Medical Examiner Release of Organs and Tissues for Transplantation

RELEASE OF ORGANS AND TISSUES Pinckard et al. • Page 497

purposes. scholarly for solely © 2014 Association of Medical Examiners National J. Keith Pinckard MD PhD is Deputy Chief Medical Investigator and Professor of Pathology at the University of New Mexico Office of the Medical Investigator. Affiliations: Hennepin Author County Medical Examiner’s Office (RG), Office of the Chief Medical San Francisco (EM), Examiner, Polk County Medical Examiner, (GAS), District Des Moines, IA 12 Medical Examiner’s Office, Tissue LifeLink and Sarasota, FL (DS), District 12 FL Tampa, Bank, Medical Examiner Office, Sarasota, Examiner (SRU), Medical FL and Commonwealth of Virginia Assistant Medical Director LifeNet (SBW). Health Virginia Pinckard at: Contact Dr. [email protected]. Acad Forensic Pathol 2014 4 (4): 497-504 - members NAME

by distributed be may but use, personal Organ donation has grown in public support and has grown in public donation Organ the media awareness in the past decades due to amazing coverage of its success stories and the world. Cur in the transplantation innovations people in are more than 100 million there rently, other Many (5). donors be up to U.S. signed the their of percentages greater even have countries The general as donors. registered population and their lobby- public, lawmakers, politicians, ists definitely support this magnanimous legacy and tissue donation. of organ tissue and organ specialized have often Children lists waiting on remain and needs transplantation Their bodies can- for a longer period of time. Al- organs. the size of adult not accommodate lograft valves are preferred in valve replacement of donor organs scarcity Thus, the children. in size since organ acute for children is especially heart, and lung transplantation matters for liver, deaths few size-matched relatively and there are pro- transplant Pediatric in younger children. because programs adult than smaller are grams they and transplantation, require children fewer health children’s in expertise special offer must care. In addition, unlike for adults, children and adolescents cannot provide first-person consent Therefore, parents and tissue donation. for organ of young children usually must make a donation knowledge direct of any absence the in decision for - - intended is article This member. NAME a by Forensic pathology, Organ transplantation, Tissue transplantation, Autopsy transplantation, Tissue Organ transplantation, Forensic pathology, ransplantation Downloaded tation successes include five-year survival rates of 54.4% for lung, 74.9% for post transplantation for kidney as and 69.3% 73.8% for liver, heart, is no less transplantation Tissue of May 2009 (1). Over six mil common. far more and impressive, allografts have been safely lion musculoskeletal (2). Currently, decade last the in transplanted over one million tissue transplants are performed successful outcomes and annually (3). Reliably problems in the population health continuing and shortages of organs led to perpetual have As of this writing, tissues for transplantation. for list waiting on the are 123 972 people over and another person is added a life saving organ, (1, 4). On average, minutes every ten list to that 18 people across the nation die every day while that may have saved them (1). awaiting an organ Incredible advances in the science of recov- science the in advances Incredible as well as transplantation, and processing, ery, have therapy, immunosuppressive improved possibilities and outcomes the improved vastly of advantages The medicine. for transplantation tissues, or and organs of human transplantation human derived cellular therapy products as first have of conditions multitude for a treatment line lifesaving these of shortage the to contributed transplan organ Solid gifts. enhancing life and INTRODUCTION KEYWORDS: for T endorsed a position Association of Medical Examiners (NAME) The National ABSTRACT: paper on the medical examiner/coroner (ME/C) release of organs and tissues in cases falling The goal of this paper is to under ME/C jurisdiction sunsetted. in 2007; this paper has now provide an update on ME/C denials and to reaffirm NAME’s position on this topic. In sum- it is the position of NAME that ME/Cs should permit the procurement of organs and tis- mary, sues in cases falling under their jurisdiction, providing that there are cooperative agreements in place to ensure that ME/Cs are able to fulfill their legal mandates regarding determination appropriate collection and preservation of evidence. of cause and manner of death and of Paper: Medical Examiner Release of Organs and Tissues and Tissues of Organs Release Medical Examiner Paper: J. Keith Pinckard MD PhD, Roberta J. Geiselhart BSN F-ABMDI, Ellen Moffatt MD, MD PhD, Roberta J. Geiselhart BSN J. Keith Pinckard Samantha B. L. Schultz MD, Suzanne R. Utley MD, A. Schmunk MD, Daniel Gregory MD Wetzler National Association of Medical Examiners Position Medical Examiners of Association National Page 498 • Volume 4 Issue 4

