Certifying a death in times of COVID-19

Certifying a death in Spain and, more specifically, Catalonia, can be confusing. Changes across Europe in times of COVID-19 vary both in time and location.

The paperwork – literally.

Before 2009, certifying a death involved completing two separate documents, one the certificate itself and another the form for the national bureau of statistics. As of 2009, this is one single document, which is the same in the whole of Spain. In certain very specific cases, such as if the body is to be transported, embalmed or incinerated, there may be a need for two certificates. The Mortuary Police Regulations or Reglamento de la Policía Sanitaria Mortuoria should be your reference for these cases. The death certificate must be presented within 24h to the Registry Office or registro of the Municipality where the death occurred.

The whole job.

As we all know, signing a death certificate is just one of the tasks a doctor undertakes. A death is an emotional time, and although we may no longer know the family and friends set-up of the person who has died, we have an ethical duty to those left behind. Our help may be practical, having the details of the local funeral homes or religious or community leaders. It is worth having the contact details of local funeral directors and religious leaders with your certification paperwork.

In times of COVID.

Certifying a death in times of COVID, especially at times when tests have not always been available, led to the Barcelona College of Physicians to provide specific guidance.(1) In the case of a laboratory-confirmed COVID diagnosis, which is deemed to be the cause of death, then the fundamental cause of death should be recorded as “COVID-19”. If there is no laboratory confirmation, and after having reviewed the symptoms and medical history of the patient, the fundamental cause of death should be recorded as “COVID-19 not confirmed” or “COVID-19 no confirmat”. Or as “Suspected infection of coronavirus” or “Sospita d’infecció per coronavirus.”

In England and Wales, the Coronavirus Act 2020 has been brought into place to cover the fact that it may not be the doctor who attended the patient during their last illness.(2) The part “last seen by me” should be deleted, and if any other doctor has seen them during the last 28 days, then that doctor’s name should be inserted there. For the purposes of describing looking after a patient, video consultations but not phone consultations are now valid.(3) Guidance has been updated to help non-medical practitioners verify a death, including remote assistance for the process.(4) COVID-19 is an acceptable direct or underlying cause of death and, although a notifiable disease, does not need to be communicated to the coroner in England and Wales.

Communicating the cause of death and epidemiological details is always important for public health reasons, but even more so in a pandemic. Sometimes accessing the information can be the limiting factor. In France, the lack of use of the electronic online system for certifying deaths, especially in prehospital contexts, made epidemiological work more complicated at the beginning of the pandemic.

In Germany the Koch institute recommends at least level 3 PPE for any health professional certifying a death in a COVID infected corpse.(5) Special attention to aerosols and droplets is to be made when pressing on a corpse’s thorax. Cremations in certain German Länder or regions require a second examination of the corpse. In times of COVID, the Koch Institute recommends that a risk-benefit analysis be undertaken before these are carried out.

Now that social distancing is required, whether COVID was the cause of death or not, breaking bad news in PPE or personal protective equipment of any level can be challenging. Although much information and research have become available as the pandemic has progressed as how to best break bad news in telemedicine, there is very little about face to face conversations. A paediatric oncologist in Marseille has written of how he has struggled with not using non-verbal ways of communication, including hugging or holding hands.(6) One of his patients says he thinks he can read his eyes above his mask. Other publications about prehospital breaking bad news in the time of COVID tend to concentrate on making sure people have time to say good bye to loved ones as they will typically not be seeing them in hospital whatever the outcome and also the burden on healthcare workers who are having to communicate this information.

Traditionally, the SPIKES model has been used to break bad news.(7) Although by the time you get to the patient to certify a death, the family and friends will usually be aware that the person has died, this may not always be the case. Even when the death is clear, it helps to have a structured procedure to take a level of distress away from the medical professional. SPIKES is an acronym and stands for:

S- Setting: Set up the interview in a space which is appropriate and away from interruptions. With the people who need to be there.

P – Perception: Work out what the family and friends have understood about the situation with open-ended questions. Questions about the inevitability of the death at this point might come out.

I – Invitation: This involves finding out just how much detail the family want about what has happened. Some people may want to know how much the person knew or if they were in pain. Others prefer less information.

K – Knowledge: Give knowledge and information to the family and friends according to what they have told you in the perception and invitation stages. Use clear language and avoid medical jargon and ambiguous terms. Especially in a hospital setting where the relatives may not have seen the dead body or see a lot of machinery, make sure you use the words death.

E – Empathy: Identify and recognise the emotions that are being felt. “I can imagine you are very sad but also worried about what will happen now in a pandemic”.

S – Strategy and summary: This is the time to explain what will be happening now, what steps the relatives need to take, and in what time frame. It is also a good moment to give them any contact details.

Finally, certifying a death, is mentioned previously a highly emotive time for all involved and as such the healthcare professional may also need some help. In Barcelona, for the past 20 years, the PAIMM service has been helping doctors deal with their own health issues. Similar services are provided by other professional medical institutions and this a theme we will be returning to later on in the series. Don’t forget to subscribe to the podcast to automatically receive new episodes as they become available.

1.        COMB – Col·legi Oficial de Metges de Barcelona. Consideracions sobre les Certificacions Mèdiques de Defunció en la pandèmia COVID-19 [Internet]. 2020 [cited 2020 Dec 5]. Available from: https://www.comb.cat/cat/actualitat/noticies/noticies_fitxa.aspx?Id=IIc5UXfbSVCnnsJjAnJ4Vw%3D%3D

2.        UK Publication General Acts. Coronavirus Act 2020 [Internet]. Available from: https://www.legislation.gov.uk/ukpga/2020/7/contents/enacted

3.        Medical Defense Union. Certifying deaths during COVID-19 outbreak – The MDU [Internet]. [cited 2020 Dec 5]. Available from: https://www.themdu.com/guidance-and-advice/latest-updates-and-advice/certifying-deaths-during-covid-19-outbreak

4.        Department of Health & Social Care. Coronavirus (COVID-19): verifying death in times of emergency – GOV.UK [Internet]. 2020 [cited 2020 Dec 5]. Available from: https://www.gov.uk/government/publications/coronavirus-covid-19-verification-of-death-in-times-of-emergency/coronavirus-covid-19-verifying-death-in-times-of-emergency#annex-1

5.        Robert Koch Insitute. RKI – Coronavirus SARS-CoV-2 – Empfehlungen zum Umgang mit SARS-CoV-2-infizierten Verstorbenen [Internet]. [cited 2020 Dec 5]. Available from: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Verstorbene.html

6.        André N. Covid-19: Breaking bad news with social distancing in pediatric oncology. Pediatr Blood Cancer [Internet]. 2020 Sep 1;67(9):e28524. Available from: https://doi.org/10.1002/pbc.28524

7.        Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A Six‐Step Protocol for Delivering Bad News: Application to the Patient with Cancer. Oncologist [Internet]. 2000 Aug [cited 2020 Dec 5];5(4):302–11. Available from: https://pubmed.ncbi.nlm.nih.gov/10964998/