Abstract
Death certificates are used for various purposes, including research, public health planning and settlement of estates. The evidence of inaccuracies in death certification is well documented in the medical literature. The cause of inaccurate death certificates is attributed principally to inadequate training, and the proposed solutions to date focus on this. The incongruity of continuing to use data which are known to be inaccurate, and the persistence of calls for "more training" as the solution, were stimulants for this research.
This study looked for factors that influence general practitioners that certify the cause of death. Both quantitative and qualitative methods of data gathering were used. The quantitative arm of the study was a questionnaire sent to 220 randomly selected New Zealand general practitioners. The qualitative arm consisted of four focus groups that were held by teleconference. Each focus group had four participating general practitioners, a facilitator and the researcher as a silent participant recording the discussion. The participants were chosen to reflect the diverse settings in general practice. The focus group discussions were semistructured with minimal facilitation.
The questionnaire was analysed by frequency analysis, and 95% confidence intervals (CI) were used. Logistic regression was used to examine the relationship between independent variables and p values applied to the findings.
There was an 87% response rate to the questionnaire. Of the respondents 53% (CI 46% to 61%) received no training or could not recall receiving training. Frequency analysis of the questionnaire showed that 72% of general practitioners (CI 63% to 77%) had experienced doubt at some time when completing death certificates. Factors that were shown to influence some general practitioners when certifying the cause of death were the wishes of the family, the access to postmortem examinations, stigma of certain diagnoses, the use to which death certificates were put, and confidentiality issues. However, the wishes of the family and relatives were the most influential always being considered by 7% (CI 4% to 13.%) and sometimes being considered by 53% (CI 46% to 61 % ) of general practitioners.
Substantive thematic analysis of the transcriptions of the focus groups identified and elaborated on each of the factors described in the questionnaire. The issues of certainty and uncertainty in clinical diagnosis, and of the nature of general practice were dominant. The expectation to provide a precise clinical diagnosis and the reality of achieving this in given clinical circumstances was a dilemma familiar to the general practitioners. The nature of general practice (focused on the person who is the patient and the people important to the patient) creates a bias for the certifying general practitioner.
Although inadequate training is a factor contributing.to inaccuracy of death. certification, there are other factors involved. The role of clinical certainty and the bias of the certifying medical practitioner need to be taken into consideration when strategies to improve the situation are planned.
There are contemporary thinkers who already acknowledge the role of certainty and uncertainty in clinical medicine, and have proposed strategies how to manage this when making health policy. The strategies they propose are integrated with the findings of this study.