Medical Certificate of Cause of Death

Start at Part 1(a) with the direct cause of death, then go back in time to the preceding (antecedent) conditions until you get to the condition that started the sequence of conditions leading to death. This is the underlying cause of death.

Part 1 (a): Direct cause of death

• Enter the disease or condition that occurred as the last part of the sequence of events or conditions leading directly to death.
• It can be the sole entry on the certificate when only one condition, such as viral myocarditis or asthma, was present at death.
• Or it may be a complication (such as peritonitis, septicaemia or pneumonia) of another condition.

Note: Do not enter the mode of dying such as collapse, cardiac arrest or respiratory failure; that information is of little value.

Part 1 (b): Antecedent cause

• If the direct cause entered in 1(a) arose as a consequence of any antecedent disease or injury, enter that antecedent cause at 1(b). For example, Perforation of colon.

• If no other condition led to the condition entered in 1(b) then the condition in 1(b) is the underlying cause of death and no entry is required in 1(c). For example Chronic bronchitis in 1(b) may have led to Bronchopneumonia in 1(a). Chronic bronchitis was the underlying cause of death.

Part 1 (c):

• It could be that a further antecedent disease or condition may have caused the conditions in both 1(b) and 1(a) and was the underlying cause of death. In such cases that antecedent condition, which was the starting point in the chain of related events leading to the direct cause of death, should be entered at 1(c). For example Diverticulitis in 1(c) may have led to Perforation of the colon in 1(b) and Peritonitis in 1(a).

• On no account must the starting point of the sequence be entered in Part 2 because of lack of space in Part 1.

Note: 

• If more than two antecedent conditions led to the direct cause of death entered at 1(a), the starting (underlying) condition should be entered at 1(c) and the most important of the intervening conditions entered first at 1(b), followed by the second intervening condition (if space allows).
• If two intervening conditions are entered in 1(b) they should be separated by a comma.

• Where the interval between the onset of each condition entered on the certificate and the date of death is known, even approximately, it should be entered in the column provided.
• This will provide a check on the sequence of causes in Part 1 and provide useful information about the duration of illness for certain diseases, especially cancers. It is also of critical importance to clinical coders when selecting the underlying cause of death for mortality statistics.
• The certifying practitioner has responsibility for deciding which condition led directly to death and what antecedent conditions, if any, gave rise to the direct cause.

• Part 2 is for entry of other conditions not directly related to the cause of death, but which have contributed to or have had an adverse effect on the conditions entered in Part 1 of the certificate.
• Conditions entered in Part 2 must not be directly related to the underlying cause of death.

• Below the section Cause of death Part 2 on the Medical Certificate of Cause of Death is a field requesting information about any infectious disease the deceased may have been suffering from at the time of death. This is to assist the funeral director to meet reporting obligations set out in section 85 of the Health Act 1956 and its Regulations.
• The infectious diseases to be reported on in certain circumstances under the Health Act 1956 are listed in Parts 1 and 2 of Schedule 1 of this Act.
• Providing this information also makes the funeral director and other professionals aware of the infection so they can take the necessary precautions to keep themselves safe when handling the body.

• State own home, lodgings, hotel, hospital, nursing home etc.
• If the deceased died in a medical facility ensure that both the name of the facility as well as the street address are entered.

• State the type if primary; cause if secondary. If drug-induced, state the name of the drug involved, and the condition for which it was prescribed.

• It is recognised that atherosclerosis will probably be generalised by the time of death. However, the site of arteriosclerosis or atherosclerosis which led to the direct cause of death, for example, coronary atherosclerosis, cerebral atherosclerosis, is needed. 
• See example: Atherosclerosis.

For a death that was assisted under the End of Life Choice Act 2019 please follow these guidelines when completing the Cause of death section of the Medical Certificate of Cause of Death (HP4720 form)

• Select the ‘Assisted Dying’ checkbox, if completing the form online in Death Documents. This will populate Part 1(a) of the certificate with the words ‘Assisted Dying’ as the Direct cause of death. If the death is certified on a paper HP4720 form then write ‘Assisted Dying’ in Part 1(a) of the certificate.
• Enter any conditions arising from the underlying cause that contributed to the terminal nature of the condition as Antecedent cause(s) in Part 1(b)
• Enter the terminal condition(s) for which the deceased was eligible to receive an assisted death as the Underlying cause in Part 1(c)
• Enter the interval between the onset of the cause of death, and death, for each condition
• Any conditions that contributed to the patient’s decline can be entered in Cause of death Part 2
  
