“They would’ve died anyway.” These past few weeks, an argument has gained prevalence in social media spheres that the death of a person with underlying conditions who has been infected with COVID-19 shouldn’t “count” as a COVID-19 death. Yes, fatal cases of COVID-19 are more common among people with conditions like heart disease, lung disease and diabetes. But this only raises the question of how officials determine that a person has actually died of COVID-19—especially as the disease’s death rate is being used as a factor to determine when businesses can reopen and people can go back to work.
“In the cases that we do autopsies, the lung changes are so severe that it is truly separable from the effects of the coronary artery disease, the emphysema, the heart disease, the diabetes, all these things,” says Dwayne Wolf, the deputy chief medical examiner for Harris County Institute for Forensic Sciences and a clinical assistant professor of pathology for Baylor College of Medicine. “It truly is a separate disease.”
The primary cause of death is why a patient died on that particular day
When it comes to determining cause of death, there will be the primary cause, as well as contributing causes. For someone who died of COVID-19, the primary cause is often diffuse alveolar damage in the lungs, which leads to patients dying because they can’t breathe.
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If COVID-19 caused a person to die on that particular day, that is considered the primary cause of death—and a COVID-19 death is still an early death, whether that death came a month or twenty years earlier than it would have otherwise.
In addition to the primary cause of death, the death certificate will list contributing factors such as heart disease or diabetes or any number of other conditions that could have worsened the patient’s condition. These are factors that, although they didn’t cause the patient to die on that particular day, also didn’t help them either.
Simplistically speaking, COVID-19 would not be considered the cause of death if a person with a mild case got into a car accident and died, as the disease wouldn’t be the reason for their death on that day.
“There are going to be those cases where people die with COVID-19 but not of COVID-19,” Wolf says.
How cause of death is determined has not changed
It’s important to remember that the way a cause of death is determined in COVID-19 patients is no different from how medical professionals determine cause of death in different times. As Wolf points out, even in normal times, there are situations where cause of death is determined based on a patient’s history, as well as statistics.
“It’s the same process that we used before the pandemic, it’s the same process we’ll use after the pandemic,” Wolf says.
Wolf’s office in Houston has handled a number of autopsies during which they’ve needed to determine whether the death was COVID-19-related or not. Their strategy for determining the cause of death is the same as it always has been.
Different states do vary in terms of how they count deaths—some include suspected COVID-19 victims whose infection status wasn’t confirmed with a diagnostic test, but whom exhibited common symptoms and were exposed to a known case. Other states have made more determinations of patients dying with, but not of, COVID-19. Yet despite the existence of these gray areas, the process and logic behind determining a cause of death is the same as is used in normal times. At the end of the day, determining cause of death is always a tricky business.
We’re probably undercounting the number of deaths
Given the lack of widespread testing, there are certainly COVID-19 deaths that are unaccounted for. A recent New York Times analysis looked at the number of deaths this year versus the same time period a year ago. They considered the difference in the death rate, factored in the number of confirmed COVID-19 cases and used the results to generate an estimate of how many COVID-19 deaths may still be unaccounted for.
Based on this analysis, they estimate there are 40,000 unaccounted deaths in 12 countries, which include countries such as Belgium France, Spain and Switzerland. For New York City, they estimate that there are an additional 4,200 unaccounted COVID-19 deaths within the time frame of March 11 to April 25.
Practically speaking, then, it’s likely we are looking at an undercount of COVID-19 deaths, even as the process for ruling a cause of death is the same now as it has been in the past. And that information could be critical in determining where we go from here.
