Saving Lives: Organ Donation in Medical-Legal Cases

JAMES R. GILL, M.D. CHIEF MEDICAL EXAMINER, CONNECTICUT

LISA PAOLILLO, ESQ. SVP & GENERAL COUNSEL, NEOG Agenda

 Legal Background  Medical Examiner (and District Attorney) Role  Restrictions in Pediatric Cases  Organ Donation in cases under investigation by MEO Legal Background

 Uniform Anatomical Gift Act  Governs authorization for deceased donation  Governs MEO (and DA) role in organ donation

 MEO and OPO shall cooperate to “maximize the opportunity to recover anatomical gifts for transplantation, therapy, research or education.”  Massachusetts: District Attorney approval required

 OPO must provide notice to the MEO (and DA) of authorization to recover anatomical gift if donor died under circumstances within jurisdiction of MEO (and DA)

UAGA

 The CME (and DA) may approve or deny removal of the anatomical gift

 Within a time period that ensures the preservation of the anatomical gift for transplantation  Attend recovery if donation would otherwise be denied  If deny recovery, explain the reasons for determining that the organs may be involved in the cause of death.

 Immunity from liability if act in good faith Medico-Legal Cases 2013-2016

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100 49 40 17 3 0 Pediatric Pediatric Organ ME Cases ME Restrictions Full Restriction Heartbeating Donors Referrals MEO CASES

 MEO investigates the circumstances surrounding deaths due to  Unnatural means  Natural means requiring further investigation Forensic Pathology

Subspecialty in pathology involved in the examination of the living and the dead in order to provide an opinion concerning the cause, mechanism, and manner of disease, injury, or death. Physicians in USA

 ~1,000,000 Physicians  ~500 Board Certified Forensic Pathologists 4 years college 4 years medical school 3-4 years residency in pathology 1 year fellowship in Forensic Pathology National Examinations Death Investigation System Needs:

 Authority to take charge of the body  Autopsy without permission  Subpoena power (e.g., medical records, HIPAA exemption)

Reportable Deaths (CT)

 Accidents, suicides, homicides (All unnatural).  Poisoning, drug abuse, addiction.  Disease with potential public health threat.  Deaths resulting from employment.  Sudden and unexpected deaths not caused by a readily recognized disease.  DOA or within 24 hours of admission to hospital (“No Case”).  Death under anesthesia, in operating or recovery room, following transfusions, or during diagnostic procedures.

Medical Legal Investigators

 Death reported and MLI does initial investigation  Hospital vs. Scene Death  Writes report of circumstances, scene (photos)  Next morning (9 AM): ME reviews case and decides if autopsy  24/7, 365 days a year Medical Examiner

 Certify Cause and Manner of Death  Identification of decedent  Testify: Homicides, civil actions  Public Health (meningitis, statistics)  Educate  On-Call ME (24/7): Organ/Tissue Donor Permission on OCME deaths MANNER of DEATH vs. CAUSE of DEATH Cause of Death

The Disease and/or injury responsible for the fatality. Proximate Cause

That which in a natural and continuous sequence, unbroken by any efficient intervening cause, produces the fatality and without which the end result would not have occurred (etiologically specific). Cause and Manner

There is NO time limit for the cause or manner of death. Manner of Death

Explanation of how the cause arose. Manner of Death

 Natural  Unnatural Homicide Suicide Accident Therapeutic Complication  Undetermined Benefits of Autopsy

 Establish Cause of Death  Assist in Determining the Manner of Death  Produce Accurate Vital Statistics  Identify New and Changing Disease  Monitor the Public Health Benefits of Autopsy

 Reassure Family Members  Instruct Medical Students and Physicians  Compare Premortem and Postmortem Findings  Assess the Quality of Medical Practice  Evaluate the Effectiveness of New Therapies Special Cases

 Infant (eyes)

 Homicides (stab wound of chest) Overview of Donation Process Hospital For Organ Donation Cases identifies potential donor

Hospital notifies Preliminary NEOB of phone screen & potential donor registry checked Organ allocation

Donation Verification of Organs accepted Coordinate Coordinator registry, chart by transplant recovery time & notified of review centers schedule OR referral

Declaration of Determination of Moment of Death by Silence, family Post mortem medical Neurological suitability with Criteria/Family statement, organ care CDOC decision to withdraw recovery support.

Huddle with Family meeting/ Ongoing Confirmation of hospital staff: Obtain support for organs & follow Pre-family Authorization family Organ allocation up testing approach huddle

Notify/Confirm Follow up with notification of Organ specific Obtain Clearance Donor MEO/DA on MEO, DA re: evaluation & from MEO/DA management requested Potential Donor testing Under Jurisdiction information MEO Cases

 Reporters  Physicians  Law Enforcement Officers  State's Attorneys  Prosecuting Attorneys  Funeral directors  Embalmers

How do we move forward in pediatric cases under investigation by the MEO/DA cases?

 MEO/DA and OPOs both serve important public purposes  Information is the Key  Medical Records (Progress Notes, Imaging Reports)  Imaging (CT, X-Ray, MRI)  Laboratory Testing (Blood Tests, Tox Screens)  Photographs  Attending Physician Discussion  CMO Discussion  Attend Recovery

Cooperation