It all started with my mother. This sounds like a statement of the blindingly obvious; it might be better to say that it started with my mother's death. Of course mothers are powerful figures for all of us, but exerting influence after death is impressive, even for my mother.
We were fortunate over my mother's death. She had been fading for a year, and then was ill for long enough at the end that we all had time to say goodbye. My sister and I planned the funeral and met a few days later to register the death. When the registrar told us the cause of death I involuntarily blurted out my disagreement. The registrar paused, and then told us that if we were unhappy with the cause as registered he could refer it to the coroner. With a vision of post-mortem and deferred funeral coming into view I immediately expressed complete agreement with the cause as registered. But the episode reminded me of doubts about the reliability of our death certification system. How often are there doubts about death certificates, and what effect does it have on the country's mortality data?
Such thoughts have returned recently with two patients dying in the nearby nursing home. In both cases there was genuine doubt about the precise circumstances of death, and no doubt at all that death was from natural causes. Conversations with the coroner's officers have, as always, revealed them to be wise, urbane, sympathetic men (they always have been men). They ask sensible questions, and we have ended up agreeing a form of words acceptable to both the registrar and the bereaved family. Whether it's a good idea for those certificates to contribute to the country's mortality data is another matter. Death certificates have to perform three different functions: to satisfy the registrar that there is nothing suspicious about the circumstances of death; not to create any unnecessary difficulties for the bereaved family as they handle their grief and arrange the funeral; and to provide data about the state of the nation's health. Most of the time no conflict or doubt arises, but there doesn't seem to be a satisfactory way of dealing with it when it does, and our knowledge of the ways that GPs behave under other circumstances would suggest that there are lots of different ways of responding. A few years ago we published a paper from New Zealand exploring how GPs complete death certificates. It gave an account of a culture of giving the highest priority to respecting the family's feelings.1 This seems reasonable, and one would expect that it is the same in other countries. Dame Janet Smith's recommendations are pulling in the same direction, that the family should have more say about what is written, although one can understand that those who originally devised the procedure feared families would more often have an interest in falsifying the reports than the doctors do.
The question is where this leaves the mortality statistics, and whether we should worry about them. The difficulty is that they are assumed to be true, and yet we don't really know how close to the truth they are, and they continue to be used to inform public policy and to make comparisons with the public health other countries. In passing, I always wonder how much the ‘Mediterranean effect’ is to do with the way death certificates are completed in Mediterranean countries (although no doubt someone has done an international validation). We all know that the phrase ‘viral infection’ is shorthand for ‘I don't really know what this is, but I don't think your illness is severe, and I'm confident that you'll be better in a week or so.’ I should like an equivalent on the death certificate to be able to report: ‘I'm quite sure this death is from natural causes. I've discussed it with the coroner's office, and neither they nor the family want the trouble of a post mortem in the name of greater certainty. But as for a definite cause of death, frankly I haven't a clue.’
- © British Journal of General Practice, 2007.
