Cause of Death: A Primer

Guest Essay by Kip Hansen – 27 November 2020

There has been massive media attention on Covid-19 deaths – and there have been a lot of them.    The CDC as of noon on 26 November 2020 was reporting that there have been 259,005 total Covid-19 deaths in the United States. 

Yet anyone who reads widely is aware that there have been reports of a motorcycle accident victim being reported as a Covid death.  There are many who correctly report that all people dying from or with Covid and even suspected of dying from-or-with Covid-19 are all being counted as certified reportable must-make-the-headlines Covid-19 Deaths.

[Note:  This is a long and rather detailed explanation of what leads to the situation in which we find ourselves regarding Covid-19 Deaths reporting.  Those who want a better understanding of the issue should continue reading.  Readers with no or little interest can just accept this brief synopsis:  “It’s  Complicated”  and move on to other posts. ]

Various experts, journalists, bloggers, and pundits tells us that “Covid Deaths” are being over-counted, mis-counted and even under-counted.  Other pundits and media-reported experts desperately try to reassure us that Covid Death counts are correct and real – and that we should all stay concerned and follow all government mandates – which vary from “reasonable” to “obviously based on magical thinking” (closing bars and restaurants at 10 PM because that’s when the Corona Virus Zombies attack)  —  all this despite various governments having different and contradictory mandates (or even an absence  of mandates) and the various States in the United States following differing rules and policies on Covid Deaths reporting.  Those reporting “facts” like “US Covid-19 Deaths overestimated by 17 times” (based on this CDC comorbitity data) are sadly mistaken and misinform the general public, just adding to the general confusion on the subject.

Doctors, Coroners and Medical Examiners will calmly explain that “Cause of Death” is complicated and not simple.  And they are right.  Most of us think that when a person dies, it is obvious what killed him/her. But that is just not the case.  In fact, everyone dies of a combination of ”heart stoppage” [cardiac arrest] and “cessation of breathing” which eventually leads to “brain death”.   But these are not usually listed as the Cause of Death on a death certificate. 

Covid Deaths are being counted and reported based on advice from the CDC, who has based its advice on advice from the Council of State and Territorial Epidemiologists  (.pdf).  More on what that means later.

The Primer:  What is meant by Cause of Death?

When a person dies in a hospital or other setting, there is some doctor, coroner or medical examiner that fills out a death certificate – officially certifying that John/Jane Doe has died and reports the date, time, place, Social Security number and other personal details along with the circumstances and sequence of events that led to that death.

Here’s a CDC-annotated image of the Cause of Death portion of a typical death certificate:

We are interested here only in Parts I and II.

“Part I

This section on the death certificate is for reporting the sequence of conditions that led directly to death. The immediate cause of death, which is the disease or condition that directly preceded death and is not necessarily the underlying cause of death (UCOD), should be reported on line a. The conditions that led to the immediate cause of death should be reported in a logical sequence in terms of time and etiology below it.

The UCOD, which is “(a) the disease or injury which initiated the train of morbid events leading directly to death or (b) the circumstances of the accident or violence which produced the fatal injury” (7), should be reported on the lowest line used in Part I.”

[ source:  CDC here – .pdf ]

Let’s look at a CDC example:

This patient had Coronary Artery Disease for seven years — which led to Coronary artery thrombosis from which the patient suffered for 5 years — which led to Acute myocardial infarction (heart attack) after which he survived for 6 days until — his heart ruptured resulting in death within minutes. Conditions contributing to his/her death were diabetes, COPD, and smoking.  Each of these “significant conditions contributing to death, but not resulting in the underlying cause” are themselves known to cause a wide range of other serious conditions.  For instance, smoking is believed to cause COPD and heart disease.  Diabetes can cause cardiovascular diseases “including coronary artery disease with chest pain (angina), heart attack, stroke and narrowing of arteries (atherosclerosis).”    Notice that there is a dedicated section “35” asking “Did tobacco use contribute to death?”  For this patient, the doctor chose “Yes” – thus the CDC will count this death as one of the 480,000 annual tobacco deaths. 

