Death as Data: Autopsy and the Death Certificate

Two basic goals value of the autopsy proper use of the death

certificate

Essential websites and URLS

Bruce.case@mcgill.ca

National Association of Medical Examiners Death Certificate Tutorials:http://www.thename.org/CauseDeath/main.htm

A Canadian angle: 1998 article from the Canadian Medical Association Journal:http://www.cma.ca/cmaj/vol-158/issue-10/1317.htm

Outline Autopsy: history in three periods;

The fall of the autopsy: 1960 onward

Evidence of continuing relevance

Some attempts to explain the problem

Effects of falling rates

An example of the effect

Death certificate: what it is, how it should

be approached

The autopsy in history

1. Classical period: “test authority”

2. Pre-modern period (17-18C) : emphasis on anatomy

3. Modern period; 19C on…

a. Rokitansky (gross autopsy)

b. Virchow (added the microscope)

c. Osler – a modern example

d. Ultimate recognition as prime goal a contribution to medical knowledge

Falling Autopsy Rates

1. From 50% in the 1960’s to2. Much lower than 10% today,

despite3. (for example) of three U.S.

studies, an incorrect diagnosis of malignant tumors was shown in

a. 36.5% of cases (1923)b. 41% of cases (1972)c. 44% of cases (1998, Louisiana)

Falling Autopsy Rates: RVH 1998

(figures from 1998) DEATHS AUTOPSIES

RATE (%)

ADULT INPATIENTS

721 92 12.8%

EMERGENCY 43 3 7%

INFANTS (OVER 500g)

19 12 63%

JAMA 1998: Louisiana study

1. All autopsies 1986-95

2. Outcome measure: discordance in clinical vs. autopsy for cancer

3. 1105 cases; mean age 48 years (very atypical)

4. 443 “neoplasms” at autopsy; 250 “malignant”

5. 111 wrong CLINICAL diagnoses of “malignancy” including 57 which caused death

So what is wrong? 1. Why do the rates keep falling in the face of continuing evidence of error?

1. Increasing reliance on imaging

2. Fear of lawsuits? May explain USA but

not elsewhere

So what is wrong? 2. Changing patterns in pathology

1. Changing patterns in pathology and pathologists

2. A new but worrying factor: regard for

autopsy practices as “violating civil

rights” (lawsuit in UK over pediatric

autopsies); reflects a constant fight over

“values” over the years coupled with

some abuses such as “Burking”…

So what is wrong? 3. Poor communication

5. Suggestions of poor communication

between pathologists and clinicians:

a. Wherever a special effort is made to

“educate” rates increase, although this

may be transitory. Rates can reach 100%

in some centres!

So what is wrong? 4.

5. Suggestions of poor communication

between pathologists and clinicians:

b. Poor pay, lack of curiosity, lack of

professional attitude to reporting can

lead to “vicious circle” of late reporting;

c. Clinical “mortality rounds” seem to result

in higher rates when pathologists attend

Is anything right?

1. In academic centres cases with

unknown cause still invoke requests for

autopsy;

2. This means that almost every

increasingly “rare autopsy” has become

more “interesting” both for the

pathologist, for teaching, and for

publication, BUT...

3. This applies only to academic centres

Effects of falling rates

1. Similar to effects of bad death

certificate reporting

2. National health statistics wrong;

3. Lack of Quality Control;

4. Problems for analytical

epidemiology (garbage in, garbage

out)

Autopsy trends and their effect on disease ascertainment: an example.

1. 1. What is this lesion?

2. 2. How rare is it?

3. 3. Difficulties in Diagnosis:

4. 1. Result in UNCERTAINTY (or “guessing” – “This could be X or possibly Y or…”)

1. 2. Result in outright error (mainly lung ca)

Special Procedures in Pathology: Trends for 228 women with mesothelioma 1970-90

0%

10%

20%

30%

40%

50%

60%

Immunopath Electron Micr. Histochem Autopsy Rate

Prior to 1985

1985 and Later

Trends among 142 and 98 female cases diagnosed 1970-1984 and 1985-1991, respectively.

Number of cases

Uncertain of Diagnosis

Accuracy (10 = perfect)

Autopsy done, 1970-

1984 59 26% 5.8 +/- 2.1

Autopsy not done, 1970-

1984 83 52% 4.7 +/- 2.9

Autopsy done, 1985-

1991 20 20% 6.9 +/- 1.2

Autopsy not done, 1985-

1991 78 42% 5.8 +/- 2.4

Effect of Autopsy Rate on Reliability and Accuracy in Two Diagnostic Eras

1. “Improving the accuracy of death

certification”

Eight case scenarios are presented

Kathryn A. Myers, MD, EdM; Donald R.E. Farquhar, MD, SM CMAJ 1998;158:1317-23

CMAJ ARTICLE

Ontario Death Certificate

An On-Line Tutorial

http://www.thename.org/

CauseDeath/main.htm

2. WRITING CAUSE-OF-DEATH STATEMENTS

Why learn this now? Often, a physician's first encounter with the

death certificate occurs upon the physician's

first patient death when he/she is handed

the death certificate form and asked to

complete it. This usually occurs during the first year of

residency. Many, perhaps most, are not told “how” –

and never learn!

The cause-of- death statement contains two parts: Part I

I. A) Due to, or as a result of B)Due to, or as a result of C)

PART I is designed so that a sequence of conditions leading to death may be reported

The cause-of- death statement contains two parts: Part II

II. Part II. OTHER SIGNIFICANT CONDITIONS: Conditions contributing to death but not resulting in the underlying cause of death in Part I

EXAMPLES: hypertension, diabetes, chronic obstructive lung disease, renal disease…diseases pre-existing or co-existing with the MAIN UNDERLYING DISEASE but NOT related to it

PART I: ONE CONDITION per line, starting with the most recent condition on the top line

and going backward in time

PART I:

A. Most recent condition (e.g., Cardiac tamponade)

Due to, or as a consequence of: B. Next oldest condition (e.g., Ruptured myocardial infarction)

Due to, or as a consequence of: C. Oldest (original, initiating) condition (e.g., Atherosclerotic coronary artery)

Part I A. Cerebral infarction

Due to, or as a consequence of:

B. Thrombo-embolism to right internal carotid artery

Due to, or as a consequence of:

C. Thrombo-embolism from bacterial endocarditis of mitral valve

Due to, or as a consequence of:

D. Floppy mitral valve syndrome (underlying cause of death-- the specific condition (disease or injury) that started the downhill course of events that led to death.)

An example

Variants; problems Single Line Part I Format (missing

data) e.g. no autopsy, patient dies at home, known to have prostate carcinoma

uncertainty or presumption: use “probable”

ALWAYS REPORT CANCER! Can “cheat” on part two to record

risk factor (smoking, asbestos exposure)

Additional Information on the Death Certificate

1. Usually a space to record TIME since onset of event

2. Always indicate whether (a) an autopsy has been asked for and (b) whether the DC includes autopsy information

3. In some places, can record occupation – “retired” is NOT an occupation!!!

4. Mandatory reporting: violent death, certain infections; varies with state

Multiple cause-of-death coding

1. All data to date are based on a SINGLE cause of death but

2. Modern national statistics programs record ALL information on the death certificate and can derive

3. “multiple cause-of-death” data

http://www.thename.org/

CauseDeath/main.htm (This is the web address for the tutorial on death certificates)