This information is designed to give you an understanding of the role of the autopsy service at the University of Iowa Hospitals and Clinics. A Decedent Care Specialist is on call 24/7/365. After notification of a death, he/she either personally visits or telephones the nursing unit/clinic/procedure area. The service can be contacted at 467-7000 or via pager 3263. The Decedent Care Specialist acts as a consultant to the physician and family at the time of a patient's death. The Decedent Care Specialist knows the requirements of state law concerning proper documentation of the death, provides assistance in preparing the autopsy consent form, and can assist you in obtaining consent for an autopsy. Note that physicians are primarily responsible for discussing an autopsy with family members and obtaining verbal consent. The Decedent Care Specialist will provide support and expertise to you, as needed, before/during/after your discussion with the family. The Decedent Care Specialist will coordinate the autopsy-related paperwork, including ensuring that the consent area is properly completed by the correct family member.
If the family is not present in the hospital at the time of death, it will be necessary for the Decedent Care Specialist to make contact by telephone. If the family agrees to an autopsy over the telephone, the Decedent Care Specialist will instruct them about how to send permission for the autopsy via fax. A monitored phone call is unacceptable as permission for an autopsy
. It is also important to inform the family that it is not necessary for them to come to the hospital after the death. If the family is at University of Iowa Hospitals and Clinics, however, it is helpful to ask the family to stay at UI Hospitals and Clinics until one of our Decedent Care Specialists has had the opportunity to speak with them in person or by telephone. Keep in mind that hospital policy requires the decedent to be delivered to the Decedent Care Center within two hours after the death, although the Decedent Care Specialist may grant exceptions to this guideline in unusual circumstances.
The Usefulness of the Autopsy
The autopsy represents the ultimate quality assurance mechanism available to the practice of medicine. The primary purpose of the autopsy is, therefore, to improve the quality of care that we provide. Studies indicate that physicians are surprised by the results of an autopsy in about 20% of cases. Furthermore, clinicians are not able to predict those cases in which they are likely to learn of significant unexpected findings. It is important to obtain an autopsy as often as possible, even in those cases where you have no doubt as to the cause of death
The Autopsy Consent Form
In a non-medical examiner case, the autopsy consent form must be signed by the next of kin, as required by state law. The Decedent Care Specialist knows which individuals constitute the legal next of kin and is a valuable resource as to proper entries on the form.
The Pathology Consultation Request for Postmortem Examination (The H-4)
The UI Hospitals and Clinics physician caring for the patient at the time of death should complete the second page of the H-4 form as soon as possible following the death. Please note the following points:
- The autopsy service cannot answer questions that you may have concerning your patient's disease processes unless you communicate your questions in the appropriate area of the H-4 form.
- The autopsy will not start until the autopsy service physician has had the opportunity to review the entire medical record.
- The more inclusive the permission you secure for the examination, the more likely it will be that optimal information will be obtained. You should always strive to obtain permission for an unrestricted autopsy (head, neck, chest, abdomen, pelvis). However, if it becomes clear that the family will not give permission for a complete examination, then discuss the option of a limited examination, which is far more useful than no examination. The Decedent Care Specialist is an invaluable resource with reluctant families, who may harbor fears of "mutilation" of the body or inability to view the body after an autopsy. Best results are often obtained if the family is allowed to recover from the initial shock of the loss before being queried about the possibility of an autopsy. It is useful to point out that ours is an important education center in the US; autopsies are a vital component of our educational mission.
- Indicate that there is no charge to the family of any patient of the UI Hospitals and Clinics for the autopsy examination.
- Please do not tell the family when the results of an autopsy will be ready! The amount of work and the length of time required to complete an autopsy are considerable. The time interval depends upon the complexity of the case. Promising results to a family by a certain date often leads to unrealistic expectations, anxiety and anger towards our institution if that promised date is not met. The uncomplicated autopsy can usually be completed in about 30-45 days. A complicated case may take longer.
- State law requires health care personnel to place a warning with the body of all cases of "known" or "suspected" infectious disease (hepatitis, Jacob-Creutzfeldt disease, AIDS, etc.). Nursing unit staff will take care of this task for you using standard mechanisms to communicate information about precautions to be taken.
