DEATH CERTIFICATES:
ADDING
MEDICAL METHODS OF MANAGING DYING (MMMD)

by James Leonard Park


SYNOPSIS:

    Greater clarify about how each life came to an end
might be achieved by the simple procedure
of adding one line to each certificate of death.
This new line would name any life-ending decisions,
any relevant changes of medical orders, or
any medical methods of managing dying (MMMD)
used in the end-of-life care of that patient.

OUTLINE:

1. ADDING A NEW LINE TO ALL DEATH-CERTIFICATES

2. DEFINING THE CAUSE OF DEATH

3. ADDING MEDICAL METHODS OF MANAGING DYING

4. AN ALTERNATIVE EXPRESSION: "MANNER OF DYING"



    The advent of new right-to-die laws
in various states of the United States and in other countries
has created a new form of possible confusion
to the practice of recording deaths for statistical purposes.

    Should a patient who is dying of terminal cancer
but who decides to shorten the process of dying by taking gentle poison
be recorded as a "suicide"?

    In the early days of the right-to-die movement,
"physician-assisted suicide" was one of the most common ways
to describe deaths achieved by means of a gentle poison
prescribed by a physician after various safeguards were fulfilled.

    Thus, it should have been no surprise to discover
that the people responsible for keeping the statistics of deaths
sometimes recorded such deaths as "suicide",
even tho the right-to-die laws usually declared
that such chosen deaths were NOT suicide for any purpose.

    The basic reason for keeping count of deaths and their causes
is to see what might be done about some causes of death.
And when some human diseases were eliminated,
the keepers of the statistics found that polio, for example,
was no longer a cause of death.

    In most cases, there was no confusion about the 'cause of death'
even when some medical decisions were taken at the end of life.
A change in medical orders was often
the immediate action that led directly to this death.
For example, when the patient's heart
had become unable to sustain that patient's life,
the patient might have been sustained by some heart-assisting device.
When the patient continued to decline despite the life-supports,
sometimes the doctors recommended ending the mechanical assistance
because all the benefits of the life-support had disappeared.
When the life-supports were removed, the patient died immediately.
But the cause of death was nevertheless heart-failure,
not deactivating the pacemaker (or other implanted heart-device)
nor disconnecting any external machines keeping the patient alive.



1. ADDING A NEW LINE TO ALL DEATH-CERTIFICATES

    A new line might be added to the death-certificate of each jurisdiction:
After the primary CAUSE OF DEATH,
the form could ask for any MEDICAL METHODS OF MANAGING DYING.
In the example just mentioned,
the CAUSE OF DEATH would be listed as heart-failure.
And the MEDICAL METHOD OF MANAGING DYING
would be noted as removal of the life-support systems.

    The validity of making such an addition to death-certificates
is illustrated even more dramatically in the case of Alzheimer's disease.
An Alzheimer's patient might have been sustained by a feeding-tube
during several years of further mental deterioration. 
The proxies and the doctor agree to disconnect the feeding-tube
because no further meanings can be achieved
by keeping the patient 'alive' in this ever-diminishing condition.

    Here the CAUSE OF DEATH should be recorded as
progressive Alzheimer's disease.
And the LIFE-ENDING DECISION
or the MEDICAL METHOD OF MANAGING DYING
should be recorded as removing the feeding-tube.
The immediate change that led to this patient's death
was disconnecting the life-supports.
But why record this death as "dehydration"?
What statistical purpose would be advanced
by naming "dehydration" as the cause of death?
This patient obviously died as the result of a brain disease
that made further meaningful life impossible.
The final change of medical orders concerning the feeding-tube
was the last fact in the medical history of this patient.

    Major controversy about reporting deaths could occur
when the last medical order is to give the patient a lethal injection.
Here it might be argued that the true cause of death
was the drug put into the patient's body by the doctor or nurse.
But the CAUSE-OF-DEATH line on the death-certificate
is for the statistical purpose of keeping numbers
about the medical facts of this population of patients.
Thus, the underlying disease or condition
that led to this life-ending decision
should be listed as the primary cause of death.

