PURPOSE: The decreasing number of autopsies performed in the United States makes death certificates crucial for epidemiological data. In most teaching hospitals residents fulfill this responsibility. We sought to understand housestaff experience regarding death certificate completion and accuracy in New York City (NYC).
METHODS: A 32-question internet-based survey was distributed to all general surgery, internal medicine, and emergency medicine residency programs in NYC (n=70). Surveys were anonymous and completed between May and June 2010. Residents were given a $5 coffee card for their participation.
RESULTS: Overall, 521 residents from 38 programs in 26 institutions responded. Residents who reported completing 10+ death certificates were considered High Volume (HV) respondents (n=178, 34.2%). The majority of residents (67%, 77.3% HV) believed the death certificate system was not accurate. 48.1% of residents (58.4% HV) experienced listing a cause of death on the certificate that did not represent the true cause. When alternate diagnoses were used, cardiovascular disease (64.6%), pneumonia (19.5%), and cancer (12.4%) were most common. Residents believed the cause of death listed was inaccurate in 26.6% of cases. Most residents (70.2%, 83% HV) were forced to list an alternate cause of death in cases of septic shock. Furthermore, 97.1% failed to update death certificates with new information when available. Perceived causes of system failure included not allowing the “true” cause of death (76.8%) and instruction to report an alternative diagnosis by hospital personnel (40.4%) or the medical examiner (30.7%). Several issues related to transfer of care between residents were highlighted, with 20.4% of residents stating they did not know the patient and 17.8% of residents stating they just recorded a diagnosis that would be easily accepted.
CONCLUSIONS: Housestaff predominately do not believe the death certificate reporting system is accurate, often knowingly documenting incorrect diagnoses. Insufficient flexibility of the system and lack of resident education in proper death certificate completion are likely responsible.
CLINICAL IMPLICATIONS: Residents recording incorrect causes of death on death certificates leads to misrepresentation of the true causes of death in communities, which impacts public health funding priorities. Several adjustments should be made to the current death reporting system to improve accuracy.
DISCLOSURE: The following authors have nothing to disclose: Barbara Wexelman, Edward Eden, Keith Rose
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