Principles for including or excluding 'mechanisms' of death when writing cause-of-death statements

To develop principles and refined definitions designed to improve the content of cause-of-death statements regarding inclusion or exclusion of so-called mechanisms of death.

Survey of readily available instruction manuals and other literature regarding mechanisms of death and instructions for death certificate completion.

Definitions and principles contained in the information sources were reviewed, and a set of specific principles, criteria, and definitions were written. These principles are consistent with, but are more extensive and practically applicable than, those found in each of the information sources surveyed and may be used to decide which conditions to report in cause-of-death statements.

Mechanisms of death include a defined list of terminal events (such as asystole) and a larger group of nonspecific physiologic derangements (such as portal hypertension) and are differentiated by definition from nonspecific anatomic processes (such as cirrhosis). Three principles may be applied in individual cases. Principle 1 states that terminal events are not reported in cause-of-death statements. Principle 2 states that a nonspecific physiologic derangement or a nonspecific anatomic process should be reported if (1) it is a recognized, potentially fatal complication of the underlying cause of death; (2) it constitutes part of the sequence of conditions that led to the death of the patient in question; (3) it is not a symptom or sign; (4) its existence in the patient would not be apparent unless included and explicitly stated in the cause-of-death statement; (5) its inclusion does not constitute an oversimplification of the facts; and (6) an etiologically specific underlying cause of death is also reported. Principle 3 states that if the existence of the complication is obvious based on the underlying cause of death or another reported complication, it need not be reported.