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By Hannah Critchfield
The coronavirus pandemic has required everyday Americans to vet a lot of public health information quickly. The sources they trust play a large role in shaping their beliefs about — and their response to — COVID-19.
Studies show Americans are sharply divided along partisan lines about the severity of the virus. Nearly one in three U.S. citizens believe the coronavirus hasn’t killed as many people as has been reported. As the election draws near, current President Donald Trump has continued to downplay its threat, telling a rally last week that the U.S. is “turning the corner” on controlling the pandemic.
These statements have continued despite public health experts’ assertions and the fact that cases and deaths have ticked up in recent weeks.
Conspiracy theories have proliferated along the way. One of them centers around the idea that medical examiners knowingly inflate the number of deaths caused by COVID-19 through manipulating death certificates.
At North Carolina Health News, we’ve been asked by readers about those COVID-19 deaths, and how health officials truly know a death is caused by the virus.
To learn more, we spoke with North Carolina’s former chief medical examiner to find out exactly how death certificates are filled out.
Natural or unnatural?
Death certificates are considered the “gold standard” in determining how many people have died of a disease in a given year. They are not used for the state health department’s COVID-19 data, which relies on reporting of positive test numbers from local health agencies; instead, these official documents are reported to the Centers for Disease Control and Prevention’s National Center to develop each state’s COVID-19 death count.
Deborah Radisch was North Carolina’s chief medical examiner between 2010 and 2018, and the first woman to hold the position.
In the state of North Carolina, how you die determines who fills out your death certificate, according to Radisch.
Deaths due to “unnatural” causes, such as homicide, suicide or accidental overdose — the most common cause of unnatural death statewide — need to be completed by a county medical examiner.
“Natural” deaths – including those due to COVID-19 – need to be filed by a physician, a physician assistant, or a nurse practitioner within five days of death. The process usually begins when a person dies at a hospital, or after a funeral home director notifies a physician that a death has occured.
There’s one exception — if the person who died of COVID-19 dies while “in custody,” then a county medical examiner instead assumes responsibility for completing their death certificate. This applies to people who die while incarcerated in a prison or jail, in police custody, or living in a state-run facility.
Every certificate completed in a given county must eventually be submitted to the state Office of the Chief Medical Examiner in Raleigh for final approval.
Once completed, these certified, final death certificates are shared with the register of deeds in the county where the person died and the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.
A likely undercount
In March, the state Office of the Chief Medical Examiner issued guidance for how COVID-19 death certificates are to be completed.
“In North Carolina, they’re just treated like other deaths,” said Radisch. “If you know that somebody died of COVID-19 or complications of COVID-19, it’s a natural death.”
However, early on in the pandemic, North Carolina, like the rest of the nation, experienced a shortage of COVID-19 tests.
Many of those early cases with COVID-19-like symptoms never received a test. For those who died before health officials could administer one, testing was even less likely.
“They would not have been the first ones to get testing when testing was hard to get,” said Radisch, who continues to work as a medical examiner in Wake County since retiring from her role as state chief medical examiner. “And that that makes sense. You’ve got to test living people.”
Certifiers were forced to determine if a death was caused by COVID-19 to the best of their knowledge and availability at the time.
“If the test results aren’t back and everything points to it, it is supposed to be based on your best medical opinion,” said Radisch. “And if that’s a pretty strong opinion, then you should go ahead and sign it out as ‘probable COVID’ because you can amend the death certificate later if you find out differently.”
Guidance recommends certifiers use their “best clinical judgment” to make this call.
“While some may be uncomfortable with the notion of uncertainty, remember that in this setting, we as providers do not have the usual luxuries of getting confirmation,” associate chief medical examiner Craig Nelson wrote in the guidance. “Also remember the certifying statement on the death certificate: ‘To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.’”
North Carolina’s medical examiner system is decentralized, with medical examiners and physicians in each of its 100 counties completing the certificates.
That lack of available testing early on, coupled with national vital statistics data, suggests there’s likely been an undercount of COVID-19 deaths in North Carolina, rather than an overestimate.
Last week, the CDC announced there have been nearly 300,000 “excess deaths” in the United States attributable to the novel coronavirus pandemic. The excess death estimation is used to describe how many more people have died than would be expected in a typical year. Two out of three of these deaths are directly due to COVID-19 infection, the agency said, the rest were indirectly caused by the pandemic and would not have occurred without the virus.
‘Not if there’s a gunshot’
Now that the state has enough capacity to test everyone, the system has improved.