  Note: Do not enter any details of the method or medication used to assist death on the Medical Certificate of Cause of Death. Those details will be entered in a separate Assisted Dying Death Report. It is under the Assisted Dying tab in Death Documents. If you have questions about the Death Report or completing an MCCD for assisted dying, you can contact AssistedDying@health.govt.nz

1. State the exact site of the primary growth. If unknown, please state this. Record precisely the anatomical structure in which the primary site originated, for example:

(a) malignant neoplasm of trachea, bronchus or lung: primary main bronchus, primary upper lobe bronchus or lung, primary middle lobe bronchus or lung, primary lower lobe bronchus or lung

(b) malignant neoplasm of pancreas: primary head of pancreas, primary body of pancreas, primary tail of pancreas

(c) malignant neoplasm of colon: primary hepatic flexure, primary transverse colon, primary descending colon, primary sigmoid colon, primary caecum, primary ascending colon, primary splenic flexure. 

     2. State the morphological type, if known.

     3. Specify the sites of the principal secondaries, if present.

     4. To avoid misinterpretation, if the term ‘metastatic cancer’ is used it should be qualified by identifying both the primary and secondary sites, for example, lung metastases from primary breast cancer. 

Note:

• Where the site of the primary cancer is not known, the sites of the secondaries should be stated and primary site specified as unknown.
• The term neoplasm or tumour should always be qualified with a statement as to whether it is benign, malignant, or indeterminate. If malignant, the notes on cancer should be applied; otherwise the site and type of tumour should be given. 
• See example: Cancer

• The cause of the dysrhythmia should always be stated, if known. 
• See example ‘Heart disease’.

• State underlying cause if known, for example, alcoholic cirrhosis.

• State underlying cause if known, for example, emphysema.

• Specify the type of diabetes mellitus, that is, Type 1 or Type 2. Conditions caused by the diabetes mellitus should be stated as such, For example. Diabetes mellitus with chronic kidney disease.

• State the cause. If acute infectious encephalitis:

1. Name causal organism if known.
2. State if death was due to late effects of the disease.

• 'Frailty of old age’ can be entered as the sole entry in line 1a of a medical certificate of cause of death (MCCD) in limited circumstances. This diagnosis refers to a gradual multi-system decline in function over a period of several months or years that is attributable to atrophic degenerative changes of ageing, in the absence of any specific organ system disease. It applies to patients aged 80 years or older whose declining function has been appropriately clinically assessed over a period of time for specific organ system disease before death. The diagnosis 'frailty of old age' should not be used as a substitute for a more specific diagnosis (if there is one), and should not be used in part 1a if the deceased suffered from an acute illness (e.g. pneumonia), or trauma prior to death. 
• Any chronic medical conditions that contributed to the deceased’s steady decline, (for example chronic ischaemic heart disease, dementia, or cerebrovascular disease), should be entered in Part 2 of the MCCD, along with the time interval in brackets after each condition. The most serious of these medical conditions should be entered first in Part 2.
• The purpose of this guidance is to provide a suitable option for medical practitioners and nurse practitioners to use when completing the certificate of cause of death for an elderly frail patient who has died suddenly, apparently of natural causes, but the exact cause of death cannot be ascertained without an autopsy. Too many deaths of this nature are being reported to the coroner contributing to the burden of deaths awaiting the coroner’s attention, unnecessary use of pathology services to identify the exact causes of deaths of elderly people from natural causes, and contributing to the distress of whānau waiting to arrange funerals or tangihanga for their loved ones. 

• State underlying cause, for example, duodenal ulcer, use of non-steroid anti-inflammatory drugs (NSAIDs) for 10 years for generalised rheumatoid arthritis. 
• See example: Gastrointestinal haemorrhage

• State the pathology of the heart condition. Particularly:

(a) Was it due to arteriosclerosis? If so, were the coronary arteries involved?

(b) Was the condition due to rheumatic fever? If so, was it acute or chronic, (late effects)? If chronic, which valve or valves were involved?

(c) Was the heart failure caused by hypertension? Was there renal involvement?

1. State the cause, e.g. cerebral infarction. If due to an old traumatic injury state the nature of the injury and details of the cause of the injury, e.g. Motorcyclist involved in collision with truck.
2. How long has the condition been present? (that is, old or acute).

1. State the type, for example lymphatic, myeloid, myelomonocytic.
2. Was it acute, subacute or chronic?

1. State the type of malformation present.
2. Which part of the body was involved?

Note: If congenital, this fact should always be stated. In the case of congenital malformation of the heart, was the condition Tetralogy of Fallot, coarctation of the aorta, interventricular septal defect, tricuspid atresia, or some other defect?

• State type, for example, tuberculous, meningococcal.