Downloaded NAME POSITION PAPER by a NAME member. This men. CBER doesnotregulate the transplantation from peripheral and cordblood,oocytes, and se- sue, hematopoietic stem/progenitor cells derived dons, dura mater, heart valves, veins, adipose tis- tissues are bone, skin, corneas, ligaments, ten- (CBER) regulates HCT/Ps. Examples of such Center for Biologics Evaluation and Research cellular and tissue-based product (HCT/P). The recipient is regulated as ahumancell, tissue, and transplantation, infusion, ortransferintoahuman Human cellsortissueintended for implantation, DISCUSSION this importanttopic. on position NAME’s reaffirm and update to is mendations (17). The purposeofthismanuscript gation published adocument with similar recom Working Group forMedicolegal Death Investi- for transplantation (16). Since then, the Scientific the topicofME/Creleaseorgans andtissues aminers (NAME) published a position paper on In 2007,the National Association of Medical Ex- 15). legislation overriding theME/C’s concerns(11- parties involved (9, 10).Somestates have passed jurisdictions, or poorcommunication between all enforcement and prosecutorsintheirrespective ME/C, whileothersareduetoattitudes of law are duetothevariousmethodsofanindividual situations (8).Someoftheserecoverydenials sought, advocated for, andpassedtoprevent such ly. Indeed, court orders and legislation have been lawmakers do notreceive these allegations light potentially be lifesaving (7). Boththe public and sarily withholdingorgans andtissuesthatcould many O/TPOs to charge ME/Cs with unneces- performance of a ME/C’s statutory duties leads that organ andtissuedonation actually impedes This discrepancy, coupledwiththelack of proof making organs andtissuesavailable toO/TPOs. United Statesarenotuniformintheirapproachto donation wishes. Predictably, ME/Csacrossthe less ofthe family’s ordecedent’s priorconsent or ceeding toorgan andtissueprocurement, regard- consent fromtheME/Cinthesecasesbeforepro- curement organizationsmust obtain (O/TPOs) falling undertheirjurisdiction.Organ/tissue pro- ing andcollecting appropriate evidence in cases ing causeandmanner of death and ofdocument nation; they have the responsibility of determin of these valued organs gatekeepers and tissues for possible do- the themselves find frequently ner (ME/C) jurisdiction (6). Therefore, ME/Cs tential donors fallundermedical examiner/coro It hasbeenestimated that as many70%ofpo- time ofgreatemotionalstress. about theirchild’s donationintentions duringa article is intended for personal use, but may be distributed - - - - -

