I love Sunday mornings. Things move at a slower pace. Danny and I enjoy coffee together on the deck. The kids generally sleep in a bit and eventually roll out of bed to help me make cinnamon rolls before we watch church online. So when my alarm clock went off this morning, I opened my eyes with all of the hope and expectation someone suffering from chronic rage could possibly expect. It lasted about 5 minutes.
Today, social media is being plastered with the most absurd misinterpretation of data that I have ever seen. Until tomorrow, I’m sure.
The following snippet from the CDC’s website caused the conspiracy theorists to lose their collective minds and gave them, what they thought was, ammunition to dispute the actual death toll of Covid-19 (you can find the page here):
I understand that not everyone is familiar with how death certificates work, so I present to you: Death Certificates 101, and why “For 6% of the deaths, COVID-19 was the only cause mentioned” means absolutely, freaking, zilch, zero, nothing.
So…for a little background. I am a Hospice and Palliative Care doctor. I have completed hundreds of death certificates, and thus, am familiar with how all of this jazz works. I’ll be the first to tell you when I am out of my wheelhouse, but this my friends, IS MY WHEELHOUSE!
Death certificates capture a person’s cause of death and the events or conditions leading to this event. Below is a generic version of a blank death certificate.
Within the red circle is where the physician documents the immediate cause of death (top line) and then lists the conditions that contributed to the immediate cause of death (next three lines).
I don’t love filling out death certificates because the chain of events isn’t always easy to tease out. Sometimes an elderly person just stops eating and dies under the care of hospice, but I don’t have any labs or imaging to inform my determination of what exactly they died from. Was it renal failure from dehydration or was it an aspiration event that lead to pneumonia? I don’t love listing an immediate cause of death as “stopped eating…?” And a contributing condition as “old…?” I prefer that my death certificates make good sense and be wrapped up in a tidy little bow.
My favorite (okay, weird choice of words, but hang with me) cause of death to document is ischemic cardiomyopathy (heart failure due to coronary artery disease). The chain of events are usually very clear cut and occur in a step wise fashion that I can easily document. A death certificate from ischemic cardiomyopathy would probably look something like this:
Immediate cause of death: Hypoxemic Respiratory Failure (from fluid building up in the lungs)
Due to: Chronic Systolic Heart Failure
Due to: Coronary Artery Disease
Now if this person had other conditions that contributed to their death, I would list these in the box for “Other significant conditions contributing to death, but not resulting in the underlying cause given in Part I.” In the above scenario, these might be things like hyperlipidemia (cholesterol), chronic kidney disease, hypertension, atrial fibrillation.
So, now…with that background information, let’s talk about Covid-19 and how a physician (such as myself) might go about completing a death certificate when Covid-19 is the cause of death.
We all know that Covid-19 is a respiratory illness and primarily causes death by leading to things like ARDS (acute respiratory distress syndrome), pneumonia, septic shock, renal failure and thrombotic events like strokes. Let’s take for example a hypothetical patient, John. John is 62 and has mild hypertension (like a fair amount of 62 year olds do) and is a little bit overweight (again…62 year old man). He works full time at Lowe’s and enjoys hanging out with his grandkids on the weekend. He contracts Covid-19 from his youngest son who came to visit from Florida. He is admitted to the hospital and develops worsening respiratory failure which is due to ongoing Covid-19 infection and related inflammation. He is intubated due to very low oxygen levels and work up demonstrates that he has ARDS. His body continues to deteriorate and he develops shock (low blood pressure requiring vasoactive medications to keep him alive) and acute renal failure requiring dialysis. He eventually dies.
The next day, you receive an email from the state notifying you that his death certificate is ready to be completed.
What should we choose as the immediate cause of death?
I would go with”Hypoxemic Respiratory Failure.”
Okay, moving on to line 2. What lead to John’s Hypoxemic Respiratory Failure?
It seems that ARDS was the condition directly leading to the Hypoxemic Respiratory Failure. So I would type “Acute Respiratory Distress Syndrome” into line 2 (the freaking death registry doesn’t like it when we use acronyms…grr).
Now line 3…what lead to John’s ARDS?