• State the cause of the obstruction. Particularly:

(a) if cancer, state site and type. See example: Cancer – exact site of primary cancer

(b) if hernia, state type.

(c) if paralytic following operation, state condition for which operation was performed, the nature of the operation and when it was performed.

1. State the condition for which the operation was performed.
2. What was the underlying cause of this condition? For example:

(a)   Peritonitis – 4 days; due to:

(b) Resection small intestine – 5 days; as a consequence of:

(c)    Strangulated inguinal hernia – 5 days

           See example: Operation

Note: If death occurred during a procedure and/or whilst person was under anaesthetic, the death would need to be reported to the coroner.

1. Specify type, for example, lobar, influenzal, viral.
2. Is it primary or secondary to some other condition such as measles, whooping cough?
3. If a terminal event, state antecedent condition leading to pneumonia.
   See example: Pneumonia

1. Specify origin and cause of embolism if known. If post-operative, state the condition for which surgery was performed and the nature of the operation.
2. Was it associated with pregnancy, childbirth or abortion? The death would need to be reported to the coroner.

• State type, for example, emphysema, chronic bronchitis.

• State:

1. Causative organism, if known.
2. Antecedent condition leading to septicaemia, for example, acute appendicitis.

(When issuing a certificate under section 46C of the Burial and Cremation Act 1964.)

• In all cases of injury give the site and nature of the trauma. In addition, details of how and when the injury occurred are required as follows:

1. How did the injury happen? For example, fell down stairs, fell from bed.
2. Where? For example, at home, in a rest home, on the street, in a public building.
3. When did the accident occur?

As a member state of the World Health Organization, New Zealand has a commitment to classify causes of death to the 'underlying cause of death'.

The high quality of cause of death statistics in New Zealand is largely due to the cooperation of doctors, nurse practitioners and coroners in providing accurate particulars of cause of death.

Ensuring cause of death information is accurate is also important for the family of the deceased. This information appears on the legal death certificate that is issued by the Office of Births, Deaths and Marriages, and which is used for administering the deceased’s estate. Genetic Services agencies also use information from the BDM Death Register when assessing an individual’s risk of inheriting a familial genetic condition.

Explanation: The problem in the above table is the Type 2 diabetes mellitus was the underlying cause of the lactic acidosis, cardiogenic shock and cardiac arrest so it should be entered in Part 1 (c) as the underlying cause of death. Cardiac arrest was the mode of death so should be omitted.

Example 1:

Explanation: The problem in the above table is that systemic lupus erythematosus with immunosuppression was the underlying cause of death so should be entered in Part 1 (c). Respiratory failure was the mode of death so should be omitted

Example 2:

Explanation: The problem here is the primary site of the carcinoma, carcinoma of the cervix, was the underlying cause of the metastatic poorly differentiated carcinoma so should be entered as the underlying cause of death in Part 1. Cardiac arrest was the mode of death so should be omitted.

Explanation: The problem in the above table is the accident that caused the fractured neck of the femur is the underlying cause of death so needs to be entered below the fractured neck of the femur in Part 1.

Explanation: The problem here is atherosclerosis can affect different organs in the body so more information needs to be entered in Part 1 to indicate the organ affected. This allows more specific classification of the underlying cause of death

Explanation: The problem here is that ‘Bowel cancer’ is not specific enough (unless the exact primary site within the bowel is unknown). Specify the site within the bowel.

Explanation: The problem here is the primary site of the cancer is not stated. Aspiration pneumonia is the direct cause of death so should be entered in Part 1 (a).

Explanation: The problem here is the type of cerebral neoplasm is unstated. The person classifying the cause of death cannot tell if the cerebral neoplasm was malignant or benign, and if it was malignant, whether it was a primary or secondary cancer.

Note: Astrocytoma is considered to be a primary cancer of the brain, (unless specified otherwise), therefore entering Astrocytoma cerebellum in Part 1 (a) provides all the information that is required to accurately describe the underlying cause of death.

Explanation: The problem here is that cardiac arrhythmias are often caused by other known heart disease. Where this is the case the underlying heart disease should be entered as the cause of the arrhythmia.

Explanation: The problem here is the cause of the gastrointestinal haemorrhage (the direct cause of death) is not stated.

Explanation: The problem here is that, whilst it is important to know the deceased had surgery in the days or month prior to death, the condition for which the surgery was required is classified as the underlying cause of death. Therefore details about that condition need to be included in Part 1 (c).

Explanation: The problem here is the condition causing immobilisation has not been documented. That condition will be the underlying cause of death.

Explanation: The problem here is that pulmonary embolism often results from a deep vein thrombosis that has developed due to immobility caused by another condition. The condition resulting in immobility should be entered as the underlying cause of death.