1. The Medical Certificate
MEDICAL CERTIFICATION OF Cause of death,
TONGA
November, 2018

2. The WHO International Classification of Diseases
Produced by the World Health Organization
Classifies causes of death in a standardised way to facilitate production of comparable statistical data
Includes recommendations regarding how causes of death should be recorded and reported utilising the Medical Certificate of Cause of Death
Certificates can then be coded to the international standard and underlying cause of death used for reporting

5. 2016 NEW DEATH CERTIFICATE PUBLISHED BY THE who
Contains several parts:
Administrative data (demographic information about the decedent)
Frame 1 – medical data relating to causes of death
Frame 2 – other medical data that is relevant to the death and which affects coding
Countries can add additional data collection items as required

6. New death certificate
Designed to be used for both adult and perinatal deaths
Perinatal death certificate is no longer recommended
Supports selection of the underlying cause of death for all deaths

7. Administrative data
Is there other administrative data that you think should be collected?

8. MEDICAL DATA – causes of death

9. Other medical data: 1

10. Other medical data: 2

11. RESPONSIBILITY FOR COMPLETION OF MEDICAL CERTIFICATE OF CAUSE OF DEATH
WHO recommends that the certificate is completed by:
An experienced doctor who is familiar with the medical history of the decedent
A coroner or medical examiner in cases of accidents, violence, unexpected deaths
Another official (who may not be medically trained) in the absence of a doctor

12. Completing the CAUSES OF DEATH part 1 #1
Two parts of medical certificate of cause of death for recording causes
PART 1 – has four lines for recording sequence of events leading to death
The TERMINAL CAUSE (previously called the IMMEDIATE CAUSE - that is, the condition that directly led to death) is always recorded on line 1a
This may be the only cause reported if there are no other conditions in the sequence

13. Completing the causes of death part 1 #2
Other conditions leading to the condition reported on line 1a are entered in sequence on lines 1b, 1c and 1d
The condition that the certifier believes is the underlying cause is reported on the lowest used line – this is also called the STARTING POINT
The underlying cause has been defined as “(a) the disease or injury which initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence which produced the fatal injury”

14. International Standard Medical Certificate of Death Form

15. Completing the causes of death part 1 #3
Diseases reported represent the best medical opinion of the certifier
Any disease, abnormality, injury, poisoning or external cause should be reported if certifier believed it contributed to the death
Well completed certificate provides an aetiological description of sequence of events that led to the death – ie it is cause-based
Should progress from
Underlying cause or starting point …
Leading to any intervening causes …
Which led to the immediate cause or terminal cause

16. 1 month 1 Disease or condition (a)…Acute on chronic renal failure
directly leading to due to or as a consequence of
death*
Antecedent causes (b)…Glomerulonephritis…..
Morbid conditions due to or as a consequence of
giving rise to the above
cause, stating the underlying (c)….Diabetic nephropathy…
condition last due to or as a consequence of
(d)…Diabetes Type II…
Time interval between onset and death
…12 days…
…1 year
…5 years
…10 years… 2
Other significant conditions Femoral neck fracture, femoral
contributing to the death, fracture repair,
but not related to the disease Post operative haematoma
condition causing it ………………………………
*This does not mean the mode of dying e.g. heart failure, respiratory failure. It means the disease, injury or complication that caused death.
1 month
…………………………………………

17. EXAMPLE 1 1a heart failure 1 hour 1b carcinomatosis 4 weeks
1c secondary in lung 6 weeks
1d adenocarcinoma of colon 2 years
What do you think is the underlying cause of death?

18. EXAMPLE 2
1a Massive haemorrhage 1b Traumatic amputation of R leg 1c Bitten by shark
What do you think is the underlying cause of death?

19. Completing the causes of death Part 2
Used to record other significant conditions which contributed to the death but were not related to the condition that caused the death

20. EXAMPLE 3
1a heart failure 1 hour 1b carcinomatosis 4 weeks 1c secondary in lung 6 weeks 1d adenocarcinoma of colon 2 years 2 type 2 diabetes mellitus

21. Your responsibilities #1
Only record one cause on each line of the certificate in part 1 (you can record more than one in part 2)
Unless there is a situation where two independent diseases contributed equally to the sequence at the same time
Use as many of the lines in part 1 as are necessary to record the sequence
Record the causes as specifically as possible – more specific documentation improves the coding and subsequent utility of the data
Don’t record the mode of dying e.g. heart failure, respiratory failure. Record the disease/s, injury/ies or complication/s that caused death.

