Autopsy and Death Certificates 2011

8/7/2019 Autopsy and Death Certificates 2011

http://slidepdf.com/reader/full/autopsy-and-death-certificates-2011 1/51

When Your Patient DiesMichael Hogarth, MD

Professor, Pathology and Laboratory Medicine

Professor, Internal Medicine

Informatics Director ± California Electronic Death Certificate System (EDRS)[email protected]

http://www.hogarth.org



My role here today Review the basics of autopsy and the death

certificate

Autopsy Help answer questions you may have about the autopsy

process or procedure

Provide you with tips on how to obtain autopsy consent

Death Certificate

What is a death certificate? What is your role?

Common issues/questions with death certificates



The Autopsy



Why do it? It is still the foremost quality control tool in medicine, yet the rate is

falling precipitously 1960: 50% rate

1994: 6% rate

Quality Control aspects of autopsies Battle et al (JAMA 1987) - major discrepancies between pre and post

mortem diagnoses 13% of the time

Shojania et al (JAMA 2003) Of 53 autopsy series reviewed, 42 reported major diagnostic errors

defined asclinically missed diagnoses involving a principal underlyingdisease or primary cause of death

There is a 24.4% major diagnostic error rate, and a 6.7% Class I major diagnostic error rate



Autopsy knowledge Most medical students today graduate without seeing an autopsy

performed«

Few institutions teach physicians about autopsies

Only 7.1% of institutions supply educational materials for the physician, asrecommended by the College of American Pathologists

74.5% of Peds&Med Chief Residents felt that educational materials wouldbe beneficial for physicians and the family

The (lack of) value of limited autopsies 93.3% of Chief Residents believed that a limited autopsy should be offered

to families

90% of Pathologists at the same institutions believed that limited autopsiesare an unsatisfactory alternative to the complete examination

Rosenbaum et al. Autopsy Consent Practice at US Teaching HospitalsArchives of Internal Medicine, 160, Feb 14 2000



How knowledgeable are you? Do you feel knowledgeable about the following?

Surgical procedures used in the removal of tissues and organs:37%

The types of tests done on these tissues/organs: 41%

The range of techniques available to perform an autopsy: 71%

As practiced in your institution, are physicians who requestautopsy instructed on the following?

The autopsy procedure: 56%

How to perform an autopsy consent: 41% Religious and cultural concerns regarding autopsy and

postmortem care: 83%

Rosenbaum et al. Autopsy Consent Practice at USTeaching HospitalsArchives of Internal Medicine, 160, Feb 14 2000



The Autopsy - consenting Could you explain it to a family member? Or to your family

if it were one of your loved ones?

What is done?

Medical history review External Examination

Internal Examination

Preliminary Autopsy Report(Gross Examination Only)

Histological Examination Clinicopathologic Correlation

Final Autopsy Report

Hanzlick et al. The Autopsy Lexicon. Arch Pathol Lab Med, 124, April 2000



WhoMay Consent Next of kin ± Spouse, Child, Parent, Sibling

Legal guardian (conservator)

Other relative

Public officer



The External Examination Presentation

How the body was wrapped, protected, prepared, or stored prior toautopsy

Clothing, personal effects, other (string used to tie the wrists may leavea mark)

Evidence of medical intervention Bandages, tubes/catheters

Post mortem changes

Post mortem imaging studies (sometimes are done)

Features of identification: hair color, length, texture, eye color, other

distinctive features External physical examination

General, head, neck, torso, upper extremities, lower extremities, etc..



Internal Examination Dissection method

does not mean the family cannot have an open casket funeral.

Organs: weight, size, features

Noting appearance of cavities and organs, if fluid is present

(cloudy, bloody?) Systems:

Chest/Abdomen

Cardiovascular system

Respiratory system

Digestive system

Hepatobiliary system Reticuloendothelial system

Urogenital system

Endocrine glands (thyroid, adrenal, parathyroids)

CNS as appropriate



Brain Examination The examination of the central nervous

system often benefits significantly from a

neuropathologist The brain is removed from the calvarium

and dissected at a later time -- once

allowed to fix adequately brain cutting occurs later, thus brain slides

may take more time to be processed and

reviewed



The Histological Examination

Histology specimens are prepared from a standard set of organs,and from areas felt to be suspicious for a disease process

In most cases, a set of representative tissue samples of eachorgan are put into cassettes for processing and later slidepreparation

It may take upwards of 2-3 weeks for these slides to be prepared,and reviewed by the pathologist Slide review is an ideal opportunity to interact with the Pathologist and

discuss the case before the final autopsy report is rendered!!

