COVID-19 death certificate change stirs controversy

An empty hospital room.
A hospital room with a negative air pressure setup sits ready for a COVID-19 patient at Bethesda Hospital in St. Paul on March 26, 2020. Instructions to count deaths from “presumed” COVID-19 cases, not just confirmed cases, are met with acceptance for some and criticism from others.
Evan Frost | MPR News file

State and United States officials expect coronavirus deaths to rise sharply in coming weeks, but what counts as a COVID-19-related fatality is a new source of controversy.

MPR News reported last week on a change in the way the disease appears on death certificates, regardless of whether someone was confirmed to have it. That shift has received praise from some quarters, but also spawned backlash and suggestions of ulterior motives.

As of Tuesday’s update from the Minnesota Department of Health, the deaths of 34 people are tied to COVID-19. That’s up from 12 the week before.

It’s unlikely there will ever be a precise count of this disease’s toll.

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Last week, the National Vital Statistics System, which is part of the Centers for Disease Control and Prevention, provided new guidance for those who submit death certificates. It said they should list coronavirus if it was assumed to cause or contribute to a death. Clinicians say COVID-19 can hasten death of someone with a chronic respiratory condition because in severe cases it deprives the body of oxygen.

Ideally, people would have been tested before they died or after. But restrictions on tests and other considerations are preventing that in some cases.

Now, if someone died from pneumonia, respiratory distress or chronic obstructive pulmonary disease, and had exhibited coronavirus symptoms, their certificate will list COVID-19 as a presumed contributing factor, what’s known as comorbidity.

Minnesota follows the lead of that federal agency and advised the state’s medical community of the change in practice on Friday.

While some people and public health experts say it will provide a fuller picture of how lethal the disease is, others call it irresponsible and contend it will artificially inflate numbers.

In some corners of the internet, conspiracy theories abound. The change is being cast as a politically motivated effort to scare the public and smear President Trump by making the situation look worse than it is. One ardent backer of the president, with more than 2 million Twitter followers, urged Trump to demand an audit on every death certificate that lists COVID-19.

Others say it gives an incentive to state, local and medical officials to pump up counts to unlock more federal money, given the all-hands-on deck effort to prioritize coronavirus cases.

Republican state Sen. Jim Abeler, a prominent lawmaker on health matters in the Legislature, tweeted out his concern Monday. Abeler isn’t pushing the theories about political or financial motives. But he said there should be precision when assigning a cause of death.

“I don’t think the death certificate is a ‘maybe’ document. There shouldn’t be assumptions on there,” Abeler said in a phone interview Tuesday. “It should be the best available information. It should be with the highest degree of certainty. The minute we put assumptions and maybes on the death certificate, we now have a certificate that is meaningless and it’s an opinion document.”

Abeler and others who share his view also say there needs to be a clear distinction between dying from coronavirus and dying with it.

Doctors, nursing homes, funeral directors and other established certifiers who supply information for death certificates routinely offer assessments of the cause of death. Autopsies aren’t conducted for every person who dies. They’re usually done in cases of homicide or other suspicious deaths.

The head of the federal office that sent out the new guidelines says an increased number of pneumonia deaths is an indicator of COVID-19’s impact.

Restrictions on testing means that many people aren’t being officially diagnosed with the illness even as they’re being told they probably have it.

Kumi Smith, an infectious disease epidemiologist at the University of Minnesota’s School of Public Health, said there is a reason to believe that some deaths will slip below the radar.

“I think we’re concerned that COVID-19 deaths will be undercounted. But the biggest concern for us as epidemiologists is — by how much and how uniform is that undercounting?” Smith said. “Every single place is trying to course correct in different ways.”

Molly Mulcahy Crawford, the state registrar in Minnesota’s Office of Vital Records, said it’s possible some prior deaths will be reviewed if they involved coronavirus-like causes.

“Could these have been COVID-19? We’re going to see a lot of that analyzing the data we have available, maybe going back to the medical chart to see if there is any additional information that wasn’t used in the death certification,” she said.

The national vital statistics center has assigned a separate code to presumed COVID-19 cases, which would allow for some sorting later on.

Smith said getting a better read is important because mortality rates can influence public health strategies for dealing with the present crisis and stopping future problems.

“If we start to have a better sense of how much of this virus is actually in the community, that is much better for informing our prevention efforts, for evaluating our prevention efforts,” Smith said. “That type of precision is really important. However, we’re still at a stage where the lack of precision is such a problem that back-calculating from deaths is really not recommended.”

Officials at the state Health Department said there are multiple reasons why post-mortem tests or exams are not being done for every suspected case.

Doing that would consume a test at a time when the supply is tight. It will also require greater use of personal protective equipment, which is strained as well. They also say it could further expose medical workers to infection.

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