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Death Certificates in the Time of COVID-19
continued from page 21

(Figure 2)
The duration of the event or disease - time of onset to death
- MUST be entered for every line (Figure 2). For example, if
line 1 says "lethal arrhythmia," the duration might be minutes.
If the underlying cause of the arrhythmia (and the death) is
atherosclerotic coronary artery disease, the interval from onset to
death may be years. Death certificates can be rejected for lack of
duration information.
Any diseases, injuries, or conditions that contributed to the
death but did not directly cause the death, can be entered in
a separate section, Part 2 of the medical certification. It's wellrecognized that the elderly, particularly those with underlying
health conditions, have been the most severely impacted by
COVID-19, so this section may list multiple conditions that may
have predisposed the patient to dying from COVID-19. When
completing this section for a COVID-19 death, I err on the side
of listing as many significant conditions as possible, since we just
don't know yet what is relevant and what isn't.
On April 6, 2020, the CDC held a webinar on certifying
COVID-19 deaths (2). It is still available on-line and free CME is
available. The National Center for Vital Statistics also has a written
guidance on the topic (3). Both emphasize entering a logical chain
of events leading to the death. An example of a logical sequence
might be "Sepsis" on Line 1, "Pneumonia" on Line 2, and
"COVID-19" - the underlying cause - on Line 3. An illogical

22 CHESTER COUNT Y Medicine | SPRING 2020

(Figure 3)
sequence would be "Pneumonia" on Line 1, "COVID-19" on Line
2, and "Dementia" on Line 3.
Unless you're a medical examiner or coroner (ME/C), you will
never certify a Manner of Death other than natural. Let me say
that another way: if any kind of accident, fall, or trauma possibly
contributed to the death to any degree, it is an ME/C case as only
the county medicolegal death investigation office can certify nonnatural deaths.

COVID-19 Terminology
Common terminal events reported on death certificates for
COVID-19 deaths are pneumonia, acute hypoxic respiratory
failure, and sepsis. As elsewhere, pneumonia, particularly
multi-focal pneumonia, quickly became the most common
terminal event in Chester County COVID-19 deaths (Figure 3).
COVID-19 is an underlying cause of these and possibly other
terminal events, but it is not a terminal event in and of itself.
"COVID-19" is the correct wording for the underlying cause
of death. Not COVID-19 virus, not COVID-19 infection. That's
because COVID-19 is a disease name, not the name of a virus.
The virus is SARS-CoV-2. It's just like the difference between
AIDS and HIV.

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