Death certificates raise questions about the role of COVID-19 in deaths

BY JENNIFER CABRERA

Alachua Chronicle has received information from the Florida District 8 Medical Examiner on an additional 22 COVID-19 deaths in Alachua County, Florida. We previously reviewed 17 deaths in this July 27 article. District 8 covers Alachua, Baker, Bradford, Dixie, Gilchrist, Levy, and Union Counties, but all 39 deaths were associated with Alachua County.

The report raises questions about the discontinuity between the different state data systems. The Medical Examiner reports show 39 deaths in Alachua County, but the Florida Department of Health case line data (8/18 file) shows 29 deaths in Alachua County (59 deaths in all District 8 counties). Perhaps some of them just haven’t worked their way through the system, but 13 of the 29 Alachua County deaths in the case line data don’t match anything on the Medical Examiner report, and a total of 12 deaths in the Medical Examiner report do not match any deaths in any of the District 8 counties. For example, the Medical Examiner report had a 57-year-old female who died on August 2, but there are no 57-year-old female deaths in the case line data for any of the District 8 counties.

Our questions to the Medical Examiner about these discrepancies were answered with an email saying that the Medical Examiner will no longer be certifying COVID-19 deaths. We asked the Florida Department of Health for more information about this, and they responded, “Florida Medical Examiners, in conjunction with physicians, are streamlining the procedure for the certification of deaths related to COVID-19. Previously, county medical examiners were tasked with the attribution and certification of all COVID-19 deaths occurring in the state. However, due to the unprecedented nature of the state’s response to COVID-19, physicians who have been treating a COVID-19 patient will certify the death without medical examiner attribution. Certifying physicians will then coordinate with funeral directors to report the death directly to the Department of Health.”

The Medical Examiner report has no identifying information but gives the date of death, age of decedent, race of decedent, gender of decedent, a “Description of incident,” a probable cause of death, a probable manner of death (generally “Natural” or “Accident”), a case number, the county of residency, residence (home, nursing home, etc.), and place of death.

All but 5 of the 39 reports list “COVID-19 pneumonia” or “COVID-19 infection” as the first entry under the probable cause of death. The other five say “complications of injuries sustained in fall,” “Ischemic heart disease,” “valvular heart disease,” and (2) “natural causes.”

Two of the cases were listed as accidents rather than natural causes, although one of those still lists COVID-19 as the primary cause of death. That case was a 71-year-old male who had a fall on April 6 that caused a C5-C7 quadriplegia. The family reported “altered mental status,” “worsening confusion,” and multiple falls at home over two days after developing a fever and headache on the morning of July 28. He tested positive for COVID-19 at the hospital on July 29, was found to have developed “full COVID-19 pneumonia,” and died late the next evening.

In addition to COVID-19, the 39 reports list an average of 4.5 other “contributory factors” (co-morbidities). Nearly 80% (31 of 39) had 4 or more co-morbidities. Only 2 reported less than 3 co-morbidities, an 81-year-old man and 82-year-old woman; those two only listed dementia as a contributory factor.

The most common contributory factors were hypertension (31), heart or circulatory diseases (30), diabetes (24), kidney disease (15), and dementia (14).

Of the 39 deaths, 17 were people living in long-term care facilities. The average age of all the deaths was 76 (the median was 78), and nearly 90% (35 of 39) were 65 or older. 17 died at Shands, 11 at North Florida Regional Hospital, 7 at a hospice facility, and 3 at home. (One record has “place of death” blank.)

Florida Governor Ron DeSantis has been calling for a better delineation of “dying with” vs. “dying of” COVID because decision-makers are using the number of deaths to justify emergency orders that close businesses and require face masks, among other things. Although the above-mentioned change in responsibility for certifying COVID-19 deaths may be an attempt to address this, it appears that Florida is still listing any death of a person with a COVID-positive test as a COVID death.

The “Description of Incident” for the 79-year-old woman with “valvular heart disease” as the primary cause of death does not list any COVID symptoms, only that she tested positive for COVID-19. According to the report, she complained of lower extremity pain and diarrhea and was not “able to ambulate” for several days. “She had an extensive medical history that included morbid obesity, congestive heart failure, diabetes mellitus, gout, hyperlipidemia, hypertension, kidney failure, mitral valve regurgitation, proximal atrial fibrillation, pulmonary hypertension due to left heart valvular disease, tricuspid valve regurgitation, chronic hypoxic respiratory failure and was on 3 liters of oxygen.”

An 84-year-old woman listed with COVID-19 as the primary cause of death had been in the hospital since early June for an L1 compression fracture and acute kidney injury (on top of chronic kidney disease). After back surgery on June 5, she was discharged in mid-July and readmitted on July 24 with thrush, a vaginal yeast infection, leukopenia, and malnutrition. She was asymptomatic but tested positive for COVID-19 on July 24 and passed on July 29.

An 85-year-old woman was admitted to the hospital for “debridement of worsening necrotic heel and sacral wounds,” tested positive for COVID-19 the next day, and died two days later. She had 6 contributory factors listed.

Another case was a 50-year-old insulin-dependent diabetic man with no COVID-like symptoms who called 911 for chest pain. He went into cardiac arrest en route to the hospital and was resuscitated with multiple rounds of epinephrine and atropine. He had “acute renal failure and a CT of the head revealed severe cerebral edema.” He tested positive for COVID-19 in the emergency room and died two days later.

These are just a few cases that seem to be deaths with COVID rather than deaths from COVID, and while COVID obviously contributes to the deaths of people who are already frail, pneumonia and lower respiratory tract infections, caused by a wide variety of respiratory infections, were already the leading cause of death in nursing home residents. It remains to be seen whether the change in responsibility for certifying COVID deaths will bring more clarity to all of these questions.