Let’s look at another example (from the same document):

This person suffered from noninsulin dependent Diabetes mellitus, often called Type 2 Diabetes, for 15 years.  As sometimes happens, this diabetes sufferer eventually went into a Hyperosmolar nonketotic coma in which she/he remained for  8 weeks before finally succumbing to Acute renal failure (kidney failure).  The family of the patient would have told friends and neighbors that their loved one died of kidney failure.  They may have mentioned this was probably the end-of-line result of his/her long-term diabetes.  Type 2 Diabetes is known to cause the following conditions:  Heart and blood vessel diseases, Nerve damage (neuropathy), Kidney damage (as in this patient), Eye damage, Slow healing, Hearing impairment,  and even Alzheimer’s disease.

It is clear that this second patient died of acute kidney failure –  “Acute kidney failure is most common in people who are already hospitalized, particularly in critically ill people who need intensive care” — and is not necessarily a direct result of diabetes – but assumed in this case as kidney damage can be caused by diabetes.  The death certificate Part I sequence is reasonable and represents the doctor’s professional opinion. 

“In certifying the cause of death, any disease, abnormality, injury, or poisoning, if believed to have adversely affected the decedent, should be reported. If the use of alcohol and/or other substance, a smoking history, or a recent pregnancy, injury, or surgery was believed to have contributed to death, then this condition should be reported. The conditions present at the time of death may be completely unrelated, arising independently of each other; or they may be causally related to each other, that is, one condition may lead to another which in turn leads to a third condition, and so forth. Death may also result from the combined effect of two or more conditions.”

Source CDC Medical Examiners’ and Coroners’ Handbook on Death Registration (.pdf)

So,  you call the Cause of Death of these two patients.    What was the Cause of Death of each?  Did  diabetes kill them both?  The first patient via atherosclerosis which kicked off the sequence in Part I?  The second from the diabetes induced coma or was the coma from simply caused by being in intensive care?  Or was it the first patient’s life-long cigarette smoking causing the coronary artery disease?  Or would you, as this doctor did, start the death sequence with his/her seven years of Atherosclerotic coronary artery disease?  In each case, there are several sequences that would be reasonable and could have been correctly entered by the attending physician, a coroner, or later by a medical examiner. 

The above are pretty common examples – long-term conditions which lead to the next condition that finally leads to death.  We don’t see the personal information part of the Death Certificate so we don’t know the age of these patients.  The age of the patient is often key to Cause of Death – but is not to be used as a cause itself. 

“Common problems in death certification

The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible. Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to death, and place any other pertinent conditions in Part II.”  [ source:  CDC   my bolds – kh ]

And then this:

“For statistical and research purposes, it is important that the causes of death and, in particular, the underlying cause of death, be reported as specifically and as precisely as possible. Careful reporting results in statistics for both underlying and multiple causes of death (i.e., all conditions mentioned on a death certificate) reflecting the best medical opinion.

Every cause-of-death statement is coded and tabulated in the statistical offices according to the latest revision of the International Classification of Diseases. “

Source CDC Medical Examiners’ and Coroners’ Handbook on Death Registration (.pdf) – my bold — kh

There are over 69,000 ICD-10 diagnostic codes.   Someone goes through every death certificate filed and translates the diseases and conditions the doctors, coroners and medical examiners enter in Parts I and II into ICD-10 codes (soon to be ICD-11 codes). There are so many codes that there are many online look-up tools and apps to help medical staff code up office visits and others to code up Cause of Death certificates.  The first Death Certificate above might be coded: “ E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma” – which would cover Part I lines “c” and “b”.  This diagnosis is billable. This app helpfully informs the staff if the ICD-10 code they select is “billable” – if not billable, we can safely suspect that office assistants coding office visits can search for a true but alternate diagnostic code that is billable.   “All conditions mentioned on a death certificate” are translated to ICD-10 codes and eventually tabulated “for statistical and research purposes”.  In our two sample Death Certificates, there are ten different diseases and conditions mentioned.  Thus each of the ten condition codes eventually, at the CDC and WHO level, gets a little “tick-mark” – a plus one – added to the number of deaths involving that ICD-10 code. 

