When Your Patient Dies

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

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 What is a death certificate? What is your role? Common issues/questions with death certificates 

Death Certificate 

The Autopsy

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 as clinically missed diagnoses involving a principal underlying disease or primary cause of death There is a 24.4% major diagnostic error rate, and a 6.7% Class I major diagnostic error rate

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, as recommended by the College of American Pathologists 74.5% of Peds&Med Chief Residents felt that educational materials would be 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 autopsies are an unsatisfactory alternative to the complete examination

Rosenbaum et al. Autopsy Consent Practice at US Teaching Hospitals Archives of Internal Medicine, 160, Feb 14 2000

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 request autopsy 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 US Teaching Hospitals Archives of Internal Medicine, 160, Feb 14 2000

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

Who May Consent 

Next of kin ± Spouse, Child, Parent, Sibling Legal guardian (conservator) Other relative Public officer

The External Examination 


How the body was wrapped, protected, prepared, or stored prior to autopsy Clothing, personal effects, other (string used to tie the wrists may leave a mark) Bandages, tubes/catheters 


Evidence of medical intervention 

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..

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

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

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 each organ are put into cassettes for processing and later slide preparation 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 RECOMMEND IT!!

The Autopsy Consent 

Not generally emphasized in training programs, but critical in improving autopsy rates« 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 one s 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 discuss what 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. 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 

Be ready to: 

Recording Deaths

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 and public health officials The 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. 

Why is it important? 

A permanent record of the fact of death It is a required document before a burial permit is issued It is a source of important personal information and circumstances of death 

for use in the settlement of the individual s estate 

Used to understand trends of disease and mortality in order to allocate research and development funding

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 in London 

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

The importance of death data 

Bills of Mortality (London, 16th Century) 

collected by parish clerks well known London merchant introduced the notion of nosology used Bills of Mortality to make important observations that were unknown, or unrealized, at the time 

John Graunt (1620-1674) 

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

John Snow and Cholera (1854) 

British physician who was skeptical of the dominant theory of disease (miasma ± bad air) Used the London Bills of Mortality and a map of London to show clustering of cholera cases around a water pump With this, Snow used statistics to show the connection between cholera and a water source The µfather¶ of of epidemiology

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

Vital Statistics ± 1851 Mortality Tables

Vital Statistics - today

California CDPH - OHIR

The Death Certificate

The Law ± California Codes Health and Safety Code Section: 102775-102805
102795. 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 physician assistant 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's certification 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.

Components of a death certificate 

Personal Information Medical Information Coroner Information (if a coroner case)  

Personal Information 

Decedent information 

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


Disposition information 

Medical Information 

Place of death 

hospital (inpatient vs ER vs DOA) Address/location
Part I - immediate cause of death and underlying causes  

Causes of death 

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

Coroner section 

Manner of death 

Homicide, suicide, natural, undetermined

Circumstances of the injury (text description) Location where injury occurred - home, school, road location, etc..

Medical Information 

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 Related Conditions 

Part II 

Cause of Death Section

Immediate cause Underlying cause(s) Related conditions

Cause of Death 

Designed to elicit the *opinion* of the medical certifier 

Don t 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

Part I: Immediate Cause of Death 


The disease or injury that started the sequence of events leading directly to death  Does NOT mean the mechanism of death or terminal event 

Cardiac arrest, pulmonary arrest, cardiopulmonary arrest are manners of death not mechanisms!!

Part I: Underlying Causes 

The Chain 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 «

Part II: Related Conditions 

Part II 

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

Common problems 

Avoid paralysis by analysis 

There 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« Cardiopulmonary arrest , no,no,no! cardiac arrest , etc« -- 

Avoid using a manner of death rather than a cause  

Avoid using a description of the individual rather than a cause: 

Senescence ,

infirmity ,

old age

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 the individual (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

Physicians on the Death Certificate 


Signs the certificate(#115) License number (#116) Only name and address (#118) 

Attending physician 

What is your legal obligation?  

You must attest to the causes of death by entering them on the death certificate and signing the medical certification within 15 hours of death You must report to the coroner s office reportable deaths (discussed later) If you unduly interfere with the completion of a death certificate, you can be guilty of a misdemeanor 

« try not to refuse to sign one -- it is a duty required of licensed physicians (not optional)


CDC Handbook on Medical Certification of Death 


Electronic Death Registration System website: 


Coroner Cases

What is a coroner? 

Coroners are an English tradition The crown established crowners causes of death the crown had a financial interest 

to investigate 

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, an amercement 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

Role 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 the circumstances surrounding all reportable 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


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 as defined 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 not necessarily a medical examiner, but there can be coroner/medical examiners in some counties.

The Sacramento Coroner s Office 

Sacramento County has an independent coroner s office , which means it is separate from the Sheriff s department. 


12 counties in California have independent coroner offices, the other 46 combine it with the Sheriff s department.

What is a
1. 2. 3. 4.



violent, sudden, or unusual deaths; unattended deaths; deaths wherein the deceased has not been attended by a physician in the 20 days before death; 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. 6. 7. 8. 9. 10. 11.

deaths in prison or while under sentence; deaths known or suspected as due to contagious disease and constituting a public hazard; deaths from occupational diseases or occupational hazards; deaths of patients in state mental hospitals serving the mentally disabled and operated by the State Department of Mental Health; deaths of patients in state hospitals serving the developmentally disabled and operated by the State Department of Developmental Services; deaths under such circumstances as to afford a reasonable ground to suspect that the death was caused by the criminal act of another; and any deaths reported by physicians or other persons having knowledge of death for inquiry by coroner.


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 following circumstances: (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.

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)

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 a surgery. He unfortunately suffers a significant postoperative infection that lands him in the ICU. He has more complications and eventually expires from a hospital acquired pneumonia ± his third infection that month. Is this a coroner¶s case?


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