Death certification: a primer part III--certainty and the unknown cause of death

The level of certainty needed to assign a cause of death may be problematic. The certification regulations stipulate that a certifier only needs to believe that a proposed cause of death be more likely than not (i.e. anything more than fifty percent likely). While there is no requirement for absolute certainty in completing a death certificate, the consequences of a specific diagnosis (for example, a diagnosis of acquired immunodeficiency syndrome) may, at the discretion of the certifier, require a higher level of certainty. At times, however, a certifier may not know even a more likely than not cause of death. In some circumstances where death was not anticipated/expected and a thorough postmortem examination fails to establish a cause of death, listing the cause of death as unknown or undetermined is perfectly acceptable. Alternatively, death occurring in an elderly individual, where death would not be entirely unexpected and with no known medical history or stigmata of disease, poses a more difficult certification situation. In these situations the certifier may either choose unknown for a cause of death, or (preferably in my opinion) choose what he or she feels would be the most likely cause of death given the statistical likelihood of causes of death in individuals similar to the decedent.