- The autopsy request form is a request and permission for an examination; it is not an order for a test. Only a state or county medical examiner has the authority to order an autopsy.
- The physicians performing the examination will determine the risk of every examination to the personnel involved with the autopsy and may rarely choose to limit the examination to those areas that are likely to answer specific questions. However, we do not in any way want to discourage you from obtaining permission for an examination in any infectious case.
- Please do not make arrangements with individuals outside this institution to do research on tissues recovered at autopsy without having the prior consent of the Department of Pathology. There are a number of strict legal requirements that need to be met before we can comply with such requests. If the autopsy permit stipulates that tissues will be sent to researchers outside this institution and prior arrangements have not been completed with our department, we will be unable to perform the autopsy examination.
The state of Iowa has maintained a registry of deaths in the Iowa Department of Public Health since 1880. The information derived from these certificates is used by state and federal officials to set funding priorities in the health field and in determining long-term health trends in this country.
In Iowa, the funeral home arranging for the final disposition of the decedent is responsible for initiating the death certificate using the Electronic Death Registration System (EDRS). Licensed Independent Practitioners (LIPs) are required to sign and enter pertinent information in the EDRS via the Iowa Vital Events System (IVES). Families need the death certificate completed in as timely a manner as possible to proceed with financial and legal issues. Following a death, the LIP who pronounced death of the patient will receive emails through the IVES system and from the Decedent Care Center staff with further instructions/information regarding the requirements to certify the death using EDRS/IVES. LIPs are encouraged to contact the Decedent Care Center at 467-7000 to request that one of our Decedent Care staff members assist you in completing the required information in the EDRS, if needed.
LIPs are prohibited from using mechanisms or modes of death on the certificate in place of causes of death.
It is often difficult to distinguish between mechanisms or modes and causes of death. As a general rule, a differential diagnosis can be made for mechanisms or modes of death, but not for causes of death. For example, shock has a number of causes and therefore is a mode of death. The sepsis that resulted in shock is the cause of death. Likewise, cardiac arrest is a mode of death. The atherosclerotic coronary artery disease that caused the myocardial infarction that resulted in the cardiac arrest is the cause of death. You may also think of this in another way. If all dead people have the entity that you would like to list as a cause of death, then it is likely to be a mode of death. All dead people suffer from low blood pressure (shock), cardiac arrest and pulmonary arrest. You will see on the death certificate instructions that these diagnoses are specifically prohibited from use as a cause of death. Their use virtually guarantees that you will be required to file an amended certificate
Cause of death
: A disease or injury that results in the death of the individual. If there is a time delay between the onset of the disease or injury and the time of death, then the cause can be divided into one of the following categories:
Underlying Proximate cause of death
: When there is a time interval between the onset of the disease or injury and the ultimate death, this is the process that started the chain of events that eventually resulted in the death. The interval may be many years (e.g., atherosclerotic heart disease, diabetes, some tumors).
Immediate cause of death
: This is the disease or injury that developed just before the death and resulted in the death.
To illustrate the difference, consider the case of the individual who was shot in the vertebral column and spinal cord, and survived. Over the next 20 years the neurogenic bladder was repeatedly infected. Finally, the patient developed pyelonephritis and died. In this case, the proximate cause of death is a gunshot wound of the vertebral column and spinal cord. The immediate cause of death is pyelonephritis.
Mechanism or mode of death
: A pathophysiologic derangement that is incompatible with life. It is a common final pathway to death for a number of disease processes.
Manner of death
: Is a legal determination of the circumstances surrounding the death. The manner of death cannot be determined by examining the patient. It is determined by the events that resulted in the death. The manner of death is listed by the medical examiner as one of the following:
The concept of manner of death can be illustrated for the spine injury example above. If the individual was shot by someone, the manner of death would be: 1) accidental, if a stray hunting bullet hit the person, or 2) homicide if the wound was intentionally inflicted. If the wound was self-inflicted, the manner of death would be: 1) accidental, if the individual was cleaning the rifle and it discharged, or 2) suicide, if the wound was purposefully inflicted. If there is no information concerning how the injury was inflicted, the manner of death would be undetermined. You may only mark "natural" as a manner of death. Only the medical examiner has the authority to mark "accidental", "suicide", "homicide" or "undetermined".