A medical certificate of death is a permanent, legal record of a person’s death and its circumstances. Death certificates are important legal documents. They also provide statistics on causes of death and data for measuring health problems, assist in public health surveillance, and guide health promotion and disease control activities.
While most physicians have experience with a patient dying, some doctors remain uncertain about who can pronounce a death, who can certify a death, and what their obligations are in both these circumstances.
Pronouncing a death means issuing an opinion that life has ceased based on a physical assessment of the patient. Contrary to popular belief, there is no legal requirement that death be pronounced by a physician. Another person, such as a nurse who was caring for the deceased, could pronounce a patient’s death. If death occurs in a hospital or long-term care home, there may be specific policies and procedures on who may pronounce death in the facility.
Certifying a death is not the same as pronouncing death. Certifying a death is the legal process of attesting to the fact, cause, and manner of someone’s death, in writing, on the form prescribed by the local authority. Each province and territory has legislation governing who can certify a death.
In general, any physician who was in attendance during the last illness of the deceased person or who has sufficient knowledge of the last illness has a legal obligation to complete the death certificate. In some provinces and territories, legislation also states that a nurse practitioner who was in attendance during the last illness can complete and sign the death certificate if the death was expected as the result of a diagnosed chronic or acute illness or condition.1 In Québec, any category of nurse is authorized to complete death certificates, but only if the death results from the deterioration or complication of a diagnosed illness. Otherwise, a physician or nurse practitioner must complete the death certificate in Québec.
It is important to note that any physician in attendance during the last illness or with sufficient knowledge of the deceased’s last illness can complete the death certificate. This physician does not need to be the patient’s primary care physician. Physicians who have sufficient knowledge of the patient’s last illness may be asked to complete the death certificate even though the primary care physician has broader clinical knowledge of the patient overall.
Death certificates and medical assistance in dying
The completion of death certificates for individuals who received medical assistance in dying (MAID), and in particular the classification of the cause of death, may be governed in individual provinces and territories by legislation, policies of regulatory authorities (Colleges), or both. The obligation to report MAID deaths to the coroner or medical examiner and the determination of who completes the certificate of death in these circumstances may also vary between provinces and territories.
When the duty to complete the death certificate is engaged, physicians must do so promptly after the patient’s death. Several provinces and territories require that the death certificate be completed immediately or without delay, while others require completion within 48 hours of death. Undue delays or failure on the part of a physician to complete the death certificate could expose a physician to the risk of a complaint to the regulatory authority (College) or a fine under the applicable statute.
Duty to report
Each province and territory also has legislation relating to a physician’s reporting obligations following a death. For example, physicians have a duty to report a death to the coroner or medical examiner that they believe is suspicious or that has occurred under the circumstances listed in the legislation. These circumstances include death that is the result of violence or homicide, negligence, misconduct, or malpractice; during pregnancy; or that is unexplained or unexpected. The specific legislation in each jurisdiction might require physicians to report information about a death to the coroner in other circumstances. In addition, physicians in some provinces and territories may also be required to report to a medical officer of health a death resulting from certain communicable diseases.2
The difference between coroners and medical examiners
The terms “coroner” and “medical examiner” are often used interchangeably, but they represent different systems of investigating deaths. For example, although medical examiners are physicians, coroners in some provinces and territories do not need to be physicians. The majority of provinces and territories use the coroner system to investigate deaths.
There are generally two objectives for reporting deaths to the coroner or medical examiner. The first is to determine the cause and manner of the death (and at times, the identity of the deceased). The second is to make recommendations about any systemic issues that may have contributed to the death. In cases being investigated by coroners or medical examiners, they are generally responsible for completing the death certificate. That said, physicians may still need to attend to the deceased to make a determination that the cause of death is suspicious, sudden, unexpected, or otherwise requires notification of the coroner under the legislation.
A family practitioner who had primary responsibility for the care of a deceased patient during the last illness might be asked to attend to the patient if the patient died at home and there are no concerns about the circumstances or cause of death. Rather than risk a complaint being made by the deceased’s family to the College or being liable to a fine, it may be prudent for physicians to attend to the deceased in these situations to certify the death.
If a physician is truly unable to attend to the deceased patient in the short term, because the patient no longer lives in the same geographic area or the physician is not immediately available, it may be helpful for the physician to remind the requesting party that any physician who has sufficient knowledge of the death can complete the death certificate. It may be more expedient and practical for another physician (or a nurse practitioner, where applicable and appropriate) to certify the death.
The College of Physicians and Surgeons of Ontario recommends a similar approach when physicians have made a commitment to care for patients who are expected to die at home. The College’s Advice to the Profession, Decision-making for end-of-life care, states that in these situations, physicians should ensure there is a plan for the certification of death, including designating the physicians or nurse practitioners who will be available to certify the death.3
Alternatively, physicians should also be aware that provincial and territorial legislation does not necessarily require that physicians formally attend to the body to certify the death in every case. If it is appropriate, physicians can rely on the patient’s file and on information reported to them by other health professionals who attended to the patient during his or her last illness. Physicians in these cases should carefully review the record and make the necessary inquiries to satisfy themselves that the information is correct, especially as it relates to the cause of death. Physicians may, however, wish to attend to the body to certify the death if they feel they have insufficient information or if they have questions about the circumstances of the death. Physicians who complete a medical certificate without making reasonably necessary inquiries could expose themselves to liability.
When a patient’s death is imminent and expected to occur naturally, physicians may prepare some parts of the death certificate in advance of the patient dying. However, the form should not be finalized until after the patient has died.
The essential points
- There is no legal requirement that death be pronounced by a physician. The medical certificate of death, however, must generally be completed by the physician in attendance during the patient’s last illness or any physician who has sufficient knowledge of the last illness. In some jurisdictions, nurse practitioners who attended the patient during the last illness can complete a death certificate. In Québec, any category of nurse is authorized to complete death certificates, but only if the death results from the deterioration or complication of a diagnosed illness. Otherwise, a physician or nurse practitioner must complete the death certificate in Québec.
- When a death occurs in unusual circumstances or in circumstances that are specified in legislation as reportable, physicians must report it to the coroner or medical examiner. Physicians should be aware of what constitutes a reportable death in their province or territory. The coroner or medical examiner will then investigate the case and complete the medical certificate of death.
- Physicians should know their legal obligations for certifying a death, be aware of the potential medical-legal issues, and act reasonably and professionally when requested to attend and certify a patient’s death.
Currently, nurse practitioners in Nova Scotia, New Brunswick, Ontario, British Columbia, Saskatchewan, Newfoundland and Labrador, Yukon, and the Northwest Territories can complete a medical certificate of death in certain circumstances.
Members should contact the CMPA if they have questions or need assistance related to their duty to report in specific cases.
The College of Physicians and Surgeons of Ontario. Advice to the Profession, Decision-making for end-of-life care [Internet]. Toronto (CA): CPSO; 2023 March [cited 2023 July 18]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2016/completing-medical-certificates-of-death-who-s-responsible.