surrounding structures. formance duetomorenatural functionwiththe pregnant women) andbetter hemodynamic per and children in beneficial (particularly therapy include no needfor long-term anticoagulation However, valves tions. heart allograft of benefits type hasitsownuniqueproblemsandcomplica are transplanted into recipients, and each tissue animals (xenograft)orhumans(allograft), which biological. Biological valves aretheof of replacement heart valves: mechanical and valvular heart disease. There are two main types device implanted into the heart of a patient with saving transplant. A replacement heart valve is a Cardiac valve replacement is consideredalife- other graftsforfutureutilization. ioned intobonepackingmaterial, bone“glue”,or maintained. Crushed bone material can be fash- Some “inventory”ofothergrafttissueisalways require patient ments. specific meet to sizes various with a selection of grafts and insertion tools of sizing must beperfect. Surgeons areprovided between vertebral bodiesafterdiscremoval,the fit to utilized is that graft engineered an In fied. identi is size/recipient specific a until stock” “in pedic spacers and other bone grafts may remain is not currently available. Neurosurgical/ortho specifi- a cally sized Achilles tendonorpatellar ligament because surgery scheduled a cancel needed. For example, a surgeon may have to such asligaments andtendonsaredesperately conditions. Certainmusculoskeletal allografts are life saving for patients with cardiovascular sues such as valves or pulmonary/aortic conduits Many tissuesareofimmediate need. Cardiac tis- tals andsurgeons. are available to bedistributed to waiting hospi- suitability and aquarantine period beforethey through a testing process for determination of highly overstated. All donated tissues mustgo for protractedperiodsoninventoryshelvesis However, theconceptthattissuesare“stocked” cases, ligament repair, andbonereplacement. extended periods oftime for futureuseinburn organs, tissuecanbeprocessed andstoredfor life forrecipients andevensavelives.Unlike valves candramatically improve thequalityof Donated tissuessuchasskin,bone,andheart Immediate Needvs.Stockingof Tissue man organs. oversees thetransplantation of vascularized hu- Resources Services Administration (HRSA) kidney, liver, heart, lung or pancreas. The Health of vascularized human organ transplants such as by NAME members solely for scholarly purposes. - - - - - RELEASE OF ORGANS AND TISSUES Pinckard et al. • Page 499 purposes. scholarly for solely ------members NAME by distributed be , while ventilated) that would may but At worst, the allegation is that the that is allegation the worst, At use, not be unexpected. The finding of an oc by the medical examiner, but release was release but examiner, medical the by medical examiner requested specificorgans personal account for a cause of death is extremely unlikely. account for a cause of death is extremely The Uniform Anatomical Gift Act Act (UAGA) is Gift Anatomical The Uniform Acts drafted by the National one of the Uniform State Uniform on Commissioners of Conference Laws (NCCUSL). For issues that are under state control, each state and not federal legislative issues (e.g., some For own laws. its enact must for such it may be desirable transplantation), from uniform and consistent laws to be relatively is to The intent of the NCCUSL state to state. with suggested language that states can draft acts ratify as written, or modify in part (ideally, either The 2006 as possible) prior to passage. as little ratified been has act gift anatomic the of revision Accord- in some form in almost all states (25). version of the 2006 UAGA, ing to the NCCUSL of procurement, a denial anticipates if the ME/C procedure. the procurement he/she must attend Once there, if he/she still insists on denying the after at- for transplantation removal of an organ mined because of the procurement of organs (24). procurement of organs mined because of the of this particular study is An extensive analysis of this manuscript. In brief, beyond the scope were infant deaths in which four of these cases the aminer’s request. In the fifth case, no denial was issued was al thought to have been granted on what In leged as incomplete or erroneous information. described this series of cases, all of the infants death cat were in the sudden unexpected infant had initial like many in this category, and, egory, asphyxial circumstances suggesting a potential mechanism. That is not a reasonable assumption, as these tion. exam were all cases in which a negative autopsy would kidneys, cult natural condition in the heart, the heart, or the lungs (with clinically functioning lungs, kidneys, liver With regard to organ donation, there is a single donation, there regard to organ With published report of five cases (four infants et al. alleging that their cause and Wolf one adult) by were unable to be deter and manner of death law Texas in keeping with a not be donated, but, ex medical the despite proceeded donation (14), were undetermined cause/undetermined manner dona the outcomes as a consequence of organ cent. Historically, nearly half of the requests to the requests half of the nearly Historically, cent. were denied donations child concerning ME/C dona- surrounding often a concern There is (21). valves) or for heart (either as an organ, tion of the of diagnosing a a fear of the inability because of organ the rate of Currently, cardiac abnormality. is 2.6% (23), which all ME/C referrals denials on many years ago. improvement over is a substantial for ------intended is article This member. NAME a by Downloaded Most of the data regarding ME/C denials are between one and two decades old (20-22), and almost certainly do not represent current practices of approvals/denials. In these studies, overall denial rates were typically between six and ten per Data about Medical Examiner/Coroner Deni- Data about Medical Examiner/Coroner als Some ME/Cs deny procurement of organs and/or and/or of organs deny procurement Some ME/Cs of not concerns to due transplantation for tissues being able to fulfill their legal mandate: to deter express death investigators Some medicolegal and tissue approval of organ concerns regarding the investiga for fear of compromising donation of- ME/C many that is line bottom important The fices have decades of zero or close to zero denials while still fulfilling their legal mandate and without having issues with subsequent legal pro- it is ceedings. Because of this proof of concept, reasonable to conclude that this is possible in all jurisdictions. Reasons for Medical Examiner/Coroner De- Examiner/Coroner Medical for Reasons and Restrictions nials en- and to death, of and manner the cause mine With is collected. evidence appropriate sure that be- and cooperation communication appropriate this should not be the tween ME/Cs and O/TPOs, of situations. case in the vast majority This is despite prosecution. tion or subsequent medicolegal of any of documentation lack the by dona- impacted been negatively having case refer are aware of no more recent We tion (18). impact donation may have on ences regarding the cases, despite the decades of examiner medical recovery of tissues and and increased continued fact This cases. examiner medical from organs is no there that allegation the support to seems significant negative impact on cause and manner of litigation nor on the determination, of death concerns of these vast majority The such cases. to be blamed to be based in a reluctance appear have there Certainly case. for compromising the prosecutors as- been rare instances of individual been had case the of prosecution the that serting (19). None of these al- by procurement damaged were not pur matters leged cases in which legal in- alleged of the because dropped sued or were published in support of this were ever terference failure possible perceived Additionally, claim. to due failure as true be interpreted should not the forensic pathologist/ However, interference. the attor ME/C has the responsibility to educate assure neys about the procurement process and examination accurate and complete a that them necessary evidence and all can be accomplished and specimens will be able to be collected. Page 500 • Volume 4 Issue 4

