Email this article Bridging the gap: Assessing death certification competency in Bulgarian healthcare education
- Authors: Kolev Y.G.1,2, Valentinova T.1, Stefanovski P.H.1, Tumbeva E.1, Mirochnik N.M.1, Kolev P.Y.3
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Affiliations:
- Medical University of Pleven
- Department of Forensic Medicine, District hospital MBAL
- Medical Faculty of Sofia University
- Issue: Vol 9, No 4 (2023)
- Pages: 391-401
- Section: ORIGINAL STUDY ARTICLES
- URL: https://for-medex.ru/jour/article/view/14219
- DOI: https://doi.org/10.17816/fm14219
- ID: 14219
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Abstract
BACKGROUND: In Bulgaria, procedural protocols following a citizen’s death are governed by an intricate network of normative documents. Despite the presumed alignment between international and national guidelines, practical experiences reveal shortcomings in the proficiency of healthcare providers, particularly in cases involving prior medical interventions or systemic vulnerabilities.
AIM: This study aimed to assess the readiness of final-year medical students and early-career physicians in navigating death certification intricacies, including their responses, documentation precision, and postmortem procedures for bereaved families, with implications for national health statistics.
MATERIALS AND METHODS: By employing a mixed-methods approach, this study distributed questionnaires to sixth-year medical students and practicing physicians, including those in emergency medicine centers and general practice. Data collection included paper-based and digital questionnaires, ensuring anonymity and ethical compliance. Statistical analysis, employing parametric (t-test) and nonparametric (Chi-square) tests, forms the basis for actionable recommendations and educational material development.
RESULTS: This study included 143 participants, of which 41% expressed apprehension about managing out-of-hospital deaths. Approximately 44% claimed familiarity with death certification regulations, with students displaying higher theoretical confidence but lacking practical knowledge. Remarkably, 74% of physicians never received formal training in death certification. Discrepancies in issuing death certificates, timing, and notification procedures were identified.
CONCLUSION: Findings reveal varying practices among physicians according to their specialties. Issues related to documentation, timing, and notification were prevalent. The study emphasizes the need for improved training, particularly for medical students. Emergency medicine doctors exhibited higher preparedness levels. Medical students and early-career physicians urgently require enhanced education in death certification preparedness. Incorporating these topics into medical curricula, offering specialized courses, and disseminating instructional materials can significantly enhance effectiveness. Future studies should assess the quality and accuracy of recorded causes of death, which affect healthcare statistics, public service, and legal procedures, underscoring the societal and administrative significance of death certification practices.
Full Text
BACKGROUND
Procedural protocols following the death of a citizen in Bulgaria are governed by an array of normative documents. International guidelines and national legislative frameworks are generally assumed to be harmoniously aligned, leaving no procedural gaps of practical significance [1]. However, real-world scenarios reveal that healthcare providers and, to some extent, the overseeing institutions are not sufficiently equipped to manage procedures associated with death certification. This inadequacy is observed not only in routine circumstances but also in the forensic medical practice within Bulgaria, particularly when preceding medical interventions have demonstrable practical implications or expose systemic weaknesses. This disconnect served as the impetus for the present study, which aimed to collate information on the preparedness of graduating medical students and early-career physicians in relation to death certification. This encompasses physicians’ responses and actions, documentation specifics, and pertinent follow-up procedures for the bereaved families. The quality of this practice is also instrumental in shaping national health statistics regarding causes of death in Bulgaria.
AIMS
This study primarily aimed to assess the preparedness of medical students in their final year of education and early-career physicians in managing cases of death in both domestic and public settings. This is carried out by comparing their experience and readiness with that of more seasoned medical professionals. This study did not aim to evaluate the accuracy of cause-of-death determinations. Upon completion of data analysis, the study aimed to formulate guidelines that could serve as actionable protocols for such scenarios, specifically targeting the education of emerging medical specialists. Further tasks include the development of an informational brochure for healthcare providers that outlines a step-by-step algorithm for appropriate actions under such circumstances, aiding clinical practice. In addition, based on the uncovered gaps and weaknesses in medical education, the study suggests necessary curriculum adjustments to enhance future training in medical programs. Prior research in this context is existent in Bulgaria, and studies in other countries are limited, mainly focusing on the quality of documenting causes of death in official certificates [2, 3, 4, 5, 6].
MATERIALS AND METHODS
A mixed-methods approach, comprising both multiple-choice and open-ended questions, was employed via a questionnaire survey to gather the required data. The study participants were sixth-year medical students (intern doctors) and practicing physicians, specifically those working in emergency medicine centers (including ambulance medical service) and general practitioners (family physicians). This cohort was deliberately chosen to evaluate the training and practical readiness of both aspiring and active healthcare providers who are most likely to encounter out-of-hospital deaths. The data collection process was conducted in two formats: paper-based questionnaires were filled out in person, and digital questionnaires were administered via Google Forms. All responses were collected anonymously and only after receiving ethical approval from the Research Ethics Commission (KENID). Identifiers such as the respondent’s specialty, employment type, and experience level were noted, without revealing their real name or place of work.
