May 2022 President’s Message

May 2022 President’s Message

Why does the death certificate say that?

by E. Jeanne Kroeker, MD

In 1977 my father, a chemistry professor at Rutgers University, developed central neurologic symptoms that were baffling and confound­ing. There was no obvious explanation for his symptoms of personality changes, mood lability, micrographia, headaches and short-term memory deficits.

A neighboring town had a new, advanced imaging machine – a “CT machine” – and he was referred there for brain imaging. In the grainy images of the 1970s CT films, abnormalities were identified.

My father was ultimately diagnosed with reticulin cell lympho­ma/sarcoma of the brain, now known as primary central ner­vous system lymphoma (PCNSL). He was referred to Columbia Presbyterian Hospital for oncology treatment and became the 11th patient they had ever documented with this particular cancer.

We think his cancer was a consequence of repeated accidental exposure to radioactive cobalt isotopes that he experimented with in the 1960s and 1970s. Ironically, cobalt radiation was a key part of his treatment protocol.

Chemotherapy and radiation treatments in the 1970s were bru­tal and non-specific. The tissue destruction from his tumor and the treatment damage left him with devastating neurologic deficits. He would never work again and died two years later from long-term complications of his tumor and its treatments.

While the cancer did not kill him, it was the primary contributor to his death. His death certificate lists sepsis as the primary cause of death and “brain cancer” as the contributing cause. If he had not had this cancer, he would not have had sepsis at age 43, so cancer was appropriately included on his death certificate.

This concept of “incident to” cause of death is something that is not always understood by people who do not fill out death cer­tificates. The COVID-19 pandemic actually helped unveil this lack of understanding, as more than a million death certificates have listed COVID.

Virtually every primary care doctor in the United States has had at least one patient die from COVID-related illness in the past two years; more than one million Americans have died from COVID since 2020. More than 250,000 children in America have lost a parent or a caregiver to COVID.

These are real statistics. These are horrifically tragic statistics. They include hundreds of thousands of people who did not die from direct action of the virus, but from the many complications of their COVID infection.

Early in the pandemic, there was much discussion about con­flated death certificates, about fraudulent death certificates and about COVID being “listed on every death certificate.” There are many in this country who still discuss such things.

Americans seem reluctant to admit the toll of this pandemic. Questioning the validity of death certificates can be an easy way to deny the statistics, and this questioning typically comes from ignorance about the process of certification of death.

A healthy young adult does not typically develop a fatal pulmo­nary embolism, but COVID infection is frequently associated with DVTs and PEs. The COVID+ patient who dies as the result of a spontaneous PE will have a death certificate that lists PE as the primary cause of death as a consequence of COVID infection.

In this current era, community-acquired pneumonia does not often lead to death, even in the elderly. But multifocal pulmonary infiltrates leading to respiratory failure is a hallmark of COVID and is especially fatal in the elderly. The cause of death should then be listed as pneumonia, as a consequence of COVID infection.

Profound hypoxia caused by COVID can lead to heart failure or myocardial infarction, and that MI would not have occurred without that COVID infection. Here, the death certificate would list MI as a consequence of, or secondary to, COVID.

In early 2020, when COVID was first identified in the United States, we never expected it to cause one million deaths, espe­cially not in fewer than 28 months.

Disputing COVID’s inclusion on a death certificate does not mask or eliminate the tragedy of this devastating illness and the permanent impact this pandemic has had on our society.