MEDICAL CERTIFICATION OF CAUSE OF DEATH

Introduction:

Death is a fact which every individual has to acknowledge some or the other day,
and one of its most important aspects is its certification. Mortality statistics form an
integral part of the vital data of a country. Understanding population growth and
providing a demographic perspective for health planning and policy formulation, the
death certification data is useful to public health planners, administrators, medical
professionals and research workers. The size and geographical distribution of deaths in
relation to prevalence of diseases, evaluation of risks of deaths from various causes at
different ages, the medical implications of combination of the conditions resulting in
death, proportion of deaths occurring in hospitals are a crucial aspect of interest to
many professionals. Public health executives, therefore depend heavily on analysis of
causes of death for vital statistical data, for formulating National and State health care
Policies and Programs. It is also helpful with practical issues like hospital
reimbursement, life insurance claims, obtaining a probate or succession certificate,
settling property claims, releasing gratuity and provident fund claims and deleting the
deceased name for the Ration Card, and Voter‟s List or employer‟s register
Though numerous commissions and committees analyzed the Indian Vital
Statistics system after independence, a pragmatic shift came in the manner of data
collection, evaluation and statistical analysis after the Registrar General of India
introduced the scheme of Medical Certification of Cause of Death in early sixties. After
passing of the Act by Parliament - Registration of Births and Deaths Act - in 1969,
registration of these events became mandatory with registration of not only the
occurrence of death, but also its cause being equally important.

Medical Certification of Cause of Death (MCCD) in India is carried out under the
Government Medical Certification Scheme, which includes training of medical
practitioners. Though Medical Certificate of Cause of Death (MCCD), commonly called
“Death Certificate”, is the most frequently issued certificate, at least by a government
employed medical officer, if not usually by a private practitioner, many of those, issuing
it, do not fill up this document of immense medical and legal importance correctly. The
reasons may be many, ranging from ignorance to indifference.

Importance of Death certification

The following are important aspects of MCCD

Legal and protective uses:

For claiming family allowance, hospital reimbursement, life insurance claims,
obtaining a probate or succession certificate, settling inheritance/property claims,
releasing gratuity and provident fund claims and deleting the deceased name for the
Ration Card, and Voter‟s List or employer‟s register etc.

Administrative uses:
 As indicators of the existence of infection and epidemic diseases and the need
for immediate control measures. For public safety, accident prevention and eradication
programs. In clearing of documents such as disease case registers, social security files,
tax registers etc.

Statistical uses:

In planning and evaluation of development plans. Useful in public health and

medical research such as, in the study of mortality and the trends in mortality by age,
sex and cause. The registration records thus are primarily useful for their value as legal
documents and secondarily as source of vital statistics.

Legal provisions

Medical Certification of Cause of Death under Civil Registration System has got
statutory backing under sections 10(2) and 10(3) of the Registration of Births & Deaths
Act, 1969.
The Registrar after making the necessary entries in the Register of Birth and
Death, forwards the certificates to the Chief Registrar or officer deputed by him, by 10th
of every month, subsequent to the month when certificate was issued.

Section 17 (1) (b) of the Registration of Birth and Death act any person can
obtain an extract relating to any death, provided he pays the necessary dues/fees as
per the existing government norms. However the information on cause of death, will not
be disclosed unless it is in the interest of the public.

It is the responsibility of the signing medical practitioner to forward the death

certificate to the registering authority, although this is usually sent through a relative of
the deceased, who receives a permit from the municipality to dispose of the dead body
only after presenting the death certificate for registration – as per the RBD Act.

Under Section 23(3) of the RBD Act, any Medical Practitioner who neglects or
refuses to issue a certificate under section 10(3) and any person who neglects or
refuses to deliver such certificate shall be punishable with fine, which may extend to fifty
rupees.

Role of Medical Officer / Medical practitioner

The medical officer has two tasks at hand.