Downloaded NAME POSITION PAPER by a NAME member. This ME/C torequest ancillary testing suchascom- examination at autopsy. This alsoenablesthe that requirefurther body thatmayhavewounds rect the medical team to avoid certain areas of the of thecase. The ME/Cmaythenchoosetodi- indicated by thehistory orvideodemonstration cialized photos foreach casecanberequestedas pre-established protocols or instructions. Spe- or anagent acting on their behalf according to tion can be obtained at this point by the ME/C to evaluate. Proper photographic documenta of the body, organs, orrecovery for the ME/C representative can transmit real-time images or tissuebank unable toattendinperson,anOPO curement. If themedical examiner orcoroner is patient goes totheoperating room fororgan pro- patient by theME/C mayalsooccurbeforethe The external examination of thehospitalized need fortoxicologicordiagnostictesting. secure specimensforemost,tosatisfywhatthey tocols can be formulated to allow the ME/C to should beobtained as soonpossibleandpro- of theOPOandME/C.Bloodspecimens also compromised or lostwell before the involvement Such trace evidence would thushavelikely been they willhavebeenundressedandmanipulated. had someperiodofhospitalization duringwhich lack of probative value. Organ donorswillhave collecting such kitsinanycircumstancesdueto ment, although most jurisdictions have stopped of gunshotresidue kits ifdesiredbylawenforce- tial assault. This willalsoapplytothecollection obtained as early aspossiblefollowinga poten- dence and sexual assault kits, which need to be propriate location for thecollection oftrace evi- the patient is still in the hospital. This isthe ap- gan procurement can readily be performed while The collection of evidence on acasegoing toor- in OrganProcurement Cases curement Organization(OPO) Cooperation Medical Examiner/Coroner andOrganPro- modified byseveralstatespriortoitspassage. the language of the NCCUSL 2006 UAGA were quirements varyfromstatetostate,asportionsof ME/Cs, thepresence or extent of theselegal re- Regarding thepotential denial of procurement by ME/C communitiesandO/TPOagencies. be beneficial to opening up dialogue between the also will data Additional justified. be to shown those judgmentsmight be improved,orperhaps exactly what sortsofsituationsarefacedandhow nials can serve theME/Ccommunity to clarify teleconferencing. A requirement to document de- could includephotography, videos,orrealtime defini- precise tion of“attending” isopenforinterpretation, and The (6). denial the for reasons provide written documentation explaining the tending the procurement procedure, he/she must article is intended for personal use, but may be distributed - found that such early notification of the ME/C the of notification early such that found decision on donation. Many jurisdictions have with the need to make a rapid and uninformed proceed with recovery only to present the ME/C then contact the ME/Cwhentheyarepoisedto or dayspriortoabraindeathpronouncement and is a tragedy foranOPO to follow a case for hours low formorepromptinvestigation of thecase.It as theybecome involved inacase. This willal- may beabletonotifytheME/Cassoon the OPO may becomeundertheirjurisdiction. Ifdesired, which a case of office ME/C the to notification in theefforts oftheME/Cbyprovidingprompt It shouldbenotedthat the OPOmayalsoassist their neededserologictesting. perform to specimens sterile sufficient have they icology testingwhilesimultaneouslyensuringthat ME/C hasenoughadmissionbloodforpropertox- It isoftenpossiblefortheOPOtoensurethat for eachagencytohaveaccesssuchspecimens. OPO andtheME/Cshouldalsoaddressneed tory protocols.Partoftheagreementbetween and notdiscardedinthecourseofroutinelabora- mission hospital specimens are properly retained The OPO should also be able to ensure that ad- curement personnelshouldpresentnoexception. with acasepriortodeath.Organ andtissuepro- medical professionalswhohavebeeninvolved tice for ME/Cs to testify as to the findings of other their ME/Cforanytestimony. Itiscommonprac- cumstances, prosecutorswouldmuchratheruse It shouldberecognizedthatinthemajorityofcir has first rights to admission laboratory specimens. if necessary;ande)anagreementthattheME/C to thejurisdictionforanyfuturelegalproceeding, for therecoveryteammemberstoreturnatnocost in therecoverysuiteifdesired;d)willingness of theME/Cortheirrepresentativetobepresent ability the c) encountered; are findings abnormal mediately stoppedandtheME/Ccontactedifany covered; b)anagreementthatrecoverywillbeim- such asthesurfacesofnormalorgans thatarere- findings, negative of photos and to damage organs, internal or rib fractures as such findings mal body priortoprocurement,photosofanyabnor the recoveryproceduretoincludephotosof provide highqualityphotographsofeverystepin minimum, for: a) an agreement by the OPO to in advance.Suchprotocolsshouldprovide,ata between theOPOandME/Cbedeveloped It isimportantthatmemorandaofunderstanding ing costsavingstotheME/Csystem. many ME/C offices, while at the same time offer tion, oftenwithmodalities that are unavailable to the OPO,allowing foramorecomplete examina- examinations can beperformedattheexpenseof in addressing future medicolegal questions. Such and retinalexamination, which maybevaluable aging, bone scans,angiography, skeletal series, puterized tomography, magnetic resonance im- by NAME members solely for scholarly purposes. - - - RELEASE OF ORGANS AND TISSUES Pinckard et al. • Page 501 purposes. scholarly for solely - - members NAME by distributed be may but use, personal sion for those blinded by cataracts. cataracts. by those blinded sion for the patient should examine the ME/C Optimally, byIf this can be accomplished prior to recovery. al- then and examination external the of means to the the recovery prior TPO to perform low the advantage it is of great autopsy, formal internal a must occur within recovery Tissue TPO. to the (usually 24 hours) followingshort period of time (LKA) time. If the ME/C re- the last known alive this time TPO to recovery post autopsy, stricts the and the donation maywindow may be exceeded - recov complete the to also valuable be lost. It is The autopsy for other reasons. ery prior to autopsy theon burden biologic the increase will process autopsy tissue culture rates,skin surfaces; post at recovery, preparation despite extensive surgical Additionally, higher. significantly be to known are incidental and easily modified autopsy incisions potential of certain tissues. may destroy recovery the pathologist examination, During the external should ensure that they recover the specimens collec The sample TPO. by the (blood) required tion vials, and sterile needles could be provided and sterile needles tion vials, TPO. If corneal recovery is anticipated, by the An agreement drawn. be not should vitreous obtain the TPO will the should be in place that recovery vitreous for the ME at time of corneal chain proper following ME/C the to it return and of custody procedures. for During the recovery process, it is important TPO to follow the same steps as outlined the photog- Extensive procurement. above for organ photos of raphy should be obtained, including negative findings such as an unremarkable chest after reflection of the skin orwithout evidence heart lying in a pericardium an unremarkable should stop the team recovery The of trauma. ME/C if unexpected the procedure and contact the of expectations The encountered. are findings ME/C for recovery of specimens and adherence to adhered should be strictly to any restrictions by the have not been obtained if the specimens The recovery personnel ME/C prior to recovery. with and strictly follow chain should be familiar specimens the obtaining in procedures custody of and promptly transport them to the ME/C. Procurement of the heart for valves is often a infor concern for ME/Cs, fearing that diagnostic been have protocols Special lost. be may mation described in order to ensure that this does not study was a large happen (26, 27). Importantly, population to docu- undertaken in the pediatric are en- abnormalities ment what types of cardiac adherence with that determined was it countered; to the protocols in place at that office, it would that any of these types of ab- have been unlikely been diagnosed had would not have normalities procurement taken place (28). for - - - intended is article This member. NAME a by Downloaded Recovery of tissues involves somewhat different different Recovery of tissues involves somewhat many although organs, of recovery issues than be always can it organs, With remain. similarities fully remaining that the surviving organ argued test of is the ultimate in the recipient functional not This is organ. lack of injury or disease to that it be as- the case with tissues. But nor should is not “lifesav sumed that tissue transplantation Medical Examiner/Coroner and Tissue Pro- Tissue and Medical Examiner/Coroner Organization (TPO) Cooperation curement Cases Procurement Tissue in of the potential death provides for a much more for a much provides death potential of the simultaneously while investigation complete other contact to ability the ME/C the providing in an orderly agencies investigative involved Although information. needed collect to manner jurisdiction have not does ME/C the that true is it forensic is pronounced, death until over the case local their at privileges have often pathologists in the role of a forensic hospitals and can serve performing what is termed as clinical consultant with the physicians They can consult forensics. and information, gather patient, for the caring steps which may be required provide advice for al- can This for recovery. consent giving to prior informa for any additional low the ME/C to ask them recovery and prepare tion or testing before to offer an empiric and scientific basispartial with or approve fully approve to decision for the the OPO is that Another possibility restriction. in general with the ME/C could discuss the case or information identifying any revealing without protected health information. the just no longer is transplantation Tissue ing.” for burn provision of split thickness skin grafts be the can certainly such skin patients, although also used deciding factor in their survival. Skin is recent advances With surgeries. in reconstructive from the recovered cells tissue transplantation, in can be used to grow aorta thoracic descending bypass artery coronary used in grafts vascular grafting and vascular shunts that are resistant to and restenosis. Stem cells from adipose rejection ma- bone donor acellular seed used to are tissue cell repopula- trix to improve graft acceptance, They provide an allograft tion, and strength. tissue with the benefits of autograft bone. Joint restoration (JR) with fresh articular tissues have joints in victims entire been used to reconstruct of devastating trauma, allowing for nearly full alterna the than rather extremity of an function young trauma of a ability The of amputation. tive arm and in- to have a functional victim or cancer man- or spouse in a normal child with their teract cartilage Juvenile life. their save literally may ner donors is processed from 29 day to 12-year-old joint in surfaces articular restore to injected and to used is It trauma. of forms some and diseases pain. reduce and cartilage in the defects reduce vi- to provide clear Corneas may be transplanted Page 502 • Volume 4 Issue 4

