Cause of Death - Christina VandePol

Post updated September 22, 2024

What’s the difference between the cause of death and the manner of death? Who determines the cause of death? How?

In this post, I’ll review some of the basics of a cause-of-death statement, as the Centers for Disease Control and Prevention (CDC) calls it. The cause of death is one specific disease or injury that initiated the chain of events leading to the death. It should be the last line on Part 1 of a death certificate.

Let’s start with a basic multiple-choice question, mainly for those of you who may not write death certificates on a daily basis. Which of the following is an accurately stated cause of death?

Asphyxia
Cardiac Arrest
Suicide
Pneumonia
Homicide
None of the above

Answer can be found towards the end of this post.

Mechanism, Cause, or Manner of Death?

The cause of death as listed on the death certificate is supposed to be the one specific underlying disease or injury that resulted in the chain of events leading to death.

Asphyxia, cardiac arrest, and pneumonia are common mechanisms of death, but are not “the” underlying cause of death. That’s because each of these physiological mechanisms has many possible underlying causes. For example, asphyxia (lack of oxygen to the body) can be due to hanging, suffocation, or cyanide poisoning. Cardiac arrest (which just means the heart stops beating) occurs in every death, so it really tells us nothing about what caused that to happen. Pneumonia can be due to any one of thousands of bacteria, viruses, and fungi. Remember, we’re looking for a single specific disease or injury.

Suicide and homicide describe a manner of death (how the death came about). Manner of death will be topic for a future post.

Cause of Death is an Opinion

The primary responsibility of coroners and medical examiners (C/MEs) is to determine the cause and manner of death for cases that fall under their jurisdiction.

If an autopsy is performed, the autopsy report states the forensic pathologist’s opinion of the cause of death. Sometimes but not always (it depends on the jurisdiction) the autopsy report may also provide the pathologist’s opinion of the manner of death. In any case, most deaths investigated by C/MEs are not autopsied. That means most of the time a C/ME must rely on other sources. Their information can come from observation of the death scene, external examination, toxicology, medical records, and other sources.

Different physicians, coroners, medical examiners may come to different conclusions even with the same data. That’s why the cause of death is an opinion. Here’s what the C/ME actually attests to when signing a DC:

“On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.“

Cause of Death – The Bottom Line

The C/ME enters the primary or underlying cause of death in Part 1 of the DC. Part 1 is mandatory.

Part 1: This part has multiple lines. Some certifiers incorrectly think this means they should enter a laundry list of the decedent’s medical problems. That just leaves it to a medical coder at the state or CDC level to decide what will go into the vital statistics database. Generally, there are two approaches to Part 1. The C/ME may choose to enter only the single specific underlying cause of death (shortcut method). On the other hand, they may choose to enter a more detailed logical sequence of events leading to the death. With the more detailed sequence approach, the underlying cause is supposed to be the last entry.

Shortcut Method for Cause of Death

It’s common for certifiers to fill out just the first line of Part 1. That’s fine as long as it’s the underlying cause of death. For example, coronary artery disease or COVID-19 pneumonia could be the only entry. Each gives the specific underlying cause.

Sequence Method for Cause of Death

This is useful with complicated cases. It helps families understand what happened. Here are several examples:

Acute Respiratory Failure (Line 1), Bilateral Pneumonia (Line 2), COVID-19 (Line 3)
Lethal cardiac arrhythmia (Line 1), Myocardial Infarction (Line 2), Atherosclerotic Cardiovascular Disease (Line 3)
Asphyxia (Line 1), Ligature Hanging (Line 2)
Multiple Drug Intoxication (Line 1), Fentanyl, Heroin, Cocaine (Line 2), Substance Use Disorder (Line 3)
Septic Shock (Line 1), Aspiration Pneumonia (Line 2), Cervical Spine Fracture (Line 3), Motor Vehicle Collision (Line 4)

Cause of Death – Contributing Factors

Certifiers can enter contributing factors—if any—in Part 2. Part 2 may be left blank and often is.

Part 2: “Significant conditions contributing to the death but not resulting in the underlying cause of death.” This section calls for a great deal of judgment on the part of the certifier. For example, did hypertension or obesity contribute to that COVID-19 pneumonia or not? What about dementia?

The role of mental health disorders in suicide or drug intoxication (drug overdose) deaths is just as challenging. Some C/MEs will list those in Part 2, while others will not.

To sum up, whatever goes in Part 2 is a matter of opinion, judgment, and even philosophy on the part of the C/ME.

A CDC example

A correctly written death certificate with Part 1 and Part 2 entries (credit CDC):

Quiz Discussion

Asphyxia is a mechanism of death, but there are many underlying causes of asphyxia, including hanging, strangulation, fire, and positional asphyxia.
Cardiac arrest means the heart stops. That is true in every death, which is why the CDC says the following right on the death certificate (see the graphic): “DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology.”
Suicide is a manner of death with many possible causes.
Pneumonia is indeed a cause of death. However, as with asphyxia, there are many causes of pneumonia. The specific cause, usually a pathogen like COVID-19, mycoplasma, or streptococcus, needs to be stated.
Homicide is a manner of death with many possible causes.
None of the above – CORRECT!