Thus the huge number of deaths reported for which smoking is claimed to be the cause, as we see in this next quote from the CDC:

“Smoking is the leading cause of preventable death.Worldwide, tobacco use causes more than 7 million deaths per year. If the pattern of smoking all over the globe doesn’t change, more than 8 million people a year will die from diseases related to tobacco use by 2030.

Cigarette smoking is responsible for more than 480,000 deaths per year in the United States, including more than 41,000 deaths resulting from secondhand smoke exposure. This is about one in five deaths annually, or 1,300 deaths every day.”

[ source:  CDC here ]

Most people simply accept those statements as fact, though they know of no one who put a cigarette in their mouth, lit up, and died as a direct result.  Through many years of public health anti-smoking/anti-tobacco education we have been taught that smoking or otherwise using tobacco can lead to a long list of health problems, many of which cause or contribute to the eventual death of the smoker.  In this case, a life-time of tobacco use is referred to, by public health officials, as a “cause” of death – though it probably would not be listed as a cause on a death certificate.  Despite not being listed as a cause on the Death Certificate, the CDC and WHO unequivocally tells us that smoking is “the leading cause of preventable death”. 

As in many complicated subjects, there are varying definitions in use for the same terms – in this case “cause of death”.  There is the general everyday use –  like “something that directly causes the death of a person, if it hadn’t happened, they wouldn’t have died”.  So, a person gets lung cancer, probably or presumably because they had been a life-long smoker, and dies from the lung cancer.  We know they died of lung cancer but accept that smoking led to that death.  It is this definition that the WHO uses above.  But it is not the official definition that is to be used on a Death Certificate as Cause of Death, which is in the quote far above, labelled Part I.

Those readers who watch any of the popular crime and police television series know that Cause of Death in trauma deaths is even more complicated — “homicide, accident or suicide?” — though those TV Medical Examiners are always portrayed as having almost paranormal insight – “blunt trauma to the head…but that’s not what killed him.”

One last quote from the handbook for medical examiners:

“Precision of knowledge required to complete death certificate items

The cause-of-death section in the medical examiner’s or coroner’s certification is always a medical opinion. This opinion is, of course, a synthesis of all information derived from both the investigation into the circumstances surrounding the death …. It represents the best effort of the medical examiner or coroner to reduce to a few words his or her entire synthesis of the cause of death.”

[ emphasis in the original – kh ]

Bottom Line:  Cause of Death determination and reporting is complicated and highly dependent on the training and opinion of the person making the report.

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Reporting of Covid-19 Deaths

Here’s the pivot point on Covid-19 Deaths:

This is from the CDC’s weekly Covid report.  See the Column 2 heading?  It says “All Deaths Involving Covid-19 (U07.1)¹”.  The keyword is INVOLVING.  To be perfectly clear, what is being reported by the CDC, as collected by the National Center for Health Statistics, are All (every one) Deaths (people dying) that Involved Covid-19.  See the little footnote indicator “1”? 

Footnote 1 says:  “COVID-19 deaths are identified using a new ICD–10 code. When COVID-19 is reported as a cause of death – or when it is listed as a “probable” or “presumed” cause — the death is coded as U07.1. This can include cases with or without laboratory confirmation.”

Not just verified cases in which Covid-19 was the immediate cause of death.   At least, to be even clearer, not necessarily what you, the average reader, would consider THE cause of death.

So, what exactly are they counting when the CDC and WHO report Covid-10 Covid-19 Deaths?  The World Health Organization’s official guidelines are:

2. DEFINITION FOR DEATHS DUE TO COVID-19

A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma). ….

A- RECORDING COVID-19 ON THE MEDICAL CERTIFICATE OF CAUSE OF DEATH

COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents where the disease caused, or is assumed to have caused, or contributed to death.  

[ my emphasis – kh  source:  WHO here .pdf ]

Note that the Death Certificate — Cause of Death Part II is “Other significant conditions contributing to…”.  So, there is where Covid-19 (ICD code U07.1) would be written for any death in which Covid wasn’t “caused, or is assumed to have caused” but only contributed to the death.  If the decedent was a “Covid case” then he/she becomes a “Covid Death” if they die.  Read on . . .