Slide review is one of the richest educational opportunities for the

clinician in the autopsy process ± I HIGHLY RECOMMEN

D IT

!!



The Autopsy Consent

Not generally emphasized in training programs, but critical in improving autopsyrates«

There are many ways to do this - everyone develops their own style.

Suggested approach post mortem conference with spouse, family The day following the death ±call the family/spouse to arrange

What does it do? Allows you to talk to the spouse/other and family in a quiet setting *after* the immediate trauma of the

loved ones death Provides closure for yourself and the family with regards to the hospital course ± you can say goodbye

to the family and they often express appreciation to you for caring for their loved one..

You can discusswhat happened and that about 25%-50% of the time an autopsy will uncover information unknown clinically and in 10% of cases it uncovers a significant issue.

Be ready to: Explain why an autopsy is important Explain how it is done, explain the process (prelim report, final report, how long, how will feedback be

provided to them) Explain whether organs are retained and for how long, etc« Consider a post-autopsy conference with spouse/family ±typically can take place ~30days after the

death



R ecording Deaths



What is a death certificate? A legal document to settle an estate

A source of information for the family

A source of mortality statistics for scientists andpublic health officials

The death certificate functions as both a legaldocument and as the raw data for epidemiologicalinformation that drives health care policy in manycountries including the U.S.





Origins of Death Certification Earliest beginnings in recording health information

deaths in Northern Italy were registered starting in the 12th century 1385 - Florence Bills of Mortality

1496 ± Mantua¶s ³Books of the Deceased´ licensed physicians issued certificates of death

placed in the ³Books of the Deceased´

England began recording deaths (and births) around 16th

century done at the Parish level (Burials and Christenings of the week)

data collected and eventually submitted to a central office inLondon

Given the past 400 years of history in collecting data ondeath and disease, it is clear that using a system tocategorize cases of disease is important to information-basedprocesses (both manual and automated) in biomedicine



The importance of death data

Bills of Mortality (London, 16th Century) collected by parish clerks

John Graunt (1620-1674)

well known London merchant introduced the notion of nosology

used Bills of Mortality to make important observations thatwere unknown, or unrealized, at the time

infant mortality, urban versus rural, etc..

for example, 36% of children died before age 6

A link to John Graunt¶s conclusions from this data set:http://www2.sunysuffolk.edu/westn/mortality.html

A link to the text of ³Observations on the Bills of Mortality´:http://www.edstephan.org/Graunt/bills.html



John Snow and Cholera (1854) British physician who was

skeptical of the dominanttheory of disease (miasma ±bad air)

Used the London Bills of Mortality and a map of Londonto show clustering of choleracases around a water pump

With this, Snow used statisticsto show the connectionbetween cholera and a water

source The µfather¶ of of epidemiology



The Emergence of Vital Statistics Statistics ± ³data about the state´

William Farr ± First Statistician - Office of

the Registrar, London had to collate µbills of mortality¶ from all parishes

and analyze trends

1880¶s: originated the idea of an µinternational

classification for causes of death¶ - ICD



Vital Statistics ± 1851 Mortality T

ables



Vital Statistics - today







The Death Certificate



The Law ± California Codes Health and Safety

Code Section: 102775-102805102795. The medical and health section data and the time of death shall be completed

and attested to by the physician and surgeon last in attendance, or in the case of

a patient in a skilled nursing or intermediate care facility at the time of death,

by the physician and surgeon last in attendance or by a licensed physician

assistant under the supervision of the physician and surgeon last in attendance if

the physician and surgeon or licensed physician assistant is legally authorized to

certify and attest to these facts, and if the physician assistant has visited the

patient within 72 hours of the patient's death. In the event the licensed physicianassistant certifies the medical and health section data and the time of death, then

the physician assistant shall also provide on the document the name of the last

attending physician and surgeon and provide the coroner with a copy of the

certificate of death. However, the medical health section data and the time of

death shall be completed and attested to by the coroner in those cases in which he

or she is required to complete the medical and health section data and certify and

attest to these facts.