Downloaded NAME POSITION PAPER by a NAME member. This style, andthustheirsuitabilityfortransplantation. tor valuableinformationwithregardtotheirlife histological examination(29). cost savingmeasuresinplace that may restrict the ME/C,whetherduetolimited examination or by documented been have not may that findings quently, willdiscloseadditional cardiovascular at no costtotheME/C.Suchtesting, not infre- vascular pathologist for complete examination, cardio qualified a to sent or studies additional for valveswillbeeither returned to theME/C for should be in place that hearts that are recovered tal specimens discussed above. An agreement additional testing and safeguarding of hospi- obtain to ability and cases of notification earlier lationship with their O/TPO that go beyond the There areadvantagestotheME/Cofagoodre- TPO involvement Advantages for theME/CinCaseswithO/ only anexternalexaminationisplanned. covery of heart valves should not be restricted if topsy, than no additional restrictions apply. Re- Additionally, ifrecovery is restricted to postau- TPO couldprovidethesedrapeswithoutcharge. ring organs to the sink andautopsystation. The drapes will reduce the bio-burden from transfer ery isplanned,coveringthelegswithimpervious viscera, iflowerextremity skin ortissuerecov- nique may allow for recovery. During removal of tech pathologist’s the of Modification shoulder. tissue bankhavingtoreject the recoveryof completely up to the shoulder, may result in the sue bank. The useofthe“Y” incision,ifextended rensic pathologistcanbeveryhelpfultothetis- autopsy, simplevariationsintechnique by thefo- If recoveryisnotorcannotbeallowedpriorto request thesereportsfromthe recoveryagency. rologically. It is recommended that theME/C They also arerequired to testtheir patients se- tissues forbacterial and fungalcontamination. Tissue banksroutinely culture their recovered their participating inautoeroticactivityatthetimeof seem irrelevanttodisclosethatthedecedentwas tory. Forexample,althoughonthesurfaceitmay one tolearncertainaspectsofthedecedent’ cess astheME/Cinvestigatormaybeonly report mayprovetobeveryimportantinthispro mine suitabilityfortransplantation. The ME/C of thedocumentationpresentedtothemdeter O/TPO. O/TPOmedicaldirectorswillreviewall tion gatheredintheirdeathinvestigationwiththe it isimportantthattheME/Cshareinforma and shouldbesharedwiththeME/C.Conversely, may proveveryusefulinthedeathinvestigation assessment prior to recovery. This information history interviewonalloftheircasesduringthe O/TPOs performaverycompletemedical-social article death, this may provide the medical direc is intended for personal use, but may be s his distributed ------help facilitate the additional examinations even from theME/Calone. may beableto The O/TPO resources of theO/TPOthan might be possible complete examination can be achieved using the sion forrecovery. Itisoftenthecasethatamore or esotericconditionsinordertoachieve permis- studies, as clinically indicated, to rule out occult The O/TPO should be useful in obtaining special covery team can be directed to avoid those areas. priate. If studiesindicate skeletal injury, the re- injury, recovery oforgans and tissues isappro- head ery. isolated indicate findings clinical the If or early retinal exam) prior to approval for recov- tomography, magnetic resonance imaging, and/ ditional injuries (e.g., skeletal survey, computed port mayrequiremultiple studies toexcludead- ogist shouldbeperformed. Patients onlife sup- Pre-recovery examination by the forensic pathol tiny, asthey are rarely simple in presentation. Alleged childabusecasesrequirespecialscru- situations isnotappropriate. merits. on itsown A uniformpolicycoveringall objects. Eachcasewillneedtobeconsidered examinations to document injuries and retained rensic pathologistandappropriateradiographic covery followingexternal examination by the fo- for skin,musculoskeletal, adipose, orcardiac re- to the torso orextremities may be given approval Victims with penetrating or perforating wounds and approval given forrecovery below the neck. head can readily be examined prior to recovery cide victim with a single gunshot wound to the with restrictions,”ifnotfullapproval. A homi- es willremaincandidatesforatleast“approval death cases. The vastmajority of homicide cas- suspected child abuse cases) and sudden infant ery: suspectedorknownhomicides (especially recov- allow to ME/C the for decisions difficult Two majorclassesofcaseswillposethemost Difficult Cases only externallyexaminedbytheME/C. but autopsied, not cases in otherwise, identified recovery in casesoftrauma which may not be and documented throughtheprocessoftissue identified be may injuries additional thermore, case otherwisedidnotrequireafullautopsy. Fur ifthe been documented have not may findings sibly retain the emboli. It is possible that such these findings, report them to the ME/C, and pos- tocols should beinplace to properly document Pro- emboli. find may team recovery the heart, the forensic pathologist. During recovery of the that may havebeenmissedornotlookedforby ties may occasionally disclose Musculoskeletal recovery fromlowerextremi vestigation. countered andmayproveusefulinthedeath- Unexpected viral diseasesorsepsismaybeen- by NAME members solely for scholarly in situ thrombi purposes. - - - RELEASE OF ORGANS AND TISSUES Pinckard et al. • Page 503 purposes. scholarly for solely

