The issue of certification of death is sometimes a source of tension between doctors, families and funeral directors. The concerns perceived by various stakeholders were outlined in a Law Commission review and issues paper published in 2011. That review may lead to improvements in the future, but doctors need to manage carefully in the interim.
This factsheet deals with certification of death by natural causes. There are separate issues about referral to the Coroner and requirements for cremation certificates that are not addressed in detail here.
The death of a patient is often a major event for surviving family and caregivers who may have significant needs and questions. Doctors sometimes take a stance that their living patients must take priority over the needs of a grieving family. Society has set out some legislative requirements for doctors to attend in a timely manner to matters related to a death, to help balance these competing demands.
Certification of cause of death by the attending doctor for a person who died as a consequence of an illness
The Medical Certificate of Causes of Death (“MCCD”) is a form provided by the Ministry of Health (form HP4720). The requirements for the completion of a MCCD are outlined in section 46B of the Burial and Cremation Act 1964.
Section 46B relates only to situations where the doctor is satisfied that the patient died as a natural consequence of an illness and there is no indication for referral to the Coroner. Referral criteria for the Coroner are outlined separately in the Coroners Act 2006 – s13. If in doubt the Coroner is available by telephone 24/7 to discuss any concerns (0800 266 800)
Section 46B(2) requires a “doctor who attended the person during the illness” to provide a doctor’s certificate for the death “immediately after the doctor learns of the death.”
Who is the most appropriate doctor to complete the death certificate?
The requirement is that this is done by “a doctor who attended the person during the illness.” In practice this may be a GP, hospital doctor, locum or one of several doctors who attended the patient.
- When several doctors have attended a patient during their illness, an appropriate doctor will be one of those who has sufficient knowledge of the patient; their past medical history, and the nature of their illness.
- There is no provision in the Act that requires a doctor to have seen the patient within a set time frame before being able to certify death, so long as the doctor did attend during the illness.
- If the doctor who attended the patient during the illness knows that subsequently some other doctor has also attended the patient, the original doctor “must not give the certificate without taking all reasonable steps to consult the other doctor” first (section 46B(7)).
In what timeframe should a certificate be issued?
The doctor who attended the patient during their illness must provide a certificate “immediately” after he or she learns of the death.
- “Immediately” is not defined by the Act. Differences in its interpretation can be a source of tension between doctors (who have other matters to attend to) and whãnau, as well as funeral directors, who want paperwork completed as soon as possible.
- A separate section of the Act (discussed below) allows another doctor to sign the certificate if the attending doctor is unavailable within the 24-hour period following the death (or longer in some circumstances). A reasonable approach would be to complete a certificate as soon as possible within 24 hours, and to liaise with the funeral director to confirm that this suits other requirements. A doctor may be called upon later to justify any delay in completing the certificate.
Does the doctor have to personally examine the body?
- Section 46B does not require the doctor who attended the patient during their illness to examine the body before providing a death certificate.
- The doctor is however required to examine the body after death if a cremation is planned. The extra requirements for a cremation certificate are not discussed here.
- Any other doctor who signs the death certificate, and who is not the doctor who attended the patient during their illness, must examine the body before providing a certificate (discussed below).
- Although a doctor who attended the patient during the illness is not required to examine the body after death, there are other good reasons for routinely examining the body. These include to satisfy oneself that the identity of the deceased is confirmed (an issue in rest homes, for example), to ensure that all relevant information has been checked, and to console and support the family and answer any questions.
Completion of a death certificate by another doctor
Section 46B(3) of the Act recognises that the “doctor who attended the person during the illness” may be unavailable in a timely manner. It defines the circumstances under which an alternative doctor (who did not attend during the illness) can then complete a death certificate. This only relates to cases in which the death was a natural consequence of an illness. The alternative doctor should make reasonable inquiries to ensure that the attending doctor is not withholding certification because they are not satisfied as to the cause of death.
The circumstances in which another doctor may sign the death certificate are:
- Where the appropriate doctor is “unavailable.” This is defined as “dead, unknown, missing, of unsound mind, or unable to act by virtue of a medical condition.”
- Where the doctor who attended the patient during the illness is unlikely to be able to provide a death certificate within 24 hours of the death.
- Where the doctor who attended the patient during their illness has not given a death certificate and 24 hours or more has passed since the death.
While the Act allows this “fall-back” option, it places more rigorous demands on the substitute certifier, who must:
a) look at the medical records made by the doctor who last attended the patient during the illness;
b) consider the circumstances of the patient’s death; and
c) examine the patient’s body.
Doctors should consider these requirements when they arrange cover for the times that they are away or not contactable. The doctor who provides cover needs access to the medical records in order to complete a death certificate.
Removal of the body by the funeral director
Section 46F(2)(a)of the Act permits the transfer of the body to the funeral director even if a MCCD has not yet been completed; thus a funeral director does not legally require the death certificate before they remove the body. However, before accepting a body, the funeral director may want assurances that the Coroner does not have jurisdiction, clarification as to who will complete the death certificate and that a certificate will be issued in a timely manner.
Good communication and goodwill will smooth over many of these situations, in the interests of finding a reasonable solution to competing demands.
Where a MCCD has been completed it must be given to the funeral director at that time. Under section 46AA(1) a body cannot be buried, cremated, or otherwise disposed of unless the person in charge of the disposal has obtained a doctor’s certificate or authorisation from the Coroner.
The gaps in the current legislation can usually be managed by acting in a reasonable and professional manner with good communication. Relevant Medical Council standards include its statements on “Medical certification” and “Unprofessional behaviour and the health care team.”