22. Your responsibilities #2
If the cause of death is unknown, it is correct to document ‘Unknown’ or ‘Not determined’ – this is better than speculating
In the case of injuries or poisonings, record:
the nature of the injury (fracture, dislocation, laceration) AND
the external cause (eg motor vehicle accident, fall from ladder, hit on head by coconut)
Write legibly using blue or black ink
Avoid using abbreviations

23. Your responsibilities #3
As well as the sequence it is important to be as specific as possible
Examples:
CANCER is only a little bit useful – Lung cancer is much more useful for public health planning
Hepatitis (without an underlying cause) codes to a completely different chapter than infectious hepatitis
Conditions such as septicaemia, multi-organ failure and abscess are all missing important information
Remember! The medical certificate of death is your best medical opinion

24. Try to certify this one
Decedent was walking across the road when he was hit by a truck. He sustained multiple fractures (skull, ribs, right femur). He subsequently went into traumatic shock and died.

25. Have another try
Mr Smith was suffering from hepatitis B which led to cirrhosis of the liver. Because of the liver disease, he developed portal hypertension and subsequently oesophageal varices which haemorrhaged leading to his death.

26. Try this one (don’t forget part 2)
Paul had been diagnosed with cardiomyopathy as a result of long term hypertension. He was admitted to hospital today with shortness of breath and swollen ankles. The doctor diagnosed congestive cardiac failure. Paul was a long term type 2 diabetic and also had significant dental caries. He died 12 hours after admission.

27. durations
On the right hand side of the medical certificate is a column titled Time Interval from Onset to Death
This is for recording the duration that the patient had the cause reported ie the time interval between when the condition is believed to have started (not necessarily when it was diagnosed) and when the death occurred
The unit of time is also recorded – minutes, days, months, years

28. Example 4
1a Pulmonary embolism minutes 1b Pathological fracture 5 days 1c Secondary carcinoma of femur 3 years 1d Carcinoma of breast (primary site) 18 months Does this look correct? Why or why not?

29. Why is this important?
Each death is counted ONCE in the national and international mortality statistics
Selection of the Underlying Cause of Death is based on the concept of where in the causal sequence you would INTERVENE to prevent that happening to someone else
There are rules for coders around how to select the underlying cause of death

30. Coding rules for cause of death
The underlying cause is the last condition listed in Part 1 – but ONLY if it can cause everything listed above
The coder is looking for a PLAUSIBLE sequence starting on the top line and working backwards from the death
eg a Lung Cancer
1b Ischaemic heart disease
X not a plausible sequence – lung cancer will be the underlying cause. IHD should appear in the contributory causes in Part 2

31. Coding rules for cause of death
If there is more than one sequence – the first reported sequence must be selected (ie the one on the furthest left)
This means if there are two causes on one line only ONE can be used, as the sequence works down the line, not across the line
If there is no sequence the first reported condition is selected as the tentative underlying cause
If the tentative cause was clearly due to something else reported on the certificate – the coder will apply rules to select that other condition

32. Underlying cause of death: Thyroid cancer
Answer?
Pulmonary distress
Left lobe pneumonia
Metastasised cancer in lungs
COPD
Thyroid cancer x
Underlying cause of death: Thyroid cancer

33. Coding rules for cause of death
Ill-defined conditions are ignored
Trivial conditions are ignored
These include:
MODE of death
“cardio-pulmonary arrest”
SYMPTOMS AND SIGNS
Fever, headache, pain
THINGS THAT GENERALLY DON’T KILL YOU
“broken finger”
NON-SPECIFIC CONDITIONS THAT CAN’T BE CODED
“old age”, “senility”, “viral illness”

34. What is coded? All conditions mentioned on the certificate first
Then…we use the coding rules to determine the underlying cause of death
Wait for it…this will scare you!

