A mixed-methods prospective study of death certification in general practice

Background: Accurate completion of death certificates is important for compiling national and regional statistics. Determining actual cause of death can be extremely difficult; internationally, uncertainty has been acknowledged in many cases. We set out to explore the issue of uncertainty further: in what circumstances do GPs feel more or less certain, and how do they feel about this? Objectives: The study aimed (i) to focus on death certification issues faced by GPs and their related attitudes, and (ii) to assess GPs' confidence in stated diagnosis and reasons influencing certification. Methods: This was a prospective, cross-sectional, mixed-methods study. Participants were 15 GP trainers in Ireland. Two focus groups, held 1 year apart, explored issues surrounding, and attitudes towards, death certification. A one-page questionnaire, completed after the death of every patient for 6 months, recorded patient age and gender, place and certified cause of death, certifier, and level of certainty about cause of death (on a 10-point scale). Results: There were 168 deaths across the 15 practices during the study period. Overall confidence in certified cause of death was relatively high but varied significantly according to certifier, and place and cause of death. The main issues surrounded the varying level of certainty with diagnosis, concerns regarding the family of the deceased, and the perceived gap in education about death certification, including legal matters. Conclusions: GPs appear to feel in an ambivalent or invidious position where death certification is required, a situation that could be addressed in postgraduate training settings.