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Michael Hogarth, MD
Professor, Pathology and Laboratory Medicine
Professor, Internal Medicine
Informatics Director ± California Electronic Death Certificate System (EDRS)
mahogarth@ucdavis.edu
http://www.hogarth.org
2 




v Review the basics of autopsy and the death
certificate
v Autopsy
v Help answer questions you may have about the autopsy
process or procedure
v Provide you with tips on how to obtain autopsy consent
v Death Certificate
v What is a death certificate?
v What is your role?
v Common issues/questions with death certificates
º


| 

v It is still the foremost quality control tool in medicine, yet the rate is
falling precipitously
v 1960: 50% rate
v 1994: 6% rate
v Quality Control aspects of autopsies
v Battle et al (JAMA 1987) - major discrepancies between pre and post
mortem diagnoses 13% of the time
v Shojania et al (JAMA 2003)
v Of 53 autopsy series reviewed, 42 reported major diagnostic errors
defined as Xclinically missed diagnoses involving a principal underlying
disease or primary cause of death
v ºhere is a 24.4% major diagnostic error rate, and a 6.7% Class I major
diagnostic error rate
 
 


v Most medical students today graduate without seeing an autopsy
performed«
v Few institutions teach physicians about autopsies
v Only 7.1% of institutions supply educational materials for the physician, as
recommended by the College of American Pathologists
v 74.5% of Peds&Med Chief Residents felt that educational materials would
be beneficial for physicians and the family
v ºhe (lack of) value of Xlimited autopsies
v 93.3% of Chief Residents believed that a limited autopsy should be offered
to families
v 90% of Pathologists at the same institutions believed that limited autopsies
are an unsatisfactory alternative to the complete examination

Rosenbaum et al. Autopsy Consent Practice at US ºeaching Hospitals

Archives of Internal Medicine, 160, Feb 14 2000
 á


 
 
v Do you feel knowledgeable about the following?
v Surgical procedures used in the removal of tissues and organs:
37%
v ºhe types of tests done on these tissues/organs: 41%
v ºhe range of techniques available to perform an autopsy: 71%
v As practiced in your institution, are physicians who request
autopsy instructed on the following?
v ºhe autopsy procedure: 56%
v How to perform an autopsy consent: 41%
v Religious and cultural concerns regarding autopsy and
postmortem care: 83%

Rosenbaum et al. Autopsy Consent Practice at US ºeaching Hospitals

Archives of Internal Medicine, 160, Feb 14 2000
 º

  


v Could you explain it to a family member? Or to your family
if it were one of your loved ones?
v What is done?
v Medical history review
v External Examination
v Internal Examination
v Preliminary Autopsy Report
(Gross Examination Only)
v Histological Examination
v Clinicopathologic Correlation
v Final Autopsy Report

Hanzlick et al. ºhe Autopsy Lexicon. Arch Pathol Lab Med, 124, April 2000
| 2 


v >ext of kin ± Spouse, Child, Parent, Sibling

v Legal guardian (conservator)
v Other relative
v Public officer
º


  

v Presentation
v How the body was wrapped, protected, prepared, or stored prior to
autopsy
v Clothing, personal effects, other (string used to tie the wrists may leave
a mark)
v Evidence of medical intervention
v Bandages, tubes/catheters
v Post mortem changes
v Post mortem imaging studies (sometimes are done)
v Features of identification: hair color, length, texture, eye color, other
distinctive features
v External physical examination
v General, head, neck, torso, upper extremities, lower extremities, etc..
˜

  

v Dissection method
v does not mean the family cannot have an open casket funeral.
v Organs: weight, size, features
v >oting appearance of cavities and organs, if fluid is present
(cloudy, bloody?)
v Systems:
v Chest/Abdomen
v Cardiovascular system
v Respiratory system
v Digestive system
v Hepatobiliary system
v Reticuloendothelial system
v Urogenital system
v Endocrine glands (thyroid, adrenal, parathyroids)
v C>S as appropriate
‰  

v ºhe examination of the central nervous
system often benefits significantly from a
neuropathologist
v ºhe brain is removed from the calvarium
and dissected at a later time -- once
allowed to fix adequately
v Ubrain cutting occurs later, thus brain slides
may take more time to be processed and
reviewed
º
á
  


v Histology specimens are prepared from a standard set of organs,

and from areas felt to be suspicious for a disease process
v In most cases, a set of Urepresentative tissue samples of each
organ are put into cassettes for processing and later slide
preparation
v It may take upwards of 2-3 weeks for these slides to be prepared,
and reviewed by the pathologist
v Slide review is an ideal opportunity to interact with the Pathologist and
discuss the case before the final autopsy report is rendered!!
v Slide review is one of the richest educational opportunities for the
clinician in the autopsy process ± I HIGHLY RECOMME>D Iº!!
º

