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I was greeted one morning last week by a death certificate on my desk.

The death itself wasn't surprising.  The patient had been in hospice, and so was comfortable through the last days.  But there's something about filling out a death certificate that seems uncomfortable.  I don't sign birth certificates, even when I witness the birth.  The government certifies you as being born, but a doctor must certify you as dead.  Odd.  I wasn't there to witness the death of the patient; I just had to take hospice's word for it.

A declaration of death is different than certifying it.  I don't do much declaring, although I did it a lot as a resident.  One time I was called at 2 AM by a nurse at the VA hospital; she asked me to come up and declare a patient I was covering.  When I arrived I noticed something: he was breathing.  That makes death much harder to declare.  I informed the nurse (with a grin) that I require a non-breathing death.  I was called a few hours later to properly declare the patient.

Certification is much more "official."  You have to decide on a cause of death, and the causes of the cause of death.  When I first started filling out death certificates as a resident, I would put "cardiopulmonary failure" as the primary cause.  Then someone pointed out that a cessation of breathing and heartbeat is pretty much the same as saying the person died of death.  Nobody called me up after auditing the death certificates, though.  I am not sure that people really care what's put on the certificate (except perhaps life insurance companies).

Death certificates are required for burial, I think.  Funeral directors hound me if there is a delay, so I suspect there is some law against burying uncertified people.  When you think about it, that may be a good thing.

This may all seem morbid, but all of my patients do die eventually.  Death is a normal part of being a doctor.  It's not the enemy, although it is sometimes not welcome.  There are times when I fight against death, doing everything I can to prevent it.  There are other times when death is most welcome.  As a doctor I have to approach death as I do with all of the pain and seemingly unfair things in life: I accept it, but I don't like it, and I try not to think about it too much.

I actually almost went into oncology after residency.  I trained at Indiana University, where Lance Armstrong was treated and cured.  The doctors there were not only very good clinicians and researchers, they were compassionate and kind.  They were good for residents to work with, and taught me much about dealing with death.  I learned that it isn't horrible to be with someone in their last days, it's an honor.  People who are dying are just as alive as those who are healthy - life is an all-or-nothing thing.  But dying people have a radically different view of things.  They don't tend to fixate on dumb things, and often are a joy to be around.  Perhaps they are trying to get as much out of their last days.

It's good to be reminded that we are all dying.  Life has a 0% survival rate.  If we remembered that and lived with that in mind, perhaps we'd spend less time buying dumb things, arguing with people, reading dumb blogs, holding grudges, and worrying about stupid stuff.

We all are certified eventually.

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