autopsy and death certificates 2011
TRANSCRIPT
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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
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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
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The Autopsy
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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
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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
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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
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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
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WhoMay Consent Next of kin ± Spouse, Child, Parent, Sibling
Legal guardian (conservator)
Other relative
Public officer
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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..
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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
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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
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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
!!
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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
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R ecording Deaths
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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.
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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
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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
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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
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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
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Vital Statistics ± 1851 Mortality T
ables
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Vital Statistics - today
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The Death Certificate
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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.
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Components of a death certificate Personal Information
Medical Information
Coroner Information (if a coroner case)
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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)
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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
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Coroner section Manner of death
Homicide, suicide, natural, undetermined
Circumstances of the injury (textdescription)
Location where injury occurred - home,
school, road location, etc..
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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
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Cause of Death Section
Immediate cause
Underlying cause(s)
Related conditions
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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
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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!!
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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
«
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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
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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
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Physicians on the Death Certificate Certifier
Signs the
certificate(#115)
License number (#116)
Attending physician
Only name and address
(#118)
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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)
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R esources
CDC Handbook on
Medical Certification of
Death
http://
Electronic Death
Registration System
website:
http://www.edrs.us
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Coroner Cases
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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
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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
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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.
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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.
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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
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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
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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)
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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?
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QUESTIONS?