Data were collected between December 2022 and April 2023 and subsequently analyzed using statistical software packages (Excel v.10.0 and SPSS). Both parametric (t-test) and nonparametric (Chi-square) tests were utilized for data analysis. The findings were employed to draw actionable conclusions that have practical implications and develop educational and informational materials aimed at enhancing physicians’ preparedness for postmortem examinations and death certification.
RESULTS
The survey encompassed a diverse sample of 143 respondents, including 67 final-year medical students—comprising 17 Bulgarian-speaking and 50 English-speaking students—and 76 practicing physicians. The group of practicing physicians consisted of 31 general practitioners, 37 emergency medicine doctors, four specialists from diagnostic medical centers, three forensic doctors, and one newly graduated, nonworking doctor. Among the practicing doctors, a majority had over 10 years of experience. Notably, 68 of the participants, predominantly students, reported never having issued a death certificate. However, most physicians reported issuing at least one death certificate annually. The sociodemographic characteristics of the participants are detailed in Table 1.
Table 1. Characteristics of the studied individuals
Characteristics | Count | Relative share (%) |
Gender: • men • women • no answer | 53 89 1 | 37% 62% 1% |
Employment: • 6th year student • General practitioner • Emergency department doctor other doctors | 67 31 37 8 | 47% 22% 26% 5% |
Acquired medical specialty: • General medicine • Emergency medicine • Other medical specialty • No specialty (yet) | 24 3 22 94 | 17% 2% 15% 66% |
Work experience: • 6th year student • up to 5 years • from 6 to 15 years • over 15 years | 67 12 9 55 | 47% 8% 6% 38% |
Frequency of issuance of death certificate: • once or more a week • once a month or more • once a year or more • less than once a year • never issued (not had to issue) | 3 45 19 8 68 | 2% 32% 13% 5% 48% |
Approximately 41% of all respondents expressed apprehension about managing cases involving out-of-hospital deaths. This concern was more prevalent among students, with 47% reporting uneasiness, compared with 37% among working doctors. Interestingly, 44% of all participants claimed familiarity with the legal documents governing death certification. Students were 2.5 times more confident in their theoretical understanding of these regulations than practicing physicians (p < 0.0001). However, this confidence appeared misplaced, as most students struggled to name specific regulatory documents. By contrast, emergency medicine doctors demonstrated the highest level of knowledge in this area.
Approximately 74% of physicians stated that they had never received formal training on issuing death certificates. Conversely, 48% of the students claimed to have undergone such training, and the remaining students were unsure. The difference in training experiences was statistically significant (p = 0.01). This formal instruction, combined with a lack of practical exposure, could account for the students’ heightened confidence in handling death-related procedures.
DISCUSSION
The study highlights varying practices among doctors when determining causes of death. Although nearly all general practitioners (97%) never declined to issue a death certificate, some emergency doctors did refuse, primarily because of the prevalence of traumatic deaths requiring further investigation. This discrepancy suggests differing levels of comfort and expertise among physicians in handling death cases depending on their specialty.
Regarding documentation, awareness is notably lacking about the correct procedure for issuing death certificates. All emergency center doctors were aware that death certificates should be issued in triplicate (Bulgarian regulation); however, about half of the general practitioners and some hospital doctors were still issuing them in duplicate (older regulation). This divergence is statistically significant (p = 0.00) and points to a gap in knowledge about current regulatory requirements. Among students, ignorance was even more widespread; that is, approximately 58% were unaware of the correct number of copies to be issued. In addition, a majority of doctors were unaware of the designated destinations for the additional copies–one for the medical facility’s register and another for the Regional Health Inspection.
Regarding the timing for issuing death certificates, 86% of doctors believed that they could only do so within 24 h post-death. In reality, Bulgarian legislation allows for a window up to 48 h, after which law enforcement and possibly an autopsy are required.
On the topic of notifying authorities, doctors across all specializations demonstrated a strong understanding of when it is mandatory to alert the police. These circumstances include suspected violence or murder, likely or apparent suicide, traffic accidents, other types of trauma, unclear cause of death, decomposition, or when the corpse is unidentified or the absence of immediate family. Medical students also showed a high level of understanding in this topic.
The most commonly accepted causes of death, as indicated by the respondents, were “acute heart failure” and/or “acute or chronic heart disease,” aligning with national health statistics. This was followed by cancer, stroke, and other conditions. The approach to determining the date and time of death varied between family doctors and emergency center doctors. Family doctors often rely on information provided by the deceased’s family, whereas emergency center doctors consider multiple factors, including the condition of the body and other available medical data [7, 8, 9].