“If somebody came in with signs and symptoms [of COVID-19], they would just order it like any other kind of lab test, and then use those results,” said Radisch.
The CDC states the virus may still be detected for up to three days after a person’s death based on their knowledge of other coronaviruses. There’s no data on post-mortem detection of COVID-19 in North Carolinians who died before receiving a test, according to the state Department of Health and Human Services.
Death certificates are designed to get at the sequence of events that led to a person’s passing.
Part I of the document asks certifiers to fill out the “chain of events” that directly caused the death. In this section, there’s an “immediate cause,” such as pneumonia or acute respiratory failure, and then the sequence of conditions that caused it, ultimately ending with an “underlying cause,” which is considered the root cause that killed the person.
“I always tell clinicians to have this ‘due to’ mantra in their head,” Dr. James Gill, chief medical examiner for the state of Connecticut, previously told NC Health News. “Cardiac arrest — well what was that due to? A heart attack. And what was the heart attack due to? It was due to coronary atherosclerosis. There you have your underlying cause of death.”
Part II of the death certificate notes any “significant conditions” contributing to, but not resulting in, the underlying cause of death. In the case of a death due to COVID-19, this might be a preexisting condition such as diabetes, hypertension or obesity.
Certifiers are advised to list COVID-19 as the underlying cause of death, as long as no other obvious factors suggest otherwise.
“If someone comes into a hospital with gunshot wounds and they test positive for COVID-19, you’re not going to put it on the death certificate,” said Radisch. “That’s where [the public has] gotten kind of crazy on these things, and confused. That’s an incidental finding that had nothing to do with the death. So it should be left off.”
According to state guidance, if COVID-19 appears to have hastened a person’s death, such as in the case of someone who died with metastatic cancer, the virus should be listed as a “significant contributing factor” in Part II. This death would be included in the CDC’s COVID-19 death count.
There is no centralized system or training for death certificate completion in the United States, according to the National Association of Medical Examiners. The upshot is that states may differ in their process for determining a death is caused by COVID-19. North Carolina’s state guidance mostly mirrors CDC recommendations for how this document should be filled out; however, the CDC always recommends listing COVID-19 as a cause of death and makes no mention of listing it as a “contributing factor.”
Lack of training
The system isn’t foolproof.
The DHHS COVID-19 guidance notwithstanding, physicians who complete death certificates for natural deaths often don’t receive training on how to properly fill out the document.
“Nobody gets trained to do this in medical school,” said Radisch. “I wasn’t.”
Errors are more likely in a paper-based system like North Carolina’s, which has fewer checks and balances than an electronic system. A certifying physician may fail to complete all parts of the death certificate, such as demographic information like race or gender, or fail to properly detail the root cause of a person’s death.
County medical examiners, however, who complete COVID-19 deaths of people “in custody,” must receive death certificate training due to a law passed in 2015.
Medical examiners in North Carolina are still susceptible to these errors in death documentation, according to medical examiners in other states who reviewed certificates from this year shared by NC Health News.
These errors, however, were not identified in death certificates that listed “COVID-19” or “probable COVID-19” as the underlying cause of death.
Instead, they were in certificates that solely stated “pneumonia” or “bacteremia,” but failed to identify a sufficient root cause behind the ailment.
Such omissions support the theory that there may be an undercount, rather than an overestimation, of COVID-19 deaths in North Carolina in the national CDC data.
Checks and balances
There’s a chance some of these errors may be corrected before the death certificate is certified, according to Radisch.
All death certificates eventually pass through the state Medical Examiner’s Office in Raleigh, creating a semblance of a “check” on the process.
“You get a final look at the death certificate that got filed on the case, and if you don’t agree with it by looking at the case, that’s your chance once everything comes back to fill out a supplemental death certificate with the final cause and manner of death,” she said.
For deaths where the certifier isn’t sure if the death was caused by COVID-19 due to a possible competing cause, they can request the medical examiner’s office conduct an autopsy.
“Say someone was found collapsed at the bottom of stairs, but they’d been having symptoms, so you’re not sure if it was a fall or if it was that, then you’d probably go ahead and do an autopsy,” Radisch said.
“Or if you know that test results are pending, then you need to make sure that you let somebody know that, and follow up on the results and report them to the state medical examiner’s office to correct the death certificate if necessary.”
If a death is listed as “due to COVID-19” but is actually caused by something else, or vice versa, the CDC will be notified and will adjust their official case count dashboard.
“As far as I know, they’re still checking all the death certificates and they’ll all be certified correctly eventually,” Radisch added. “How long that takes, I don’t know.”