well-written ones, may result in queries that could have been avoided, or in codes for the underlying cause of death that differ from those intended by either the certifier of death. In an attempt to foster improvement in cause-of-death statements and to facilitate coding, this article presents basic information about queries and coding rules so that certifiers of death will be aware of potential problems and coding issues. In general, cause-of-death statements that are complete, specific, timely, correct in temporal sequence, and written according to guidelines reduce the need for queries and facilitate the ICD coding process.

On the basis of data collection procedures and forms used in various death investigation offices, we developed generic death investigation report forms (DIRFs). One form was designed for documenting information collected by the initial investigator of death, and another form was designed for documenting information collected by the medical examiner, pathologist, or other person who certifies the death or otherwise finalizes the investigation by determining the cause, manner, and circumstances of death. The benefits, problems, and criteria associated with designing the forms are discussed. Both the investigators DIRF (IDIRF) and the certifier's DIRF (CDIRF) are available in printed or electronic form for those who wish to use them or to modify them according to their specific needs. We hope that these DIRFs will be useful and promote uniformity in documenting death investigations.

Although instructions for proper completion of the cause-of-death section of the death certificate are available, a number of published examples are controversial, confusing, or inconsistent with other recommendations and guidelines. Several such examples are described to illustrate the need for improved instructions for death certification, with the goal of improving the consistency, accuracy, and reliability of death statistics. Also discussed is the general relationship between state vital records registrars, the National Center for Health Statistics, and the World Health Organization, in terms of death certification paperwork, procedure, policy, and death certificate revision. Since medical examiners certify substantial numbers of deaths, the need for medical examiners to be involved in revisions of death certificate forms and policies is emphasized.

Previous studies have identified an apparent underreporting of alcohol-related natural deaths on death certificates. This survey consists of a review of death certificates in one urban county, and provides further evidence that alcohol-caused natural deaths are underreported by physicians who sign death certificates.