    What this change of death-certificates requires
is a somewhat more elaborate definition of the "CAUSE OF DEATH".
And the new line called "MEDICAL METHODS OF MANAGING DYING"
would allow some useful details of the terminal care to be included. 

    The statistics about causes of death should not be changed
because we have developed better methods of managing dying.



2. DEFINING THE CAUSE OF DEATH

    The cause of death is the whole constellation of medical conditions
that prevented this patient from continuing to live.

    Heart-disease, breathing problems, cancer, infection, injury, etc.
will continue to be the causes of death,
just as all human beings of the past have died.
No matter how this patient's dying is managed by the doctor,
the causes of this patient's death will remain the same. 

    Here is another way to decide the official cause of death:
If absolutely no medical interventions had been applied,
what facts in the patient's body would lead to death?
If this human life were coming to an end before the year 1900,
what would be the most obvious reason for this death to occur.

    Frequently there are several causal factors contributing to a death.
But for statistical purposes, the doctor who declares death
is expected to name the primary cause of death
and then perhaps add some other contributing factors.

    And when there is not enough space on the death-certificate,
the complete medical record should give a full picture
of what biological facts were causing this patient to die.



3. ADDING MEDICAL METHODS OF MANAGING DYING

    However, an additional line could be added to each death-certificate.
This would ask about any changes of medical orders
that might have shortened the process of dying.
Disconnecting life-supports is the most obvious example, as noted above.

    Most deaths in modern hospitals include
some meaningful element of choice.
The patient is given medical treatments
intended to cure the disease or heal the injury.
But there comes a point in every life
when further medical treatments no longer benefit the patient.
Then the purpose of medical care shifts from cure to comfort.

    What might appear on this new line on death-certificates?
Here are the four most common changes of medical orders,
life-ending decisions, or medical methods of managing dying:
(1) increasing pain-medication, comfort-care only.
(2) beginning terminal sedation, inducing terminal coma.
(3) ending curative treatments and life-supports.
(4) withdrawing water and other fluids.

    Let's discuss each of these life-ending decisions briefly.
These four methods of managing dying can be used in any combination:

    (1) Increasing pain-medication means adjusting drugs already in use
with the explicit purpose of controlling the symptoms
of the patient on the way towards death.
Such medical orders are given by the terminal-care doctor
with the consent of the patient and/or the proxies.
And everyone acknowledges that the higher doses of drugs
might possibly shorten the process of dying.
Rather than saying this change of medical orders
is a life-ending decision, we might call it a life-shortening decision,
or at least that no one should be surprised
if the result is fewer days of suffering on the way towards death.
Drugs were used appropriately to manage this patient's dying-process.

    The new line on the death-certificate might say something like this:
"The terminal symptoms were treated with appropriate drugs."

    (2) Beginning terminal sedation is a step beyond increasing pain-medication.
The doctor orders sufficient drugs
to keep the patient completely asleep for the rest of his or her life.
This medical order also requires the consent of the patient and/or the proxies.
An induced terminal coma will normally last a few days.
And the amounts of the sedative drugs might be adjusted occasionally.

    The line on the death-certificate
for medical methods of managing dying might say:
"The patient was kept in a medically-induced coma beginning on (date)."

    (3) Ending curative treatments and life-supports
is another medical order given by the terminal-care doctor,
with the consent of the patient and/or the proxies for this patient.
All of the methods of curing the medical problem have not worked.
This patient is actively dying,
no matter what additional treatments might be tried.
And if there are any life-supports in place,
these will be disconnected and/or discontinued at this time.
The doctor can explain how long the process of dying
will take after the curative treatments and life-supports have ended.

    The new line on the death-certificate will say something like this:
"All life-supports were disconnected or discontinued on (date)."

    (4) Withdrawing water usually comes with ending other life-supports.
Perhaps the patient had been supported by a feeding-tube
or an intravenous line that was providing nutrition and hydration.
Without water, the patient is certain to die within a few days.
But (as with all medical methods of managing dying),
the recorded cause of death should be the underlying medical condition.

