When COVID-19 kills: Deciding death causes not ‘black and white’

Target 8

GRAND RAPIDS, Mich. (WOOD) — Andrea Mullennix has no doubt what killed her mom.

The 68-year-old pharmacy technician had fought through lung cancer, COPD, sleep apnea and mental health challenges.

But Debra Mullennix couldn’t beat COVID-19.

“Her life was cut short due to the virus, even though she had other difficulties,” Andrea Mullennix explained in an interview outside the Grand Rapids home she had shared with her mom. “I just know that the virus is what ultimately did it because she had such a drive to live.”

While her mother’s prior health challenges were well documented on her death certificate as “contributing” conditions, the actual “causes” of her death were listed as “acute on respiratory failure, COPD and COVID-19.”

At least that was the opinion of the physician who signed the certificate.

“Really, the death certificate is always going to be an opinion, a medical opinion,” said Dr. David Start, Kent County’s deputy chief medical examiner. “So many things in medicine aren’t necessarily black and white. Our bodies are very complex… You’re going to get differences of opinion.”

Start was one of three West Michigan doctors who explained to Target 8 how they fill out death certificates when a patient had COVID-19. Each has declared the disease a cause in at least one death.

Target 8 reached out to the physicians to gain insight into how death causes are determined, which has been the subject of multiple viewer and reader emails to News 8.

While they did not talk about specific cases, they did address several scenarios. At times, they differed in their responses.

WHAT IF A PERSON DIED OF CARDIAC ARREST BUT ALSO HAD COVID-19?

For instance, Target 8 asked the doctors what they would do if a person died of cardiac arrest at home but also happened to be COVID-19-positive.

All three said they would cite cardiac arrest as the primary, immediate cause of death, but two of the three said they would not necessarily include COVID-19 as an additional cause.

“If the patient had no symptoms whatsoever of an illness and then had a heart attack and died, I doubt very much that they would put COVID as a potential cause because physicians have to use the best available information,” said Dr. Gabriel Pedraza, a pulmonologist at Metro Health-University of Michigan Health in Wyoming.

Dr. David Start, the medical examiner, agreed that it would depend on the evidence at hand.

“That’s a tricky question,” he said. “There have been cases of COVID-19 infection that are associated with thrombosis or blood clots, and certainly a heart attack is usually caused by a blockage of blood vessels, so I would defer to the clinician or attending physician who’s been treating the patient: Does it seem like COVID played a role in their heart attack or is it that their underlying coronary disease was so severe the COVID had a minimal role, if any?”

Spectrum Health’s Dr. Simin Beg had a different take.

“If somebody had a heart attack and was positive for COVID-19, then you would list the heart attack as number one (the immediate cause of death), and you would list COVID-19 because we are seeing that there might be some relationship there.

“We are seeing that COVID-19 does make people more vulnerable to other illnesses, and we don’t know that connection entirely yet, and that’s what we’re trying to study,” explained Beg, division chief of hospice and palliative care at Spectrum Health.

Beg pointed out that death certificates are an important data collection tool, helping researchers identify patterns and develop public health strategies to control the virus’s spread.

WHAT IF A CAR CRASH VICTIM HAD COVID-19?

Beg brought up the hypothetical example of a person dying in a car crash who “incidentally” had COVID-19.

“If I’m filling out the death certificate, I will put motor vehicle accident as the primary (cause), and whatever injuries happened due to the accident as the direct cause of death,” Beg said. “But in the ‘contributing’ factors I would list COVID-19 because we know COVID-19, as far as we know, it does make people more vulnerable to other nonrelated issues.”

Beg reiterated she would list COVID-19 as a “contributor” but not a “cause” of the death.

The other two physicians said it is unlikely they would list COVID-19 anywhere on the death certificate of a car crash victim.

“I, personally, probably would not put (COVID-19) as a contributing factor if it was truly a traumatic injury,” Pedraza said.

Start agreed.

“If the death was clearly due to trauma, severe head injury, chest injury, then we’re going to list the trauma as the cause of death. We would not list COVID on the death certificate,” Start said.

It should be noted that the example is purely hypothetical, since Beg, as a hospice doctor, would not be signing a death certificate in a fatal car crash. Such cases are handled by forensic pathologists in the medical examiner’s office because crash victims require autopsies.

COVID-19-related deaths, on the other hand, are considered natural and do not generally undergo autopsies.

STATE: REPORTING DIFFERENCES ‘NOT SURPRISING’

“The causes of death listed on the death certificate represent the clinical judgment of the physician completing the death certificate and the causal sequence resulting in death,” Michigan Department of Health and Human Services spokesperson Lynn Sutfin wrote in an email exchange with Target 8.

“Physicians can and do often disagree with their clinical opinions, so it is not surprising that different physicians would report this scenario differently,” she continued.

Sutfin said Michigan calculates the number of COVID-19 deaths based on national standards developed by the Council of State and Territorial Epidemiologists.

>>PDF: CSTE standards

The U.S. Centers for Disease Control and Prevention also published vital statistic reporting guidance for COVID-19 data.

>>PDF: CDC guidance

According to Sutfin, if COVID-19 is listed as either a “cause” or “contributing” factor on a death certificate and the state is successful in matching that certificate to a confirmed positive lab test, the death is counted as a COVID-19 fatality.

She pointed out that The COVID Tracking Project, a website that compiles daily statistics from every state and U.S. territory, gives Michigan an A+ for the quality of its data.

DOCTOR: COVID-19 DEATHS LIKELY ‘UNDERREPORTED’

The physicians Target 8 interviewed said medical professionals are committed to providing the most accurate, relevant data based on research, training, expertise and evidence.

Pedraza of Metro Health said COVID-19 death data is not overstated.

“If anything, (COVID-19) deaths are probably underreported,” Pedraza said.

The physicians also debunked rumors that hospitals receive additional funds based on cause of death determinations.

“The death certificate is a legal document and falsifying information on that is a crime,” Beg said. “Doctors will not falsify medical records.”

In addition, the extra funds providers receive from the government for treatment of COVID-19 patients are not tied in any way to cause of death determinations.

“Nobody gets any money for signing a death certificate. The hospitals don’t get more when death certificates are signed. That is not related to any kind of revenue,” Beg said.

Pedraza explained that hospitals receive additional payment based on diagnostic-related groups, a patient classification system that standardizes prospective payments to hospitals.

“COVID-19 does require a lot of resources,” Beg of Spectrum Health explained. “(The federal government) is recognizing that caring for patients with COVID-19 is unique from other diseases we’ve cared for and so they are accommodating that. But the death certificate has nothing to do with that.”

DAUGHTER: MOM HAD TIME UNTIL GETTING VIRUS

No one has to convince Andrea Mullennix of the depth of the COVID-19 crisis. If anyone doubts it, she figures it hasn’t hit them directly.

“Your mom’s not laying there struggling to breathe in ICU.. and to live,” she said. “I think she had plenty of time (left) if she hadn’t have caught the virus — at least five to 10 more years.

“I’ve got to rebuild and start over and try to make it without her,” she continued. “I’m going to try to make her proud. That’s why I’m doing this interview because she would have just loved this. If she could help somebody or if this does any good, then she didn’t die in vain.”

An undated courtesy photo of Debra Mullennix.

Mullennix was only able to talk to her mom one time on the phone after she was admitted to the hospital.

“She could hardly talk,” she recalled. “She was very weak, and she had to go. It was less than a minute, and she said, ‘I love, love, love you.’ That’s what she always said.

“I said, ‘I love you so much, and you’re going to get through this.'”

Debra Mullennix died in the hospital May 2.

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