The doctor’s responsibility is to certify that an individual has died of the particular cause/causes based on his/her individual assessment of the available medical history, symptoms, diagnostic tests, clinical treatment and medical records, based upon his/her training and knowledge of medicine.

In cases of deaths suspected of homicides, suicide, accidents and any other medico-legal cases, the post-mortem results are considered and the certificate may be completed by the medical examiner on the basis of evidence noticed by him/her.

The doctor completes the MCCD form in India called FORM No 4 (institutional deaths) and FORM No 4A (non-institutional deaths) to certify the cause of death.

Form No 4 Form No 4A

The following pertinent details are required to be clearly specified in the medical part of the certificate corresponding to the major cause groups of mortality:

Manner of death could be natural ( an illness or an internal malfunction of the body) like death due to complications from influenza (an infection) or a heart attack (an internal body malfunction)
OR
Unnatural deaths where an external event or force is involved such as Accident, Suicide, Homicide. Even the deaths caused by external events have a definite pathophysiological sequence which ultimately leads to death. Cause of death has to be identified from that sequence.

AVOID terms such as Natural / Natural death / Normal death as cause of death.

Explain the nature of injuries and parts of body injured; whether accident, suicide, homicide, war injury; place and circumstances of accident. This will help in completing cause of death sequence.

Be sure to answer YES /NO on the question on pregnancy and delivery. This information is needed for all women of child-bearing age (15 to 49 years), even though the pregnancy may have had nothing to do with the death.

Many times doctors find it difficult to describe the process of death as they are uncertain what illness led to what illness.

• List the health conditions / diseases / sickness presentations of the deceased.
• Think through the causes about which you are confident and what could be the possible/probable reasons/etiologies that could have resulted in these conditions.
• You should select the causes that are suspected to have been involved and use words such as "probable" or "presumed" to indicate that the description provided is not completely certain.
• The initiating condition could be the immediate cause of death. If this was caused by a pre-existing condition, this could be noted down. But if the causes for these are unknown, it should be noted as unknown, undetermined, or unspecified, so it is clear that the doctor did not have enough information to provide a cause of death description.

What the physician will mention as cause of death when he is seeing the patient after death has occurred and no previous medical information is available ?
In such case physician has to certify on the basis of information available in medical records or autopsy (pathological or medicolegal ) report.

Other points to remember

• When malnutrition is involved, the certifier should consider if other medical conditions could have led to malnutrition.
• When a number of conditions or multiple organ/system failure resulted in death, the doctor should choose a single sequence to describe the process leading to death and list the other conditions in Part II of the certification section.

The doctor’s legal duty and responsibility is to complete the ‘Medical Cause of Death Certificate (MCCD-Form No 4 for institutional deaths or 4A for non institutional deaths)’ to state that an individual died from the reported cause/causes of death.

What do you need to do to complete MCCD?

• Certify that death has occurred
• Verify and complete the date and time of death
• Provide a simple description of the sequence or process leading to death
• State the Causes of death-these represent the best possible medical opinion.
• Complete all other details
• Provide your signature, Medical Registration Number and Institution seal

What should you write as Cause of death ?

The doctor should complete the medical part of the certificate regarding all diseases, morbid conditions or injuries which either resulted in or contributed to death of the person.
This is the best medical opinion based upon his/her training, knowledge of medicine, available medical history, symptoms, diagnostic tests, and if any available autopsy results of the deceased.

Why do you need to complete MCCD?

According to the Registration of Birth & Deaths Act (RBD), 1969, death is to be certified by a medical practitioner who has attended the deceased during the latter’s last illness.
Section 10 (3) of the RBD Act specifies that doctors shall issue a certificate in the prescribed form stating to the best of his/her knowledge and belief the cause of death, without charging a fee.
In 2014, the Government of India has issued instructions to all States/UTs to implement the MCCD Scheme in all medical institutions in the country, i.e. Government, private and non-profit medical Institutions.

Are there any ethical issues involved ?

The cause of death details in MCCD form is recorded by the Registrar office and is used for statistical analysis on mortality statistics.
Section 17(1) (b) of the Act, allows maintaining confidentiality of the information on cause of death, and is not indicated on the Death certificate issued by the Registrar Office. This safeguard is to enable doctors to write the certificate carefully to reflect the best medical opinion on cause of death.