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Certification of Death – Physician Obligations

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Professional Standard on Physician Obligations Regarding Certification of Death

Background: The Importance of the Medical Certificate of Death

A completed Medical Certificate of Death is a permanent legal record of the death of an individual. It records the personal information about the deceased and the details of the circumstances of death that are legally required to issue a burial permit and to settle the estate, insurance, and pensions.  A completed Medical Certificate of Death is required before visitation and funeral arrangements can be finalized and before funeral directors can prepare the remains of the deceased.

Death registration forms, specifically the Medical Certificate of Death, are also the source of mortality statistics. These statistics form the basis of one of the oldest and most extensive public health surveillance systems. They provide information on characteristics of the people who die and important information on the cause of death. These statistics are indispensable in public health surveillance, health education and promotion, in medical research and health planning.  Research based on mortality statistics is much more meaningful if all details in the deceased person’s medical records regarding the precise diagnoses are incorporated in the Medical Certificate of Death.

Physicians, with their legislated responsibility for completing the Medical Certificate of Death, play a key role in the Canadian death registration system. The quality and value of statistical data derived from these certificates depends on physicians’ care and judgment in providing complete and accurate information.

This professional standard deals specifically with the completion of the Medical Certificate of Death. The declaration or pronouncement of death are functions outside the scope of this professional standard.

Physician Issues Regarding the Medical Certification of Death

There is a lack of clarity among physicians about who can sign a Medical Certificate of Death under the Nova Scotia Vital Statistics Act, which can delay funeral arrangements. The Act provides a fair amount of latitude and discretion to physicians in this regard.

In December 2011, the Timely Medical Certificates Act was passed which allows a nurse practitioner or other qualified person as authorized by regulation and in the circumstances defined by regulation to sign a medical certificate of death. A nurse practitioner who has completed the Medical Certificate of Death education session may sign the medical certificate of death in the following circumstances: (a) the death of a person was expected as the result of a diagnosed chronic or acute illness or conditions; and (b) there is no reason to believe that the death was a result of any of the circumstances referred to in sections 9-12 of the Nova Scotia Fatality Investigations Act.

Involving a medical examiner in an expected death is generally not necessary or practical. A small but significant number of deaths in Nova Scotia are needlessly investigated by the Nova Scotia Medical Examiner Service solely because a physician was unavailable or unwilling to complete a medical certificate of death. This creates needless public expense and distress for families.

Funeral directors frequently experience difficulty in locating physicians after hours, even when they have committed to signing a death certificate. This likewise creates needless expense and distress.

For various reasons, physicians may be reluctant to complete a medical certificate of death, even when the cause of death is obvious and not suspicious. In most cases, this reluctance can be addressed by reviewing Medical Certification of Death and Stillbirth: A Handbook for Physicians and Medical Examiners (see below), or by contacting the Nova Scotia Medical Examiner Service.  For more information, consult sections 5.12 (3) and 17 (3) and (4) of the Nova Scotia Vital Statistics Act (Appendix I below).

Standard: Physician Obligations and the Medical Certification of Death

To avoid needless delays and stress for friends and families of the deceased, physicians have a professional obligation to act in good faith and a legislated responsibility to be available (or to make arrangements with an alternate physician or nurse practitioner for an expected death) to complete a Medical Certificate of Death. A Medical Certificate of Death should be completed no more than 24 hours after the death has occurred and ideally sooner (particularly in cases where religious custom dictates an immediate burial). Although physicians completing Medical Certificates of Death may use their professional judgment and choose not to view the body, they should carefully review the medical records or make the necessary inquiries to satisfy themselves that the information provided about the circumstances of the death are correct. If possible, they may also wish to attend upon the body to make the determination of death, particularly if they have any questions about its circumstances. For more information, consult section 20 of the Nova Scotia Vital Statistics Act (Appendix II below).

  1. Disagreements about who is the “last attending physician or nurse practitioner” in a particular situation can delay the timely completion of a Medical Certificate of Death. Given the ambiguity sometimes associated with this term, the following criteria should be used to determine who should complete the Medical Certificate of Death:
    1. In general, the physician or nurse practitioner who has the most complete and recent knowledge of the decedent should complete the Medical Certificate of Death. This is often a family physician or nurse practitioner, but may also be a specialist who has a good knowledge of the decedent’s medical history.
    2. The above criteria comply with the terms of the Nova Scotia Vital Statistics Act. Physicians and nurse practitioners should not permit semantic disagreements about these criteria to delay the timely completion of a Medical Certificate of Death.
  2. In accordance with the Nova Scotia Fatality Investigations Act, physicians and nurse practitioners should notify the medical examiner in certain circumstances, including:
    1. when the cause of death is unknown or cannot be determined
    2. when the death is known or suspected to be the result of violence, accident, poisoning or suicide
    3. when the death is unexpected
    4. when the decedent was not previously under the care of a physician
    5. when improper or negligent treatment of the decedent are suspected
    6. when the death has occurred soon after a fracture or other injury, no matter how trivial
    7. when there is reason to believe that the death occurred as a result of suspected misadventure, negligence or accident on the part of a physician or other healthcare provider
    8. when a still birth or a neonatal death has occurred where maternal injury has occurred or is suspected either before admission or during delivery
    9. when the death occurs within ten days of an operative procedure or under initial induction, anesthesia, or the recovery from anesthesia

When an autopsy has been performed and the medical examiner has not been involved, the physician or nurse practitioner must submit a supplemental death certificate to the Nova Scotia Vital Statistics office in cases where autopsy findings or further investigation reveal the cause of death to be different from the one originally reported.

