In this WHO guidelines document: Guidelines for certification classification of covid-19 as cause of death, it says:


A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma). There should be no period of complete recovery from COVID-19 between illness and death.

A death due to COVID-19 may not be attributed to another disease (e.g. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19.

Now, suppose I have advanced-stage cancer (to follow the example in the quote); and also, a lab test established with certainty that I am is infected with a SARS-nCoV-2 virus variant (so we can ignore the "probable" case for the sake of the example). Then some time later I die.

Now, ignoring the guidelines - it could be that I am an asymptomatic covid-19 carrier, who died from cancer; and it could be that I died from the combined effect of covid-19 and my cancer; and it might also be that my cancer did not have significant effect on my death and I died "purely" from covid-19.

If I'm reading the guidelines correctly, it seems like in my case I will be registered as having died from covid-19 regardless of how exactly I died, even if it can be reasonably established that covid-19 was not actually a contributing factor.

Am I misreading or misinterpreting? Or is the guideline just very expansive?

  • I think the guideline is intended to combat mislabeling of deaths caused by COVID to underlying "pre-existing conditions". For all causes of death, there's a bit of art to deciding what exactly is a contributing factor, since no one actually dies of "cancer" or "diabetes" or even "heart disease": everyone dies when their heart stops beating ("cardiac death") or their brain ceases to function ("brain death"), but limiting the record keeping to which medical definition of death is being used is really not that useful. I don't see how the title question can be answered except with opinion. Jan 11 at 18:17
  • @BryanKrause: What I'm asking for is a confirmation that the policy is as I describe it to be - and that is not a matter of opinion. Such a policy may or may not be justified/wise/fair - that indeed is a matter of opinion.
    – einpoklum
    Jan 11 at 19:59
  • I mean, you're quoting the WHO's policy from the WHO; what authority's confirmation are you looking for? Jan 11 at 20:05
  • I guess in your scenario you are probably missing the work done by the phrase "clinically compatible illness" which leaves a lot up to the physicians to determine whether a death is clinically compatible with COVID. Getting hit by a bus would not be a consequence clinically compatible with the pathophysiology of COVID. Jan 11 at 20:08
  • If you are asymptomatic you wouldn't die from COVID-19, the only time you are likely to die from it is if it causes severe disease, so your hypothetical situation is not realistic and COVID-19 would not be considered a cause of death, or even a contributing factor. There's a bit of wiggle room in the cause of death workup where longer term effects of COVID-19, such as pericarditis or clotting might be seen, especially if a post-mortem is done and the cancer wasn't expected to kill you immediately.
    – bob1
    Jan 11 at 20:15

I would say that the guideline gives physicians quite a bit of leeway in determining a death is caused by COVID-19. The standard is not "any positive test + death = COVID-caused death"; it gives 2 necessary criteria and two exclusions:

a clinically compatible illness

in a probable or confirmed COVID-19 case

unless there is a clear alternative cause of death that cannot be related to COVID disease

There should be no period of complete recovery from COVID-19 between illness and death

The phrase "clinically compatible" is the part I see as giving discretion above and beyond the exception for "clear alternative cause of death". I don't immediately see a definition of this phrase from the WHO (though I also don't think a definition is necessary, the meaning can be deduced from the meaning of the words), but the CDC does have a definition here for "clinically compatible case":

Clinically compatible case: a clinical syndrome generally compatible with the disease, but no specific clinical criteria need to be met unless they are noted in the case classification.

Clinically compatible illness is slightly different, but in plain terms I would say that this is requiring a clinical presentation associated with the illness; for COVID-19, that would mean presenting symptoms of a respiratory illness, possibly with fever and other associated systemic symptoms. I cannot see how an asymptomatic infection could be considered a "clinically compatible illness" contributing to death; sure, I suppose someone could decide to mark such a death as in your example as related to COVID-19, but nothing in this guideline says clearly they have to in order to comply with the guideline.

A tumor would not be a clinically compatible illness, because tumors are not an observed feature of COVID-19 infection. If a patient is immune-suppressed due to cancer or cancer treatment, and this immune suppression made them susceptible to COVID-19 and they developed pneumonia and died, however, that would be a case clinically compatible with COVID-19 and the guideline is clear that they should be counted, and that they should not be excluded even if their physicians determine that COVID-19 only caused their death because they also had cancer and they would have otherwise survived.

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