    The new line for life-ending decisions would say something like this:
"Artificial nutrition and hydration were discontinued on (date)."

    (5) A few jurisdictions have authorized
an additional medical method of managing dying: gentle poison.
After all attempts to cure the patient have proven ineffective,
the patient and/or the proxies might ask for a quick death.
And under defined conditions, observing careful safeguards,
the terminal-care doctor can prescribe specific drugs
whose only purpose is to bring a speedy and painless death.

    Even in this case, the cause of death
should still be listed as the underlying medical condition
that led the deciders to choose this shortest pathway towards death.
All right-to-die laws permitting such end-of-life behavior
explicitly declare that such deaths shall not be recorded as "suicide".
This life-ending choice was made
because of the disease or condition that was killing the patient.
Heart-disease, cancer, infection, multi-organ failure, etc.
should be listed as the causes of this death.

    And the line for medical methods of managing dying might say:
"The patient (and/or the proxies) chose immediate death
in accordance with the right-to-die law of this state."



4. AN ALTERNATIVE EXPRESSION: "MANNER OF DYING"

    A Canadian panel recommends adding "manner of dying"
to the official certificate of death.
Specifically "manner of dying" might be a good way
of including "physician-assisted dying" on the death-certificate.

    The causes of death would remain the incurable medical conditions.
But a more complete picture would be achieved
by the addition of the notation that this patient chose gentle poison
as a method of achieving immediate death. 

    However, the expression "manner of dying" might be misunderstood.
Might the doctor write: "peacefully", "reluctantly",
"cooperatively", "in agony", or "unconscious"?

    The expression "medical method of managing dying"
asks for some activity or choice made at the end of this patient's life:
comfort-care only, terminal coma, withdrawing life-supports,
medical dehydration, death pill, or lethal injection.
These would be separate from the underlying causes of death,
which would continue to be the biological facts
that made it impossible or intolerable for this patient to continue living.

    But "medical methods of managing dying"
would be broader and more acceptable than "manner of dying".
In carefully managing this patient's process of dying,
what specific life-ending decisions were made?



    When used carefully and appropriately,
this new line on the certificate of death for
medical methods of managing dying (MMMD)
should clarify more precisely than ever before
the importance of naming both the CAUSES OF DEATH
and any MEDICAL METHODS OF MANAGING DYING
chosen for this patient.

    Because laypersons seldom see death-certificates,
the medical abbreviation would become acceptable: MMMD.
Each doctor who is called upon to complete a death-certificate
would soon learn that this means:
Medical Methods of Managing Dying.

    Each future certificate of death would be expected to state:
the primary CAUSE OF DEATH (the underlying disease or condition)
and the MEDICAL METHODS OF MANAGING DYING (MMMD).



AUTHOR:

    James Leonard Park is an advocate
of making wise end-of-life choices using careful safeguards.
His longest book details 26 safeguards
useful for making all life-ending decisions:
How to Die: Safeguards for Life-Ending Decisions.
One chapter discusses separating
CAUSES OF DEATH from METHODS OF DYING:
Methods of Managing Dying in a Right-to-Die Hospice.


Created December 10, 2015; Revised 12-16-2015; 12-28-2015;
1-12-2016; 2-9-2016; 5-1-2016; 11-3-2017; 12-30-2018; 1-13-2020; 


See Five Medical Methods of Managing Dying
for further discussion of the need for this expansion of Death-Certificates.
This article also provides links to chapters
for each Medical Method of Managing Dying.

Here is a recommendation for putting these methods of dying
into any new legislation concerning end-of-life medical care:
Putting the Right-to-Die into Health-Care Laws and Regulations:
Authorized Methods of Dying,
Safeguards for Life-Ending Decisions.

Another kind of document that might separate the CAUSES OF DEATH
from the METHODS OF DYING is an End-of-Life Medical Order—ELMO.

Go to the beginning of this website
James Leonard Park—Free Library