For more information, consult sections 9 and 10 of the Nova Scotia Fatality Investigations Act (See Appendix III below).

Appendix I

Sections 12 (3) and sections 17 (3) and 17 (4) of the Nova Scotia Vital Statistics Act

Registration of stillbirth

12 (3) The medical practitioner in attendance at a stillbirth, or, where there is no medical practitioner in attendance, a medical practitioner or the Chief Medical Examiner shall complete the medical certificate included in the prescribed form showing the cause of the stillbirth and shall deliver it to the funeral director.

Registration of death required

17 (3) The funeral director shall forthwith after the death obtain from (a) the medical practitioner who was last in attendance during the last illness of the deceased; (b) a nurse practitioner in the circumstances prescribed by the regulations; (c) a qualified person authorized by the regulations and in the circumstances prescribed by the regulations;  or (d) where the Chief Medical Examiner has conducted an inquest on the body or an inquiry into the circumstances of the death, the Chief Medical Examiner,  a medical certificate in the prescribed form stating the cause of death according to the International List of Causes of Death, as last revised by the International Commission assembled for that purpose.

(4) Upon the request of the funeral director, the person who has been asked to provide the medical certificate pursuant to subsection (3) shall complete the medical certificate in the prescribed form and cause it to be delivered to the funeral director.

Appendix II

Section 20 of the Nova Scotia Vital Statistics Act

Requirement for burial permit

20 (1) No person shall bury or otherwise dispose of the body of a person who dies in the Province unless a burial permit respecting the body has been obtained.

(2) Unless a statement in the prescribed form respecting the death of the person has been completed,

  1. no person shall remove the body of the person from the area in which the death occurred or the body was found, except for the purpose of preparing the body for burial;
  2. no person shall remove or permit the removal from a public or municipal hospital or institution of the body of a person who has died therein.

(3) No person shall conduct a funeral or religious service in connection with the burial or other disposition of a body unless he has satisfied himself that a burial permit has been issued.

(4) A common carrier shall not remove the body of any person to the place of burial or other disposition unless the burial permit is affixed to the outside of the casket.

(5) The funeral director at the place of burial or other disposition shall remove the burial permit affixed to the outside of the casket, exhibit the burial permit to the person conducting the funeral or religious service and deliver it to the cemetery owner.

(6) Where a death occurs outside the Province and the burial or other disposition of the body is to take place in the Province, a burial permit or such other document as is prescribed under the law of the province or country in which the death occurs, signed by the division registrar or other proper officer, shall be sufficient authority for the burial or other disposition of the body. R.S., c. 494, s. 20; 1998, c. 8, s. 66.

Appendix III

Sections 9 and 10 of the Nova Scotia Fatality Investigation Act

Duty to notify of death

9 A person having knowledge of or reason to believe that a person has died under one of the following circumstances shall immediately notify a medical examiner or an investigator:

  1. as a result of violence, accident or suicide;
  2. unexpectedly when the person was in good health;
  3. where the person was not under the care of a physician;
  4. where the cause of death is undetermined; or
  5. as the result of improper or suspected negligent treatment by a person. 2001, c. 31, s. 9.

Death in health-care facility

10 (1) Where a person dies while in a health-care facility and there is reason to believe that

  1. the death occurred as the result of violence, suspected suicide or accident;
  2. the death occurred as a result of suspected misadventure, negligence or accident on the part of the attending physician or staff;
  3. the cause of death is undetermined;
  4. a stillbirth or a neonatal death has occurred where maternal injury has occurred or is suspected either before admission or during delivery; or
  5. the death occurred within ten days of an operative procedure or under initial induction, anaesthesia or the recovery from anaesthesia from that operative procedure, the person responsible for that facility shall immediately notify a medical examiner or an investigator.

(2) Where a person is declared dead on arrival or dies in the emergency department of a health-care facility as a result of a circumstance referred to in subsection (1), the person responsible for that facility shall immediately notify a medical examiner or an investigator. 2001, c. 31, s. 10.

 

Further Reading

Service Nova Scotia and Municipal Relation, Registry and Information Management Services, Vital Statistics:  Medical Certification of Death and Stillbirth: A Handbook for Physicians and Medical Examiners

Nova Scotia Vital Statistics Act

Nova Scotia Fatality Investigations Act

Nova Scotia Timely Medical Certificates Act

 

Acknowledgements

The College of Physicians and Surgeons of Nova Scotia thanks the Nova Scotia Medical Examiner Service and Service Nova Scotia and Municipal Relations, Vital Statistics for their assistance in preparing this document.

 

Document History

Approved by the Council of the College of Physicians and Surgeons of Nova Scotia:  May 24, 2013

Approved amendments reflect changes to provincial legislation that permit nurse practitioners to sign the Medical Certificate of Death under certain circumstances

Approximate date of next review:  May 2018