For the general public, who want to know “How many people are being killed by the SARS-CoV-2 Pandemic?”, this definition does not supply the answer to their question.  The vagueness and breadth of these definitions is exacerbated, in this “possibly-too-broad” sense, by the definitions being used to define “What is a Covid-19 case?”.  We see that the WHO definition of a Covid death includes “a probable or confirmedCOVID-19 case”.

So, how do WHO and the CDC define or advise doctors how to define/determine a Covid-19 case? 

Clinical Criteria

At least two of the following symptoms: fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, new olfactory and taste disorder(s)

OR

At least one of the following symptoms: cough, shortness of breath, or difficulty breathing

OR

Severe respiratory illness with at least one of the following:

      Clinical or radiographic evidence of pneumonia, OR

      Acute respiratory distress syndrome (ARDS).

AND

No alternative more likely diagnosis

[ source:  CDC here ]

So, by this definition, I could at this very moment be declared to be a Covid-19 case.  I have muscle pain (myalgia) and a headache  — two symptoms – — and yesterday, I had a cough — and, if I have reported to the ER and doctors are both rushed and spooked by the pandemic, there might be “no alternative more likely diagnosis”, in their minds at least.  (Of course, I have these symptoms for reasons well known to me and my personal physician but this might not save me in the ER.)  Especially if they also ask me a bunch of epidemiological questions:

“Epidemiologic Linkage

One or more of the following exposures in the 14 days before onset of symptoms:

    Close contact** with a confirmed or probable case of COVID-19 disease;

OR

    Close contact** with a person with:

        clinically compatible illness

        AND

        linkage to a confirmed case of COVID-19 disease.

    Travel to or residence in an area with sustained, ongoing community transmission of SARS-CoV-2.

    Member of a risk cohort as defined by public health authorities during an outbreak.

**Close contact is defined as being within 6 feet for at least a period of 10 minutes to 30 minutes or more depending upon the exposure. In healthcare settings, this may be defined as exposures of greater than a few minutes or more. Data are insufficient to precisely define the duration of exposure that constitutes prolonged exposure and thus a close contact.”

[ source: see previous quote ]

So, if I were in the Emergency Room, the ER doctor might ask me these questions:  Do you know anyone who isn’t feeling well?   Have you been in close contact with them for more than 10 minutes? Have you attended any meeting with more than 10 people in the last 14 days?  Have you been to church or a party?  Have you visited a restaurant or a bar?  Any YES epidemiologically qualifies me as a Covid case. More questions: Do you wear a face mask whenever you are out of your own home? in your car? in WalMart? at the park? while mountain biking? Any NO qualifies me as a Covid case epidemiologically.

You can see how easy it is to be classified as a Covid-19 case.  And they haven’t even tested me yet.  (Read the link to see why even testing wouldn’t save me.)  They would report me as a Covid case even if I tested negative – I might not be positive “yet”.

And while I describe my pending Covid-19 Case classification jokingly, it is a very real scenario.  And, heaven forbid, were I to die of almost anything (except obvious trauma) in the next 14 days, I would become another Covid-19 Death statistic.

As most of us know by now, advanced age is a key factor in the vast majority of Covid-19 deaths:

Eighty percent (80%) of Covid-19 deaths are of those 65 years of age of or older – and a full one-third of the deaths occur in those over 85 years.   If you are an adult today, then you were born between 1925 and 2000.  At your birth, you could expect to live (life expectancy at birth)  between 58 to 72 years, depending on your birth year.  Those who are dying at 85 or older had a life expectancy at birth of less than 61 years.   [My life expectancy at birth was about 66 years – so I have beaten the odds and hope to continue to do so for many years more.] 

If this does not seem significant to you, I’ll repeat the  CDC quote on reporting cause of death for the elderly – those 65 year of age or older. 