102800. The medical and health section data and the physician's or coroner'scertification shall be completed by the attending physician within 15 hours after

the death, or by the coroner within three days after examination of the body. The

physician shall within 15 hours after the death deposit the certificate at the

place of death, or deliver it to the attending funeral director at his or her place

of business or at the office of the physician.



Components of a death certificate Personal Information

Medical Information

Coroner Information (if a coroner case)



PersonalInformation

Decedent information dob, dod, place of birth current address, marital status,

occupation, spouse/parent information

Informant name and address of the person supplying the information

Disposition information type of disposition (cremation, burial -- where ?at sea)

Who is doing the disposition - funeral home, family(California allows families to perform their owndispositions - need to have a funeral home overseeing it)



MedicalInformation

Place of death hospital (inpatient vs ER vs DOA)

Address/location

Causes of death Part I - immediate cause of death and underlying causes

includes *estimated* time between onset and the death

Part II - related conditions

?Any operations performed for the cause or underlying causes

?Autopsy performed - ?used to establish cause of death ?Pregnant

?Smoker

?Coroner case



Coroner section Manner of death

Homicide, suicide, natural, undetermined

Circumstances of the injury (textdescription)

Location where injury occurred - home,

school, road location, etc..



MedicalInformation

Basic demographics plus«

Causes of Death - 3 basic components in

two parts (Part I and Part II) Part I

Immediate cause of death

Underlying cause(s) leading to immediate cause

Part II

Related Conditions



Cause of Death Section

Immediate cause

Underlying cause(s)

Related conditions



Cause of Death Designed to elicit the *opinion* of the medical

certifier

Dont get hung up on avoiding being wrong -- it is your

opinion, your best judgment, based on available

information

Properly completed, it provides an etiologic

explanation of the order, type and association of

events resulting in death



PartI:Immediate Cause of Death

Immediate Cause

The disease or injury that started the

sequence of events leading directly todeath

Does NOT mean themechanismof death or terminal event

Cardiac arrest, pulmonary arrest,cardiopulmonary arrest aremanners of death notmechanisms!!



PartI: Underlying Causes

TheChain of events leading to death,proceeding backwards from the final stage or condition resulting in death Due to:

Underlying Cause A Due to:

Underlying Cause B

«





Common problems Avoid paralysis by analysis

There is more than one way to write a cause-of-death statement± dont think you can only do it one way or only one opinion iscorrect«

Avoid using a manner of death rather than a cause Cardiopulmonary arrest,cardiac arrest, etc« --

no,no,no!

Avoid using a description of the individual rather than acause: Senescence,infirmity,old age



Physicians on the death certificate There are two places that identify a physician on the death

certificate

Certifier

Attending Physician Certifier -- certifies as to the causes of death (his/her

opinion!)

Attending Physician -- the physician who attended theindividual (the physician who best knew him from a clinical

perspective) NOTE:

The certifier and the attending are typically the same person,but it is not require that they be the same person



Physicians on the Death Certificate Certifier

Signs the

certificate(#115)

License number (#116)

Attending physician

Only name and address

(#118)



What is your legal obligation? You mustattest to the causes of death by

entering them on the death certificate and signingthe medical certification within 15 hours of death

You must report to the coroner s officereportable deaths (discussed later)

If you unduly interfere with the completion of adeath certificate, you can be guilty of a

misdemeanor « try not torefuse to sign one -- it is a duty required

of licensed physicians (not optional)



R esources

CDC Handbook on

Medical Certification of

Death

http://

Electronic Death

Registration System

website:

http://www.edrs.us



Coroner Cases



What is a coroner? Coroners are an English tradition

The crown establishedcrowners to investigate

causes of death

the crown had a financial interest

suicide was a felony offense and felons forfeited all their

belongings to the crown

Murder allowed collection in two ways

Murder was a felony offense Town was punished by a murder fine, anamercement

levied by the crown against the town for allowing a civil

disturbance

Davis, The American Journal of Forensic Medicine and Pathology: Volume 18(3) September 1997 pp 219-223



