A Public Death: Getting It Right On the Final Diagnosis

When in doubt, call it heart disease.

This seems to be the mantra of many in medicine, unfortunately, according to a recent study in Preventing Chronic Disease. The study found evidence that heart disease is too frequently reported as a cause of death when other causes are more likely culprits. It also found that cancer, pneumonia and other causes of death are more likely to be left off death certificates, in part, because they are harder to pinpoint.

For the study, the New York City Department of Health and Mental Hygiene tracked doctors in a training program aimed at improving the accuracy of death certificates. They knew that doctors by default often list heart disease as a cause of death, knowing that it does cause a massive amount of death in the United States and elsewhere and ,therefore, is a safe bet.

As I mentioned on Friday, accuracy on death certificates has a downstream effect as those death records become important research tools for academics and policymakers. They can skew funding decisions, staffing plans, and treatment recommendations. So what happened when physicians were trained and encouraged to consider other causes before they wrote “heart disease” on the death certificate?

It dropped 54 percent as a cause of death.

Flip that around and you’ll find that doctors were getting it wrong at least half the time.

So what were people dying of instead?

Various cancers accounted for 11% of all deaths before the training program and climbed to 16% after.

Cerebrovascular disease went from 2% to to 4%.

And before the training program, influenza and pneumonia accounted for only 4% of all deaths. After, they accounted for 11%.

Lawrence K. Altman in a recent must-read column in the New York Times described the solemn duty doctors have to get these final diagnoses right.

A doctor’s role is to describe the chain of medical events or conditions leading to death, based on four categories. One is the immediate cause of death, the specific ailment that preceded it. The second is intermediate causes that created the immediate cause. The third is the underlying cause, the ailment that set off the chain of events. (“Cardiac arrest” is never acceptable as the underlying cause of death because it is a tautology: The heart stops in every death, and cardiac arrest can result from hundreds of ailments.) Last, doctors are asked to list the patient’s other ailments, even though they did not cause death.

The chain of causes is often long and complicated, and sometimes the starting point is not clear. For example, was the cause of a drowning the inability to swim? Being pushed or falling into water? A heart attack, abnormal heart rhythm or a stroke? Inebriation? The side effects of a prescribed or illicit drug? Or hot weather?

If you don’t think it matters what a doctor writes on a death certificate, consider that every year billions of dollars are spent in government and private research funding trying to come up with better tools, treatments, and prevention strategies for the things that ail us the most. If we are underreporting one piece of the health problem picture and exaggerating others, we’re not spending our money as wisely as we could be. In health care, that could mean lives saved or lost.

So, send a copy of Altman’s column to the physicians in your life. Take it to your next doctor’s visit. Fly in a helicopter and drop a thousand copies on your nearest medical school. Just spread the word. Because this final documentation of our existence creates echoes that continue long after we have left.