 


v >ot generally emphasized in training programs, but critical in improving autopsy

rates«
v ºhere are many ways to do this - everyone develops their own style.
v Suggested approach post mortem conference with spouse, family
v ºhe day following the death ±call the family/spouse to arrange
v What does it do?
v Allows you to talk to the spouse/other and family in a quiet setting *after* the immediate trauma of the
loved one s death
v 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..
v You can discuss Uwhat 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.
v Be ready to:
v Explain why an autopsy is important
v Explain how it is done, explain the process (prelim report, final report, how long, how will feedback be
provided to them)
v Explain whether organs are retained and for how long, etc«
v Consider a post-autopsy conference with spouse/family ±typically can take place ~30days after the
death
ï



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v A legal document to settle an estate
v A source of information for the family
v A source of mortality statistics for scientists and
public health officials

v Xºhe death certificate functions as both a legal

document and as the raw data for epidemiological
information that drives health care policy in many
countries including the U.S.
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v A permanent record of the fact of death
v It is a required document before a burial permit
is issued
v It is a source of important personal information
and circumstances of death
v for use in the settlement of the individual s estate
v Used to understand trends of disease and
mortality in order to allocate research and
development funding
A 





v Earliest beginnings in recording health information
v deaths in >orthern Italy were registered starting in the 12th century
v 1385 - Florence Bills of Mortality
v 1496 ± Mantua¶s ³Books of the Deceased´

licensed physicians issued certificates of death

placed in the ³Books of the Deceased´

v England began recording deaths (and births) around 16th

century
v done at the Parish level (Burials and Christenings of the week)
v data collected and eventually submitted to a central office in
London
v Given the past 400 years of history in collecting data on
death and disease, it is clear that using a system to
categorize cases of disease is important to information-based
processes (both manual and automated) in biomedicine
º






v Bills of Mortality (London, 16th Century)
v collected by parish clerks
v John Graunt (1620-1674)
v well known London merchant
v introduced the notion of nosology
v used Bills of Mortality to make important observations that
were unknown, or unrealized, at the time
v infant mortality, urban versus rural, etc..
v for example, 36% of children died before age 6
v A link to John Graunt¶s conclusions from this data set:
http://www2.sunysuffolk.edu/westn/mortality.html
v A link to the text of ³Observations on the Bills of Mortality´:
http://www.edstephan.org/Graunt/bills.html
    
  !"#$
v British physician who was
skeptical of the dominant
theory of disease (miasma ±
bad air)
v Used the London Bills of
Mortality and a map of London
to show clustering of cholera
cases around a water pump
v With this, Snow used statistics
to show the connection
between cholera and a water
source
v ºhe µfather¶ of of epidemiology
º



%




v Statistics ± ³data about the state´
v William Farr ± First Statistician - Office of
the Registrar, London
v had to collate µbills of mortality¶ from all parishes
and analyze trends
v 1880¶s: originated the idea of an µinternational
classification for causes of death¶ - ICD
%



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v Personal Information

v Medical Information

v Coroner Information (if a coroner case)


  ˜

v Decedent information
v dob, dod, place of birth current address, marital status,
occupation, spouse/parent information
v Informant
v name and address of the person supplying the information
v Disposition information
v type of disposition (cremation, burial -- where ?at sea)
v Who is doing the disposition - funeral home, family
(California allows families to perform their own
dispositions - need to have a funeral home overseeing it)
2
 ˜

v Place of death
v hospital (inpatient vs ER vs DOA)
v Address/location
v Causes of death
v Part I - immediate cause of death and underlying causes
v includes *estimated* time between onset and the death
v Part II - related conditions
v ?Any operations performed for the cause or underlying causes
v ?Autopsy performed - ?used to establish cause of death
v ?Pregnant
v ?Smoker
v ?Coroner case




v Manner of death
v Homicide, suicide, natural, undetermined
v Circumstances of the injury (text
description)
v Location where injury occurred - home,
school, road location, etc..
2
 ˜

v Basic demographics plus«
v Causes of Death - 3 basic components in
two parts (Part I and Part II)
v Part I
v Immediate cause of death
v Underlying cause(s) leading to immediate cause
v Part II
v Related Conditions
  






