Death Certificates Are Not Reliable: Revivification of the Autopsy

BACKGROUND: Medicine assumes that vital statistics are accurate, but they are only as good as the death certificates. OBJECTIVE: To evaluate the accuracy of death certificates in reporting vital statistics with an emphasis on cardiac deaths. DESIGN: A population-based retrospective study within one community hospital. PATIENTS: During the study period, 1,619 patients expired during hospitalization, of which 223 underwent autopsy. INTERVENTIONS: Clinical diagnoses were determined from the death certificate and autopsy results from the final pathology reports. MEASUREMENTS: Concordance of myocardial infarction as the underlying cause of death between the death certificate and the autopsy was measured. New diagnoses uncovered by the autopsy were tabulated. RESULTS: The death certificate missed acute myocardial infarction in 25 of 52 autopsy-proven cases (48% errors of omission). Conversely, it erroneously asserted the presence of an acute myocardial infarction in 9/36 cases (25% errors of commission). Autopsy showed these nine cases actually were pneumonia (5), sepsis with ARDS (2), cerebral hemorrhage (1), and cardiac tamponade (1). Autopsy proved 52 myocardial infarctions causing death, while death certificates accurately reported only 27. Myocardial infarction was more likely to be unsuspected in extreme ages, in women, when found in right ventricle or posterior wall, and in the presence of sepsis or ARDS. Death certificates were frequently inaccurate and in 21.5% of cases were of no value because of an inadequate diagnosis, ie, cardiopulmonary arrest, arrhythmia or respiratory failure. CONCLUSION: Major discrepancies of commission and omission occur frequently between the death certificate and autopsy. 1) Death certificates are often wrong. 2) The time-honored autopsy is more valuable than ever. 3) Physicians need to write better death certificates and correct them. 4) Death certificate-based vital statistics should be corrected with autopsy results. 5) Vital statistics should note deaths confirmed by autopsy. 6) More autopsies would improve vital statistics and the practice of medicine.