- members NAME gans and/or by falling under falling These expenses are not otherwise to avoid an adversarial an adversarial to avoid the recovery of organs organs of recovery the distributed be that with proper communi- proper with that may falling under their jurisdiction falling under their jurisdiction n and procuring of organs and/ of organs procuring n and encourages ME/Cs and O/TPOs and ME/Cs encourages and to avoid the enforcement of enforcement the avoid to and but inflated simply to discourage dona- cases involving procurement should should procurement involving cases use, cases of suspected child abuse, other abuse, child suspected of cases of out of hospital deaths investigated of hospital of out It is recognized that blanket approvals blanket that is recognized It be “reasonable and customary” and not and customary” and “reasonable be ME/Cs and between cooperation and jurisdiction in virtually all cases, to all virtually in jurisdiction as potential donors, as any case not going not case donors, as any as potential fulfill their legal mandates without detri- and this should be the goal of every ME/C ME/C of every goal the be should this and ME/C offices where the last known alive personal infants. may may not be possible in every case, and require an “approval with restriction(s).” ME/C offices should refer all cases to be eval- uated thorough the hospital 100% referred. ME/Cs should have a goal of referral by time is within 24 hours. deni- “zero have currently offices ME/C Some als” office. of Academic . Pinckard is the Editor-In-Chief tion, NAME tion, cooperatively to work relationship such legislatio of the ME/C. over the objections or tissues for additional incurred by ME/C Expenses work in O/TPO. be reimbursed by the should artificially tion. NAME contends cation can allow for procurement O/TPOs, the ME/C if not all, or of at least some, tissues in cases and ment. ME/Cs should permit and/or tissues from decedents their include in homicides, and sudden unexpected deaths

