HONOLULU (KHON2) — There have been 876 COVID-19 deaths in Hawaii, and confusion over how those deaths are counted has led to some misconceptions.

If a patient dies in a hospital, the cause of death is determined by the physician who pronounced the death. If not, pathologists at the medical examiner’s office make that determination.

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Each case is different and many patients have underlying health conditions, but it’s up to these medical professionals to make nuanced decisions about what goes on the death certificates.

According to the Department of Health, off Hawaii’s COVID deaths, 751 had underlying conditions while 38 did not. The rest are unknown.

“COVID has to be a contributing factor,” Healthcare Association of Hawaii President & CEO Hilton Raethel said. “Now the question is, how much it does contribute and we don’t make judgment calls about that. That’s a much more scientific level of analysis that needs to happen,”

A death certificate has four primary causes and other contributing conditions that a physician can list. COVID can cause many different ailments in the body that lead to death.

“People can die that could have been actually by a number of different events they could have a heart attack, they could have pneumonia, they could have respiratory failure,” Raethel said.

There are circumstances where individuals will not be counted as a COVID death even if they had the virus when they died.

“If somebody is in a car accident, or drowns, that probably has nothing to do or very rarely will have something to do with them actually dying or the cause of death so COVID would not be included in most of those cases,” Honolulu Medical Examiner Lead Investigator Charlotte Carter said.

Still, trauma accidents can be attributed to COVID. The Honolulu Medical Examiner dealt with a case where a COVID patient collapsed and died.

“They passed out probably because of their COVID symptoms, and when they passed out they fell and hit the floor and they hit hard enough to end up with a brain bleed that was lethal,” Carter said, “So in that case the cause and manner was listed as an accident, but COVID was part of that because that’s the likely circumstance that led to the collapse.”

Hospitals do get a 20% add-on from the federal government to cover the cost of COVID patients on medicare, but Raethel says there are no financial incentives to inflate COVID deaths.

“We are very fortunate to have very ethical people,” Raethel said. “There’s no truth at all in the rumor that the doctors or hospitals are somehow incentivized to inflate COVID numbers,”

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Carter agrees.

“One of those theories out there is, people are making money off of putting COVID on the death certificate. Our doctors are paid by the city and county. Their salaries don’t change depending on what they put as a cause of death,”