The issue of certification of death is sometimes a source of tension between doctors, families and funeral directors. This factsheet deals with certification of death by natural causes in persons over 28 days of age. There are separate issues relating to neonatal deaths, referrals to the Coroner and requirements for cremation certificates that are not addressed in detail here. Recent amendments to the Burial and Cremation Act 1964 mean that a nurse practitioner is now able to complete a Medical Certificate of Causes of Death.
The New Zealand Government has also recently developed an online platform called Death Documents, where health practitioners can complete death certificates and cremation forms on line. This system allows funeral directors to access these certificates as soon as they have been completed. Details regarding registering to use this system can be found at https://deathdocs.services.govt.nz/practitioners-help. Health practitioners are required to have a ‘Realme’ login, in order to access this system and if their Realme account has been verified, they can retrieve patient details from the NHI when completing documents. Documents completed on the online system are automatically sent to the Ministry of Health and will be made available for funeral directors to retrieve digitally. A health practitioner is only required to print and sign the documents if the person taking responsibility for the body and death registration is not a funeral director, as online access is not available to members of the general public.
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. Government has set out some legislative requirements for medical or nurse practitioners 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 medical or nurse practitioner 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 medical or nurse practitioner 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 “medical practitioner or a nurse practitioner who attended the person during the illness” to provide a certificate for the death “immediately after learning of the person’s death.”
Who is the most appropriate clinician to complete the death certificate?
The requirement is that this is done by “a medical practitioner or a nurse practitioner who attended the person during the illness.” In practice this may be a GP, nurse practitioner, hospital doctor, locum or one of several doctors who attended the patient.
- When several clinicians have attended a patient during their illness, an appropriate health practitioner 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 health practitioner to have seen the patient within a set time frame before being able to certify death, so long as the health practitioner did attend during the illness.
- If the health practitioner who attended the patient during the illness knows that subsequently some other health practitioner has also attended the patient, the original health practitioner “must not give the certificate without taking all reasonable steps to consult the other health practitioner” first (section 46B(2)(b)).
In what timeframe should a certificate be issued?
The health practitioner 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 health practitioners (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 health practitioner to sign the certificate if the attending health practitioner 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 health practitioner 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 health practitioner 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 health practitioner
Section 46B(3) of the Act recognises that the “health practitioner who attended the person during the illness” may be unavailable in a timely manner. It defines the circumstances under which an alternative health practitioner (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 health practitioner should make reasonable inquiries to ensure that the attending health practitioner is not withholding certification because they are not satisfied as to the cause of death.
The circumstances in which another health practitioner may sign the death certificate are:
- Where the appropriate health practitioner is “unavailable.” This is defined as “dead, unknown, missing, of unsound mind, or unable to act by virtue of a medical condition.”
- Where the health practitioner 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 health practitioner 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 health practitioner who last attended the patient during the illness;
b) consider the circumstances of the patient’s death; and
c) examine the patient’s body.
Health practitioners should consider these requirements when they arrange cover for the times that they are away or not contactable. The health practitioner 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 health practitioner’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.”