The study also highlighted varying levels of awareness among students and doctors regarding the issuance of death certificates in complex situations, such as multiple casualties or disputed cases. For instance, an autopsy is required when the cause of death is uncertain or requires further investigation, even if relatives are opposed to it. Students were generally less aware of these procedural details.
Regarding training needs, a staggering 98% of respondents felt that additional instruction is necessary, particularly concerning death certification. Moreover, 58% of general practitioners felt confident in communicating with the relatives of the deceased, whereas 63% of emergency room doctors reported challenges in this aspect (p = 0.00). Over half of medical students also felt unprepared for such sensitive interactions, indicating a gap in their educational training.
Suggestions for additional training varied widely, which included incorporating this topic into university medical education and offering thematic lectures, specialized courses, online modules, and employer-led briefings. Written guides or brochures were also recommended.
Doctors from emergency medical care centers exhibited the highest level of preparedness in handling death-related procedures, likely because of their frequent exposure to such cases and their structured training programs. By contrast, medical students’ primary limitation was their lack of practical experience. For family doctors, lower awareness could be attributed to the infrequency of such cases and perhaps their more isolated professional environments [7, 10, 11].
Briefly, the study reveals critical gaps in both knowledge and comfort levels across specialties concerning death determination and certification procedures. Nearly all participants agree on the urgent need for more comprehensive training in these areas, emphasizing the need for curricular reforms and additional educational resources.
This extensive analysis offers a strong foundation for improving existing procedural actions related to death certification in Bulgaria, which can be integral in enhancing national health statistics and possibly informing changes in legislation and medical training curricula [12].
CONCLUSION
In this study, the principal takeaway is the urgent need for enhanced, specialized training in areas such as the determination of death, management of deceased patients, and the issuance of death certificates. This applies to both medical students and practicing physicians, regardless of their experience duration. Incorporating educational modules focused on these topics into existing curricula in general medicine and forensic medicine is recommended [13, 14, 15, 16]. Furthermore, offering specialized courses for practicing physicians can help fill this knowledge gap [17, 18]. The long-term effectiveness of such interventions could be further augmented through the dissemination of instruction booklets and comprehensive guides on death determination and certification procedures. These conclusions align with findings from similar studies in other regions [19–30].
Future research should focus on evaluating the quality and accuracy of the recorded causes of death. This is crucial not only for improving the training of medical professionals but also for understanding its effect on national healthcare statistics. Strategies for improvement have already shown positive outcomes in various international settings.
Finally, practices surrounding the determination of death and issuance of death certificates are integral to the healthcare infrastructure of any country. These practices have far-reaching consequences, which affects medical statistics, public service, and legal procedures. Therefore, the quality of these activities has social and administrative significance.
ADDITIONAL INFORMATION
Funding source. This research was performed with a partial funding from the Medical University — Pleven, under Project D15/2022.
Competing interests. The authors declare that they have no competing interests.
Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. Y. Kolev and Tsv. Valentinova made substantial contributions to conception and design of the study, acquisition of data, analysis, and interpretation of data, took part in drafting the article and revising it during the peer-review process; P.H. Stefanovski, E. Tumbeva and N. Mirochnik contributed for the data acquisition among general practitioners and emergency care doctors, took part in the analysis and interpretation of the data, drafting of the article; P-G. Kolev took part in drafting of the article and language revision.
Приложение 1. Брошюра «Краткое руководство по освидетельствованию смерти» (2 страницы) с практическими рекомендациями по установлению факта смерти и освидетельствованию смерти
About the authors
Yanko G. Kolev
Medical University of Pleven; Department of Forensic Medicine, District hospital MBAL
Email: drforensic@gmail.com
ORCID iD: 0000-0003-2958-1702
MD, Dr. Sci. (Med.), Assistant Lecturer
Bulgaria, Pleven; GabrovoTsvetelina Valentinova
Medical University of Pleven
Author for correspondence.
Email: tsvm2002@yahoo.com
ORCID iD: 0000-0001-7095-5572
MD, Assistant Professor
Bulgaria, PlevenPetko H. Stefanovski
Medical University of Pleven
Email: p.stefanovski@gmail.com
ORCID iD: 0000-0002-9676-3605
MD, Assistant Professor
Bulgaria, PlevenElka Tumbeva
Medical University of Pleven
Email: e.tumbeva@abv.bg
ORCID iD: 0000-0003-0292-7347
Assistant Lecturer
Bulgaria, PlevenNikolay M. Mirochnik
Medical University of Pleven
Email: nikolaimirochnik@gmail.com
ORCID iD: 0009-0004-0115-9985
Bulgaria, Pleven
Preslav-Geo Y. Kolev
Medical Faculty of Sofia University
Email: preslavgeo1@gmail.com
ORCID iD: 0009-0008-7679-1124
Bulgaria, Sofia
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