This is where we would list Sars-CoV-2.
Strong work so far, friends!
Now on to the box for other conditions that may have contributed to death, but weren’t directly related to the underlying cause, which in John’s case was Sars-CoV-2.
It would probably be reasonable to list “Hypertension” and “elevated BMI” as conditions that may have contributed to death as we know that hypertension and obesity are risk factors for death in Covid-19.
Now sign your electronic signature, hit CERTIFY and it’s off to the state!
Lets look back….
We have listed “Hypoxemic Respiratory Failure,” “ARDS,” “Sars-CoV-2,” Hypertension” and “Elevated BMI” on John’s death certificate. If you are counting, those are two acute conditions (respiratory failure and ARDS) and two chronic conditions (hypertension and elevated BMI) not including Covid-19. You can see how the list of diagnoses can lengthen…. We didn’t even mention “shock” and “renal failure.”
Lets consider a different scenario. Jennifer is 35 and perfectly healthy. She is a waitress at a restaurant and probably contracted Covid-19 from a large, indoor table of loud individuals, several of whom were coughing. She comes to the hospital because she is having a hard time breathing. She immediately decompensates in the Emergency Room and is intubated. A CT scan shows multifocal pneumonia and a small pulmonary embolism. She is started on broad spectrum antibiotics and anticoagulation. Her test for Covid-19 comes back positive and she is taken to the intensive care unit where her oxygen levels continue to fall and her heart stops beating. Despite CPR and chemical interventions to resuscitate her, Jennifer dies.
Her death certificate is routed to you the following day. Here we go…
Immediate cause of death: We could go with “Hypoxemic Respiratory Failure” again for Jennifer.
What lead to this? I would list “Multifocal Pneumonia” though you could make a case for the pulmonary embolism as well.
And what caused the Multifocal Pneumonia? This is where we list Sars-CoV-2.
Other contributing conditions? Jennifer doesn’t really have any – we can leave that box empty.
So even in this otherwise healthy 35 year old woman, her death certificate will list Sars-CoV-2 as well as two other diagnoses.
Lordy…is anyone even still with me here? If you are (and props to you, by the way), you’ve probably figured out that a death certificate with ONLY the diagnosis of Sars-CoV-2 doesn’t even make sense. Jennifer didn’t go from perfectly healthy to dead from Covid-19 without SOMETHING HAPPENING in the interim. When people die from Covid-19, they die because the virus has caused something to go very wrong in their body. I would go so far as to argue that the doctors completing the death certificates on those 6% without any other factors listed were either 1) in a hurry, 2) lazy or 3) didn’t understand how to fill out a death certificate in the first place. I would be embarrassed to submit such a half-assed death certificate, personally!
If you look at Chart #3 from the CDC (here’s the link again – you’re welcome), you will see that the conditions listed are a mishmash of both chronic and acute illnesses. Things like ARDS, pneumonia, respiratory arrest and cardiac arrest are all acute illnesses most likely CAUSED by Covid-19. Other conditions like chronic lower respiratory disease, hypertension, diabetes and Alzheimer’s are all more chronic conditions that could have been exacerbated by Covid-19 or predisposed to a poor outcome. I’ll let you peruse the chart for yourself.
Seriously….you’re still here? You have my permission to stop reading and go grab a drink. This has become way more tedious than I generally prefer, but such is data and science.
One more example before I shut the hell up and get myself a drink. Mike is a 19 year old kid. Totally healthy. He gets shot in the chest walking home one night and is immediately taken to the hospital. Despite heroic efforts by the trauma team, Mike dies. Mike’s death certificate will likely include “hemorrhagic shock” as the immediate cause of death. This was caused by a “traumatic injury to the aorta” which was the direct result of a gunshot wound. Does the fact that the gunshot wound caused hemorrhagic shock mean that Mike didn’t die of a gunshot wound?
Okay, I’m really done. Thanks for hanging in there with me. I didn’t have my editorial team (Danny) proofread this one because he is out picking up dinner. And because this seems to be an incredibly hot topic today and I wanted to get this out ASAP.
Feel free to leave comments if you have questions or feedback. This is something that needs to be clearly understood.