This appendix is designed to give you an understanding of the role of the autopsy service at the UIHC. A hospital mortician is on call 24 hours a day, 365 days a year and comes to the unit after every death. The service can be contacted at 335-8258. The mortician acts as a consultant to the physician and family at the time of a patient's death. The mortician knows the requirements of state law concerning proper documentation of the death, provides assistance in preparing the autopsy request form, and can greatly assist you in obtaining permission for an autopsy with reluctant families. Taking advantage of their expertise can be a tremendous time and trouble saver for you during your stay at the UIHC.
If the family is not present in the hospital at the time of death, it will be necessary to make contact by telephone. It is advisable to wait until the mortician arrives on your unit to make contact with the family. If the family agrees to an autopsy over the telephone, the mortician will need to instruct them about sending a collect telegram confirming their permission for the autopsy. Datagrams and faxes are now also permissible. 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. Keep in mind that hospital policy requires the body to be sent to the morgue within 2 hours after the death, although the mortician may grant exceptions to this rule 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 all provide. Studies over the last 25 years 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 be surprised. 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 Request Form
The autopsy request form must be signed by you and the next of kin, as provided by state law. The mortician knows who constitutes the legal next of kin and is a valuable resource as to proper entries on the remainder of the form. Please note the following points:
1. 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.
2. The autopsy will not start until the autopsy service physician has had the opportunity to review the entire medical record. It is imperative that you do not hold the chart if an autopsy is to be performed.
3. 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. However, if it becomes clear that the family will not give permission for a complete examination, then remember that a limited examination is vastly superior to no examination. The mortician 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 research center in this country and we need as many autopsies as possible if we are to do our part in the advancement of medical knowledge.
4. It should be indicated that there is no charge to the family of any patient of the UIHC for the autopsy examination.
5. 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 is 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.
6. 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 service will take care of this task for you.
7. 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.
8. The physicians performing the examination will determine the risk of every examination to the personnel involved with the autopsy and may occasionally 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.
9. Please do not make arrangements with individuals outside this institution to do research on tissues harvested 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.
Physician in Charge of Patient
Discuss and obtain authorization for post-mortem examination from family, next-of-kin, or person having custody of the body. Criteria for requesting an autopsy have been approved by the Professional Practice Subcommittee. The following circumstances should initiate a special effort on the part of the physician to obtain an autopsy.
I. Deaths occurring during or within one (1) week of an invasive procedure (e.g. central catheter placement, angioplasty, chest tube placement, induced abortion, therapeutic hemapheresis procedures). Deaths under anesthesia, during or after surgery, particularly those cases in which new surgical procedures are employed, due to postoperative complications, and deaths following an unscheduled readmission within 15 days of discharge.
II. Deaths occurring within one (1) week of major trauma.
III. Maternal postpartum death within one (1) week of delivery.
IV. Cases in the following categories:
A. Fever of unknown origin.
B. Malignancies, treated or untreated.
C. Suspected transfusion or drug reactions.
D. Cases in which the primary disease process is not clearly supported by clinical and laboratory data.
E. Cases in which secondary or incidental disease processes may have significance for the family.
F. Deaths related to occupational exposure.
G. Deaths in patients in which new diagnostic techniques have been used and in which correlative data on the efficacy of the test can be gathered.
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. Starting January 1989, a modified death certificate has been used in the state to help insure that accurate information is provided in a timely manner. Several new regulations have been added to improve the usefulness of the data. These regulations place significant time restraints on our state's physicians and funeral directors.
The death certificate must be signed by a physician within 24 hours of the death. The certificate must be filed with the clerk of court within 72 hours of the death and prior to final disposition of the body. Finally, and more significantly, the physician is now prohibited from using mechanisms or modes of death on the certificate in place of causes of death. If you put a mechanism or mode of death on the certificate instead of a cause of death, the Iowa Department of Public Health will return the certificate to you and will require that you file an amended report. Because you are going to be very busy, and because we are too, our time will be conserved for more productive duties if this situation does not arise.
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.
Some Definitions
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 or Proximate cause of death: When there is a delay 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.
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, take the case of the individual who is shot in the spine and survives. Over the next 20 years the neurogenic bladder becomes repeatedly infected. Finally, the patient develops pyelonephritis and dies. In this case, the proximate cause of death is gunshot wound to the spine. 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:
Natural
Accidental
Suicide
Homicide
Undetermined
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".