CASE 33 (52)_ Challenges With Death Certification

CHALLENGES WITH DEATH CERTIFICATION
CLINICAL CASE
Dr. López works at a long-term care facility. Upon arriving for his shift on Sunday at 9:00 a.m., he
is informed that a resident was found deceased at approximately 6:00 a.m. The individual was
discovered unresponsive when staff entered the room to administer morning medication. Given
the resident’s advanced age (90 years) and extensive medical history, Dr. López is not initially
surprised by the death. He requests the official documentation for the medical death certificate
and proceeds to the room to perform a physical examination of the body, to rule out the
possibility of a violent or suspicious death. Upon entering the room, however, he finds the bed
already cleaned and unoccupied. Staff inform him that the body was moved to the morgue out
of concern for the roommate, who had become distressed by the presence of the deceased. No
physician had been notified between the time of death and Dr. López’s arrival.
Before Dr. López is able to examine the body, the resident’s family arrives. He explains that he
has concerns about whether he can proceed with certifying the death or whether the case must
be referred to judicial authorities—an action that would require a forensic autopsy. Although he
does not suspect a violent or suspicious death, the way the body was managed raises doubts
and he cannot fully rule out unnatural causes. The resident’s granddaughter pleads with Dr.
López not to involve the judicial system. She explains that her grandmother had died following a
fall, which led to a mandatory autopsy, and the family wishes to avoid going through a similar
experience again.
Dr. López remains uncertain about how to proceed. Should he sign the death certificate based
on the available information, or refer the case to judicial authorities for further investigation?
ETHICAL ANALYSIS OF THE CASE
Beyond legal considerations—which are a fundamental foundation of clinical practice—it is
essential to examine the ethical conflicts that emerge in this case. The question Dr. López faces
may initially appear to be purely legal in nature; however, it undoubtedly has a profound ethical
dimension.
On one hand, there is the strict obligation to uphold the truth and comply with current legal
standards regarding the certification of death. Dr. López is unsure whether the body was
manipulated after death. It was moved to the morgue before he could examine it. At times, the
physician’s legal responsibility (i.e., strict compliance with the law) leads to the judicialization of
deaths unnecessarily. In such cases, the medical death certificate is not signed, and a judicial
process is initiated. If this judicialization proves to be unwarranted, it results in the
inappropriate use of public resources—thus undermining the ethical value of responsible
resource management.
On the other hand, there is empathy and compassion for the family’s pain. If the death is
judicialized, the family will have to go through the process of an autopsy, legal proceedings, and
forensic examination. This may delay the burial and result in damage to the body—something
the family believes is unnecessary. By signing the death certificate, the physician demonstrates
understanding toward the family and helps preserve the quality of care and emotional support
provided to them. It also allows the family to be included in decisions regarding the handling of
their loved one’s body.
Therefore, this case presents a conflict between strict adherence to truth and current legal
standards, and compassion and empathy toward the family and their psychological
well-being—without overlooking the importance of responsible management of healthcare
resources.
POSSIBLE COURSES OF ACTION
​ Sign the death certificate directly, without examining the corpse.
​ Examine the deceased to confirm the absence of vital signs, since no physician has
diagnosed the death. .
​ Examine the body and rule out violent death.
​ Examine the body, make a death report and notify the appropriate legal agency and court.
​ Review the resident’s medical history over the last few days to rule out that there is no
event that would require a judicial autopsy.
​ Talk to the family to inform them of everything that is being done. In any case, show
concern and understanding regarding their situation.
​ Consult the case with the Judge and the Medical Examiner on duty.
​ Talk to the family and explain the need to judicialize the case.
​ Review the facility’s protocol or develop one- if one doesn’t exist- to prevent this situation
from happening again.
RECOMMENDED COURSE OF ACTION
​ Since no physician has yet diagnosed the death, the first step for Dr. López is to examine the
body to confirm, first, that death has occurred, and second, that there are no signs of a
violent death (such as suicide, accident, or homicide).
​ The physician must review the patient’s medical history to verify whether there are any
conditions that justify a natural death. He should also assess the patient’s condition in the
days and hours prior to death for any indications that could help determine the cause.
​ Dr. López should speak with the family, explaining the findings of the examination and the
steps he will take. In this communication process, it is important to be empathetic and show
understanding of what the family is experiencing.
​ Given that the body has been moved and the scene of death altered, it is advisable for the
physician to consult with the on-call judge or forensic examiner to inform them of the
situation, the medical history, and the examination findings.
​ Afterward, he must follow their instructions: if they determine that judicialization is
necessary, the forensic physician will intervene and Dr. López will complete the death report.
Most likely, judicialization will not be required, and Dr. López will be able to sign the medical
death certificate.
​ Additionally, the facility’s protocols for managing deceased patients when no physician is
present at the time of death should be reviewed and/or developed.
DISCUSSION
The death of a patient is a difficult moment that requires certain ethical and legal aspects to be
guaranteed, as well as providing support to the family to avoid adding further pain. First, it is
essential to have a medical diagnosis of death, with a physician objectively confirming signs of
irreversible death. Once death is confirmed, it is necessary to review the medical history and
examine the body to rule out the possibility of a violent death.If there are signs of violent death,
judicialization of the case is mandatory (the judge and forensic physician are notified and will
carry out the forensic autopsy).
In the presented case, if there are no indicators of violent death, the physician should have no
objection to signing the death certificate, thereby avoiding additional harm to the family,
preserving their trust, and preventing the improper use of resources. In doing so, he ensures
adherence to both factual accuracy and legal requirements.
In any case, in exceptional situations like this one, it may be necessary to confirm with the
competent judicial authority that there is no objection to signing the certificate—that is, that
the exceptional circumstances do not require judicialization. The family should be regularly
updated on all developments, with communication delivered in a sensitive and supportive
manner.
Sgd: Bioethics and Health Law Committee of ASISA-Lavinia
May 30, 2025