R ole of the coroner today

to ensure, on behalf of the community, that sudden

and unexpected death, or those deaths that occur under

violent or suspicious circumstances are thoroughly

investigated. The Coroner will examine thecircumstances surrounding allreportable death

determine the identity of the deceased

determine the time, place, cause and manner of death

comment on matters, including public health and safety,connected with the death

http://coroner.saccounty.net/aboutUs.htm



Who is the Coroner? The coroner and deputy coroners are sworn peace officers

The coroner and deputy coroners have investigative

authority

They are required to perform the coroner functions asdefined in Calif. Government Code, section 27491

In short -- it is the duty of the coroner to investigate sudden and

unexpected death, accidental death, or those deaths that occur

under violent or suspicious circumstances

NOTE: A medical examiner is a physician trained in forensic autopsies. A coroner is notnecessarily a medical examiner, but there can be coroner/medical examiners in some

counties.



The Sacramento Coroner

sO

ffice Sacramento County has anindependent coroner soffice, which means it isseparate from the Sheriff s

department. http://coroner.saccounty.net/

12 counties in California haveindependent coroner offices,the other 46 combine it with

the Sheriff s department.



What is a

reportable

Deaths1. violent, sudden, or unusual deaths;

2. unattended deaths;

3. deaths wherein the deceased has not been attended by a physician in the 20 days before death;

4. deaths related to or following:· known or suspected self-induced or criminal abortion;

· known or suspected homicide, suicide, or accidental poisoning;

· deaths known or suspected as resulting in whole or in part from or related to

accident or injury either old or recent;· deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure,

starvation, acute alcoholism, drug addiction, strangulation, aspiration, or where

the suspected cause of death is sudden infant death syndrome;

· death in whole or in part occasioned by criminal means;

· deaths associated with a known or alleged rape or crime against nature;

5. deaths in prison or while under sentence;

6. deaths known or suspected as due to contagious disease and constituting a public hazard;

7. deaths from occupational diseases or occupational hazards;

8. deaths of patients in state mental hospitals serving the mentally disabled and operated by the State

Department of Mental Health;9. deaths of patients in state hospitals serving the developmentally disabled and operated by the State

Department of Developmental Services;

10. deaths under such circumstances as to afford a reasonable ground to suspect that the death was caused bythe criminal act of another; and

11. any deaths reported by physicians or other persons having knowledge of death for inquiry by coroner.

http://www.co.el-dorado.ca.us/sheriff/coroner.asp



Attention!CALIFORNIA CODES

HEALTH AND SAFETY CODE

SECTION 102850-102870

102850. A physician and surgeon, physician assistant, funeral

director, or other person shall immediately notify the coroner when

he or she has knowledge of a death that occurred or has charge of a

body in which death occurred under any of the followingcircumstances:

(a) Without medical attendance.

(b) During the continued absence of the attending physician and

surgeon.

(c) Where the attending physician and surgeon or the physician

assistant is unable to state the cause of death.

(d) Where suicide is suspected.

(e) Following an injury or an accident.

(f) Under circumstances as to afford a reasonable ground to

suspect that the death was caused by the criminal act of another.

Any person who does not notify the coroner as required by this

section is guilty of a misdemeanor.

http://www.leginfo.ca.gov/cgi-bin/waisgate?WAISdocID=84912110374+1+0+0&WAISaction=retrieve



What happens when you call them They assign a number (coroner s

number) to the case -- does not mean they

will conduct an autopsy/investigation They may elect to investigate and they will

let you know during the phone call (usually)



A Case A 35 year old man is in a bar fight in Reno and

sustains a neck injury. After four weeks of constant

neck pain, he sees his doctor (in Sacramento). He

is found to have a neck fracture and undergoes asurgery. He unfortunately suffers a significant post-

operative infection that lands him in the ICU. He

has more complications and eventually expires from

a hospital acquired pneumonia ± his third infectionthat month.

Is this a coroner¶s case?



QUESTIONS?

Documents

Autopsy and Death Certificates 2011