35. 4.2.1 Find the starting point (Steps SP1 to SP8)
First assign ICD codes to all conditions mentioned in the death certificate
see section 4.3 Coding Instructions for mortality: multiple causes
Annex 7.10 Workflow diagram of the application of the coding instruction for the selection of underlying cause of death
SP1
Only one condition,
either in Part 1 or 2?
　　Notes:
Refer to for basic concepts:
4.2.1 Find the starting point (Steps SP1 to SP8)
Yes
Choose the condition as the starting point.
Go to M1.
Sequence
Causal relationship
Duration
Terminal cause of death
Starting point
Tentative Starting Point: TSP
Obvious cause
First-mentioned sequence
First-mentioned condition
Underlying cause of death: UCOD
Modification
Tentative underlying cause of death: TUC
SP2 No
Two or more
Choose the first mentioned condition as the TSP
Go to SP6
Only one line
used in Part 1?
Yes
How many
conditions are
mentioned
on this line?
Choose single condition in Part 1 as the TSP.
Go to SP6.
SP3 No
One, but one or more in Part 2.
Condensed title of each step in 4.2.1
see also
SP1 Single cause on certificate
SP2 Only one line used in Part 1
SP3 First cause on the lowest line explains all entries above
Section 4.2.3
SP4 A sequence ends with the terminal condition
SP5 No sequence in Part 1
SP6 Obvious cause
Section 4.2.4
SP7 Ill-defined conditions　
Annex 7.3
SP8 Conditions unlikely to cause death
Annex 7.4
Does the first
condition on the lowest
line explain all entries
above?
Yes
Choose that condition as the TSP.
Go to SP6. No
(Try to get clarification from the certifier)
SP4
Yes
Choose the starting point of this sequence as the TSP. Go to SP6.
Is there a
sequence ending in the
terminal condition?
Yes
Is there
only one sequence?
Identify the first mentioned sequence, and choose the starting point of that sequence as the TSP. Go to SP6. No No
SP5
Choose the terminal condition as the TSP. Go to SP6.
In Part 1
Search for an obvious cause of the TSP, first in the same line in Part 1, next on lower lines in Part 1, and finally in Part 2.
Yes
Choose the first mentioned obvious cause as a new TSP, and check again.
SP6
Where is
the TSP?
Was there another condition
reported on the same line
or further down that could have
obviously caused the TSP?
Are there
several possible
obvious causes?
Yes
(Carefully follow instructions in SP6 )
Choose the obvious cause as a new TSP, and check again.
Search for an obvious cause of the TSP only in Part 2.
In Part 2 No No
SP7
Yes
Keep the TSP as the starting point. Go to M1.
Is the TSP an
ill-defined condition?
(Annex 7.3)
Are other conditions
mentioned in the certificate
all ill-defined?
Yes
Disregard this ill-defined TSP.
Go back to SP1.
SP8 No No
Is the TSP a
condition unlikely to
cause death?
(Annex 7.4)
Are other conditions
mentioned in the certificate
all ill-defined, or unlikely to
cause death?
Was the death
caused by a reaction to
treatment of the TSP?
Is the TSP the cause
of the condition
that is not ill-defined or
unlikely to cause death?
Yes
Keep the TSP as the starting point. Go to M1.
Yes No No
Disregard this TSP unlikely to cause death.
Go back to SP1.
Yes
Yes No No
Keep the TSP as the starting point. Go to M1.
Select the reaction to treatment as the starting point. Go to M1.

36. The TUC is the underlying cause of death.
TSP identified by SP1 to SP8 is now considered the tentative underlying cause (TUC).
4.2.2 Check for modifications of the starting point (Steps M1 to M4) M1
Special Instructions
Does any
special coding instruction
apply to the TUC?
Yes
Assign a new TUC
and check again.
Carefully follow the instructions in M1 and refer to
4.2.5 Special instructions on linkages and other provisions No M2
Specificity
Is there
a more informative term
than the TUC?
Yes
Assign a new TUC
and check again. No M3
Recheck
Is the TUC
same as the
starting point identified
by SP1 to SP8?
The TUC selected in
M1 or M2 is not ill-defined
and is reported correctly due
to another condition
The TUC is a reaction
to treatment of a condition
unlikely to cause death
selected in SP8 No No No
Go back to SP6.
Repeat the procedures in SP6, M1 and M2.
Yes
Yes
Yes M4
Medical procedures, poisoning,
main injury, maternal death
TUC is…
Special instructions
Refer to section…
Surgery or
medical procedure
4.2.9 Other medical procedures
Chapter XIX
Injury or poisoning
Code the external cause as the UCOD
Chapter XX
External cause
Also select the main injury.
4.2.6 Main injury in death from external causes
Poisoning and more than toxic substance is reported
Identify the most important drug involved.
4.2.7 Poisoning by drugs etc.
Decedent is a woman and pregnancy, childbirth or pueperium is reported.
Determine whether to assign Chapter XV as the UCOD
4.2.8 Maternal mortality
Does the
TUC apply either of the
special instructions
for M4?
Yes
Follow instructions and
refer to sections indicated in the following table. No
Confirmation: The TUC is not
further changed in either SP6 or M1 to M3
Yes
The TUC is the underlying cause of death.

37. Coding rules - Finding the starting point
Series of rules to determine the underlying cause of death from a medical or aetiological perspective
Step SP1 – Single cause on certificate
Step SP2 – Only one line used in Part 1
Step SP3 – More than one line used in Part 1, first cause on lowest line explains all entries above
Step SP4 – First cause on lowest used line does not explain all entries above, but a sequence ends with the terminal condition
Step SP5 – No sequence in Part 1
Step SP6 – Obvious cause
Step SP7 – Ill-defined conditions
Step SP8 – Conditions unlikely to cause death

38. Coding rules - Checking for modifications
Series of rules to determine underlying cause of death from a statistical perspective
Step M1 – Special instructions
Step M2 – Specificity
Step M3 – Recheck Steps SP6, M1 and M2
Step M4 – Instructions on medical procedures, poisoning, main injury and maternal deaths

39. RESOURCES Quick reference tool – how to complete a medical certificate
WHO on line training tool
Hawaii State on line training tool
CDC Physicians handbook
University of Queensland/ WHO Handbook on medical certification
D4H Handbook on medical certification