 “Common problems in death certification:  The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible. Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to death, and place any other pertinent conditions in Part II.”  [ source:  CDC   my bolds – kh ]

For the elderly, the aged, the older citizen, which comprise the majority (80%) of Covid-19 deaths, any illness or condition that leads to breathing problems is prone to being classified as a Covid case, and thus a Covid-19 death in “a clinically compatible illness, in a probable or confirmed COVID-19 case”. 

Bottom Lines:

• It is complicated.
• Make no mistake, there are lots of people dying deaths that involve confirmed, assumed, or suspected Covid-19.
• Somewhere between “Most” and “Almost All” of those deaths involved other conditions that were already killing the patients – sometimes slowly, sometimes rapidly.
• The official health organizations have their own reasons for what they are counting and they are counting exactly what they say they are counting – but it is not what you or I would expect them to count.  They are counting, as the CDC does, “All Deaths Involving Covid-19”.
• The Covid-19 Death statistics represent the counts of the WHO, the CDC and other National and State public health agencies. The general public often mistakenly thinks those counts mean deaths in which Covid-19 was the immediate cause of death – deaths in which the person was killed by Covid-19.   That is not the case – it is far more complicated than that.
• The common citizen would have grave doubts about including each and every one of those dead people in the count of “Deaths Caused by Covid-19” if they were tasked with the job of reviewing all of the details of each death.  Our citizen might make up our own sensible classifications: such as:  ”Old Age complicated by Pneumonia initiated by a viral respiratory infection: maybe Covid-19 or influenza or the common cold”.
• Doctors (and here), Coroners and Medical Examiners are not immune to taking easy shortcuts.  The official definitions for Covid-19 cases  (in the essay) make it an easy choice for hurried doctors, and official guidance requires at least Covid-19’s mention on Death Certificates, under a vast array of  normal circumstances during this pandemic.    This is exacerbated by  RT-PCR tests returning “positive” test results for very small amounts of viral RNA fragments in asymptomatic people. 

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Addendum:

There has erupted a flap concerning Genevieve Briand’s research at John Hopkins on U.S. Covid-19 Deaths: I supply these links on the controversy:

Covid-19 Deaths: A Look at U.S. Data

pdf file: https://drive.google.com/file/d/1iO0K75EZAF8dkNDkDmM3L4zNNY0X-Xw5/view

William Briggs: https://wmbriggs.com/post/33680/

Twitter Thread on the Paper: https://mobile.twitter.com/jhunewsletter/status/1332100136152035330

YouTube: https://www.youtube.com/watch?v=3TKJN61aflI

WayBack: https://web.archive.org/web/20201126163323/https://www.jhunewsletter.com/article/2020/11/a-closer-look-at-u-s-deaths-due-to-covid-19

John Hopkins News-Letter retraction notice: https://www.jhunewsletter.com/article/2020/11/a-closer-look-at-u-s-deaths-due-to-covid-19

Author’s Comment:

I have mentioned previously that I come from a medical family and studied the prerequisites for medical school in university, before changing majors for personal reasons.  Our home was filled with the joys of new life and the sorrow of babies’ and children’s deaths.  My generation fought and died by the thousands in the misguided military intervention in Viet Nam – some of these were my cousins and high school and college friends. 

We are all sad when lives are cut short.  

Covid-19, the illness caused by the SARS-CoV-2 virus, is shortening the lives of thousands in the United States and around the world.  One blessing is that it is mostly shortening the lives of those who have already had a life – as opposed to stealing the entire lives of our children and young people. 

Public health organizations have valid reasons for counting “All Deaths Involving Covid-19”  using their own internal definitions, which are suitable for epidemiological studies and research when combined with all the other information being collected to produce that statistic.  That statistic, created with their surveillance and epidemiological definitions, is not suitable for release to the general public without a long and complicated explanation – releasing just the number, and labeling it as Covid-19 Deaths is a form of misinformation.

The media, politicians, health agencies and governments have utterly failed to effectively communicate the reality of Covid deaths, failed to illuminate the caveats and complexities of Cause of Death reporting and instead of have repeatedly just reported this “Big Number” in a usage that is seems to be intentionally misleading.   

Opinions vary on this subject.

Address your comments to “Kip…” if speaking to me.

Thanks for reading.

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