6. 7. DISCLOSURES Dr of the Muscu- and a member Pathology Forensic Ex- Medical Foundation’s Transplant loskeletal Dr. Advisory Committee. and Coroner aminer of the Musculoskeletal is the co-chair Moffatt and Examiner Medical Foundation’s Transplant Schultz is the Dr. Committee. Advisory Coroner Ser Tissue President of Medical Director/Vice Foundation and Chair-Elect vices for LifeLink Banks. Tissue Association of American of the Director of Assistant Medical is the Wetzler Dr. LifeNet Health and a member of the Physicians of the Council Council and Media Relations Banks. Tissue of Association American The opinions and conclusions of this paper have As- been reviewed and approved by the National Direc- Board of Examiners of Medical sociation

3. 4. 5.

for

- - intended in situ in is article This - con in situ vascular prohibiting ME/Cs from member. in cases falling under their opposes any existing or existing opposes any NAME recognizes that “one NAME and specifically, opposes the that each local jurisdiction and jurisdiction local each that under ME/C jurisdiction can be can under ME/C jurisdiction may have unique considerations, a The protocols described herein are herein described protocols The both parties get what is needed and get what is needed both parties to restrict and/or deny organ and/or and/or deny organ to restrict or memoranda of understanding to of understanding or memoranda regarding this topic in the 2006 the in topic this regarding by individual ME/C offices and the or promote any specific protocols. In states already having such legisla- In states already agreements should be formulated be should agreements does not necessarily “fit all” and does not does and all” “fit necessarily not does procurement of organs and/or tissues from and/or tissues of organs procurement language UAGA. proposed legislation attempting tissue procurement jurisdiction, O/TPOs with which they interact. NAME strongly Recognizing environment these between might interact. size” endorse that cases falling maximized. suggestions regarding how ME/Cs and O/TPOs together protocols, ensure that ME/Cs and O/TPOs should work cooperatively

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agreements, prospective and establish 1. CONCLUSION: THE NAME POSITION cardiac abnormalities. Other options such as pho- cardiac abnormalities. Other options such on thetos or videos may be considered depending cardiovascular pathol- The of the ME/C. comfort cardiacogy examination will then address other cartilage/ issues. Subsequent recovery of juvenile offresh joints will not compromise the evaluation and organs other the of All death. infant sudden will stilltissues normally examined in such cases be available and uncompromised. on recently deceased patients in the hospital and hospital in the patients deceased on recently hospi - the dying outside patients on on occasion the hospital, who dies outside patient tal. For the to go to pathologist the for may be necessary it recovery the in participate and room recovery the the Once examination. after external of the heart the that confirms pathologist death in apparently healthySudden unexpected additional challenge. But theinfants presents an by the forensic pathologistschallenge can be met the realization that with effort with some additional can be achieved with justa complete examination As with the child a modicum of additional effort. the bodyabuse cases, the pathologist can examine sur before recovery and rule out injuries. Skeletal nections are appropriate, the heart may be recov- appropriate, the heart nections are then sent for formal cardio ered for valves and without loss of diagnostic vascular examination survey and ex- skeletal negative A (28). ability of will allow permission for recovery amination not will recovery Skin and adipose fresh joints. small patients. be requested in such The pathologist may vey will exclude bony injury. exclude and recovery the attend to desire Page 504 • Volume 4 Issue 4

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REFERENCES any relevantconflictsofinterest. The editors andpublication staff donotreport Pathology as such,wasnotsubjected to Academic Forensic that time. This workisaproductofNAMEand before or at retired or revised, reaffirmed, unless publication after years five expire automatically the National Association ofMedicalExaminers by endorsed papers position scientific All org). available on the NAME website (www.thename. ed, written, reviewed, andapprovedispublically cess bywhich NAME position papers are initiat right toreviseorupdatetheseopinions. The pro- edge andexperience grow,reserves the NAME knowl- Scientific As topic. this on theories ing of the current literature, knowledge, and prevail opinions andpositionsarebasedonaconsensus tors andassuchareendorsedbyNAME. These MS, Greenwald AS, Boden S, et al. Musculoskel- 10) 9) 8) 7) 6) 5) 4) 3) 2) 1)