Ist - To diagnose the occurrence of death i.e. permanent disappearance of all evidence
of life. Once it is concluded that the person is dead, a “Death Report” is forwarded to
the Death Registry Authority (along with the MCCD)
IInd - To decide the cause of death. It is the morbid condition to which can be traced
the sequence of events ultimately resulting in death. Deaths due to natural causes

Procedure and Practice:

The death events are recorded at the place of occurrence, in the office of the
Registrar of births and deaths for that area. On occurrence of death, the informant
specified by the RBD act 1969, (Head of the house, Incharge of a Medical
Establishment, Jailor incharge of a jail, Incharge of hostel, dharmasala, boarding-house,
lodging-house, tavern, barrack, public resort etc) , for such an event has to declare the
fact of the event along with certain particulars to the Registrar of Birth and Death for that
area. Death Report (Form 4) along with Form 8 / 8 A Medical Certificate of cause of
Death for hospital inpatients (Form 8) and for non institutional deaths (Form 8 A) to the
registrar of local area.

Every registrar maintains a register which consist of three parts such as I / II / III
for registration of live births / still births/ deaths respectively. The certificate of death
(Form 10) can be obtained from the registrar. It gives all facts of death such as date of
death, place of death etc. but no disclosure is made regarding cause of death. It is
certified by sub registrar or any officer specified under rules.

It is common (though wrong) practice to refer to form 8 / 8A (Medical Certificate

of cause of death) issued by doctors as Death Certificate As per the act the term
Certificate of Death or death Certificate refer to Form 10 issued by Office of Registrar
and not by Doctor.

Doctor issues Medical Certificate of Death and the Registrar issues Death
Certificate / Certificate of Death.

The format of the certificate proper (medical part) conforms to the standard
prescribed by the WHO and has the following features.
Guidelines for issuing of MCCD

Medical Practitioner can issue the Certificate of cause of death. Issuing MCCD, is
done immediately after deciding the person is dead, by the same doctor who has
declared the person dead, provided that the doctor is certain about of the cause of
death and if it is a natural death. There should be no delay, for any reason, in issuing
the medical certificate of cause of death, once the doctor is sure of the cause of death.

The doctor should not sign medical certificate of cause of death in advance (i.e.
before the individual has died) or without viewing and examining the dead body
personally.

In some establishments the Death Certificate is to be counter-signed by the

Medical Superintendent (legally not required), who should do it only after personal
examination of the body.

The death report (Form 4) and MCCD (Form 8/8A) should reach the registrar
with in 14 days of occurrence of death.

No fee is to be charged for issuing the certificate.

He should not withhold issuance of medical certificate of cause of death even if

his dues have not been cleared by the relatives.

The doctor must have attended to the deceased in the last seven days preceding
death.

MCCD should not be issued and dead body should not be released if:

The injured is brought dead.

A crime has already been registered by the police.

The police have already been informed about the case.

The cause of death is not known.

In case it is an Unnatural death, body should be handed over to the police, who
holds an inquest and sends the body for Postmortem examination. However the doctor
is responsible to inform the registrar about the occurrence of death. The registrar can
note the event of occurrence of death and mention in the column of Cause of Death that
– The Inquest report is awaited.

How to fill the MCCD?

The Medical Certificate of Cause of Death is of two types

1. Form No. 8 - For deaths occurring in the hospitals.

2. Form No. 8A - For non institutional deaths.

They differ only in that Form 8 has the details of the hospital where death occurred,
while Form 8A has the details of the attending doctor.

Technically the Medical Certificate of Cause of Death (Form 8/ 8A) has two parts

1. Upper part: Particulars of the Deceased are filled along with Medical data in
respect to the disease causing death.

2. Lower part: Particulars of the deceased along with the date time place of
occurrence of death. It is handed over to the relatives.

3. The personal particulars of the deceased should be filled as under:

a. Name: Write in full, initials not to be used. Fathers name/ husbands name
(in case of married female), to be written after the name of the deceased. For
infants not yet named, write son/daughter of , followed by the name of Mother
and Father.

b. Age: For more than 1 year, write age in years. For age less than 1 year,
write in months and days, and for less than 1 day, write in hours and minutes.

The Medical data to be filled is designed as per the WHO norms and has two
parts. Part I mentions the events which lead to death and Part II mentions the
conditions which contributed to the death .

Part I:

Cause of Death -

One cause is to be entered on each line. Underlying cause is to be filled on the

lowest line. It is the condition that started the sequence of events which lead to
immediate cause of death from normal health to immediate cause of death.