Immediate cause

Underlying cause(s)

Related conditions
 


v Designed to elicit the *opinion* of the medical

certifier
v Don t get hung up on avoiding being wrong -- it is your
opinion, your best judgment, based on available
information
v XProperly completed, it provides an etiologic
explanation of the order, type and association of
events resulting in death
 
˜(˜


 


v Immediate Cause
v ºhe disease or injury that started the
sequence of events leading directly to
death
v Does >
mean the Xmechanism
of death or terminal event
v Cardiac arrest, pulmonary arrest,
cardiopulmonary arrest are
Umanners of death not
mechanisms!!
 
˜(,
  

v ºhe XChain of events leading to death,
proceeding backwards from the final stage or
condition resulting in death
v Due to:
v ù
  Cause A
v Due to:
v Underlying Cause B
v «
 
˜˜(ï




v Part II
v All other important diseases or conditions that
were present at the time of the death that may
have contributed to the death, but did not lead to
the underlying cause of death in Part I


v Avoid paralysis by analysis
v ºhere is more than one way to write a cause-of-death statement
± don t think you can only do it one way or only one opinion is
correct«
v Avoid using a manner of death rather than a cause
v XCardiopulmonary arrest , Xcardiac arrest , etc« --
no,no,no!
v Avoid using a description of the individual rather than a
cause:
v XSenescence , Xinfirmity , Xold age
   








v ºhere are two places that identify a physician on the death
certificate
v Certifier
v Attending Physician
v Certifier -- certifies as to the causes of death (his/her
opinion!)
v Attending Physician -- the physician who attended the
individual (the physician who best knew him from a clinical
perspective)
v >OºE:
v ºhe certifier and the attending are typically the same person,
but it is not require that they be the same person
   








v Certifier
v Signs the
certificate(#115)
v License number (#116)
v Attending physician
v Only name and address
(#118)
|
   
 

v You must Xattest to the causes of death by
entering them on the death certificate and signing
the medical certification within 15 hours of death
v You must report to the coroner s office
Xreportable deaths (discussed later)
v If you unduly interfere with the completion of a
death certificate, you can be guilty of a
misdemeanor
v « try not to Urefuse to sign one -- it is a duty required
of licensed physicians (not optional)
ï


v CDC Handbook on
Medical Certification of
Death
v http://
v Electronic Death
Registration System
website:
v http://www.edrs.us



 |
  

v Coroners are an English tradition
v ºhe crown established Xcrowners to investigate
causes of death
v the crown had a financial interest
v suicide was a felony offense and felons forfeited all their
belongings to the crown
v Murder allowed collection in two ways
v Murder was a felony offense
v ºown was punished by a murder fine, an Uamercement
levied by the crown against the town for allowing a civil
disturbance

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





v Xto ensure, on behalf of the community, that sudden
and unexpected death, or those deaths that occur under
violent or suspicious circumstances are thoroughly
investigated. ºhe Coroner will examine the
circumstances surrounding all Xà
à o  o
v determine the identity of the deceased
v determine the time, place, cause and manner of death
v comment on matters, including public health and safety,
connected with the death

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



v ºhe coroner and deputy coroners are sworn peace officers
v ºhe coroner and deputy coroners have investigative
authority
v ºhey are required to perform the coroner functions as
defined in Calif. Government Code, section 27491
v 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
>OºE: A medical examiner is a physician trained in forensic autopsies. A coroner is not
necessarily a medical examiner, but there can be coroner/medical examiners in some
counties.
º
  


 A

v Sacramento County has an
Xindependent coroner s
office , which means it is
separate from the Sheriff s
department.
v http://coroner.saccounty.net/

v 12 counties in California have

independent coroner offices,
the other 46 combine it with
the Sheriff s department.
 |
  X





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


v ºhey assign a number (coroner s
number) to the case -- does not mean they
will conduct an autopsy/investigation
v ºhey may elect to investigate and they will
let you know during the phone call (usually)


v 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 a
surgery. 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 infection
that month.
v Is this a coroner¶s case?
r