(a) Immediate cause of Death:

Disease or injury or complication that precedes death. Mode of dying eg, heart
failure, respiratory failure should not be entered.

(b) Due to (or as a consequence of)

If immediate cause occurred as a consequence of another condition it should be

entered here. Antecedent condition might have just prepared the ground for Immediate
cause of death, even after a long interval.
(c) Morbid condition leading to the underlying condition

Part II

All diseases or conditions, which were not directly related to the disease directly
causing death, though might have unfavorably influenced the morbid process.

Interval between Onset and Death :

Exact period from onset of morbid condition and the date of death is to be
mentioned. In cases where period is not known, approximate period- “from birth”,
“several years” or “Unknown” is to be filled.

Accident, Suicide, Homicide:

Explain briefly the circumstances or cause of accident. In case of medicolegal

cases Pending Investigations should be mentioned there.

Female death:

If women are of child bearing age group (15-49 yrs), information on pregnancy
and delivery is to be give even though the pregnancy may have nothing to do with
occurrence of death.

Name of the Practitioner:

The name with rubber stamp mentioning the registration number of the Medical
practitioner should be mentioned.

The part below the perforations should be filled by the Medical practitioner
mentioning that the deceased was under his care or was admitted at the hospital and
died on the date and time. This will be endorsed in form no 8 by doctor and in form 8A
by the medical superintendent of the hospital.

The following are some of the examples of medical certification of cause of death;

A. Part I
(a) Peritonitis
(b) Perforation of duodenum
(c) Duodenal Ulcer
Part II
Carcinoma of Bronchus
B. Part I
(a) Acute exacerbation of Chronic Pancreatitis
(b) Chronic Pancreatitis
(c) Chronic alcoholism
Part II
Diabetes Mellitus

C. Part I
(a) Acute Myocardial Infarction
(b) Atherosclerotic Heart Disease
(c) Hyperlipidemia
Part II
-------------------

D. Part I
(a) Hemorrhagic Shock
(b) Disseminated Intravascular Coagulopathy
(c) Abruptio Placenta
Part II
Gestational Hypertension

E. Part I
(a) Bronchopneumonia
(b) Fracture of Neck of Femur (Lt)
(c) ----------------------------
Part II
Essential Hypertension

F. Part I
(a) Gangrene Foot
(b) Diabetes
(c) -----------------
 Part II

-----------------

Precautions to fill MCCD

1. Obviously, it has to be filled up by the doctor who has full knowledge of the
events which lead to death.

2. The names of the diseases should be written in full and legibly, preferably in
block capital letters.

3. Abbreviations and short forms of diseases are not to be used as they are likely to
lead to confusion in the statistical office.

4. Terminal events like circulatory failure, respiratory failure etc and modes of dying
should be avoided as they are no more than signs of death and provide no useful
information as to the underlying disease process.

5. If at all entered, the disease which led to them must be entered in the next line.
They can not be the sole entries.

6. The underlying cause of death which started the sequence should be the last
entry under PART- I.

7. Consequently, if there is no chain of events and underlying cause is the only

event, it should be entered under Part I (a) as it is both the immediate & underlying
cause.

8. Line (a) must always have an entry.

9. Due thought should be given to the last entry under PART-I as it is picked up
for statistical purposes as underlying cause of death.

10. Although, it is a general rule that only one condition is to be entered on each line
(a, b, c, d),

11. When the sequence consists of more than 4 entries, more than one condition can
be entered on one line, of course maintaining the correct causal relationship. This will
retain the internationally accepted form of the certificate.

12. However, even if the alternative of increasing the lines beyond „d‟ is resorted to,
the last entry must be the underlying cause

13. Issuing a false certificate is a criminal offence; all doctors should refrain from it.
Conclusion

Medical certificate of Death is an important aspect of documentation after death

of an individual. It is legal as well as ethical responsibility of doctor to issue medical
certificate of cause of death based on International Classification of Diseases ICD,
which he or she has attended. A lot of haze exists in the minds of medical fraternity
about the correct way of filling of medical certificate of death. Concerted efforts by the
Government and private institutions is required to address this issue. Correct reporting
and registration of cause death will play a very important role in proper health program
planning and national development.