article weighs-court-intervention-8070.shtml. newsroom/top_stories/videos/organ-donation-advocacy-group- cases? Proposedguidelinesforor Sturner 156-9. zations. ners, medical shortage byincreasing Jaynes 2014]. A intervention; c2014. Or WMSN Fox47[Internet]. http://www.organdonor.gov/legislation/acotrecs118.html. A recommendations U.S. c2014. U.S. DepartmentofHealthandHumanServices; donation andtransplantation U.S. Government tions. dead victims cal examiner/coroner Goldstein from: c2014. U.S. DepartmentofHealthandHumanServices; donation andtransplantation U.S. Government [cited 2014Jan7]. mond (V United NetworkforOr http://www.aatb.org/About-AATB. c2010. McLean American emy ofOrthopaedicSur etal allograft Joyce able from: c2014. U.S. DepartmentofHealthandHumanServices; donation andtransplantation U.S. Government vailable from: Clin IntensiveCare. 1997;8(3):136-41. http://www.organdonor.gov/becomingdonor/index.html. Department ofHealthandHumanServices is editorialreview. Advisory Committee Advisory onOrgan Transplantation: Becoming a donor; [cited 2014 Jan 7]. Available The needisreal: data; [cited 2014 Jan7]. Avail- bu u; ctd 04 a 7.Aalbe from: Available 7]. Jan 2014 [cited us; About L Srne J. eraig h ogn donor organ the Decreasing JW. Springer CL, WQ. Canbabyorgans bedonatedinallforensic Am JForensic MedPathol A): UnitedNetworkforOrgan Sharing;2014 (VA): American Association of Tissue Banks; intended vailable from: vailable gan donationadvocacy group weighscourt B, Shafer T, GreerD,StephensBG.Medi- http://www.organdonor.gov/about/data.html. Association of Tissue Banks[Internet]. examiners and organ procurement organi- tissue safety. Chicago: American Acad- 03 o 2 [ie 21 Jnay 7, January 2014 [cited 21 Nov 2013 of childabuse:controversiesandsolu-

1-18; [cited 2014 January 7, 2014]. 7, January 2014 [cited 1-18; Available from: for information on organ and tissue information on organ and tissue information on organ and tissue denial fororgan donationinbrain- personal geons; 2006.6p. communication betweencoro- gan Sharing[Internet]. Rich- http://wmsn.webtest.sbgnet.com/ Madison (WI): WMSN; [Internet]. Washington: [Internet]. Washington: [Internet]. Washington: use, http://www.unos.org. gan donationfrom . 1994 Jun; 15(2): Jun; 1994 . but may be distributed - -

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by transplant-vs-probe/stories/201311210241. Ju from: life? Investigate W (Summer):15-21. by or investigations Strama bankinteractions.published6-20-13.pdf. http://swgmdi.org/images/organ1.standardsforme.c.opo.eye [updated Group forMedicolegal tions offices interactions tigation Scientific Or tion. examiner of Medical ciation Pinckard California Health&SafetyCode2003;§7155:7. T New JerseyStat T New For infants 993-6. MMWR carditis Three Centers forDiseaseControlandPrevention (CDC). Pathol. 2003Sep;24(3):248-53. pediatric does Pinckard protocol (FP05-6). Gunther Med Pathol selected ectomy: W aspx?title=Anatomical Gift http://www.uniformlaws.org/LegislativeMap. gift Laws; c2014.Legislative ional ConferenceofCommissionersonUniformState UniformLawCommission Med Pathol ner ofdeath W ment Or Unpublished 2013data, 30; 271(12):891-2. tion coexistforthepublicgood? V tion. medical Shafer 1607-13. in theUnitedStates. medical Shafer [cited exas Health&SafetyCode Ann 1995;§693:002. ennessee Code Ann 1993;§38-7-108-c(2). oelker R. Canforensicmedicine andorgan dona- dge-weighed-transplant-vs-investigation-Judge-weighed- ard PR. Allegheny Countyjudgehadtochoose: olf DA,Derrick SM. Undetermined causeandman- NAME ensic MedPathol c (06; ctd 04 a 7. vial from: Available 7]. Jan 2014 [cited (2006); act Am JForensic MedPathol.2007Sep;28(3):202-7. Am JTransplant. 2004Feb;4(2):160-8. not preclude the diagnosis of clinically significant clinically of diagnosis the preclude not York, CountyLaw, art17-A,§674-a,1977. Pittsburgh Post-Gazette [Internet]. 2013 Nov20 gan donation.NewslMedLawComm.1994; and eye banks [Internet]. Scientific Working Scientific [Internet]. banks eye and 04 a 7; elh [bu 3 .. Available p.]. 3 [about Health: 7]; Jan 2014 TJ, Schkade LL, Evans RW, et al. Vital role of role Vitalal. RW,et Evans LL, Schkade TJ, sudden cardiac deaths associated with lyme T, Schkade LL, Warner HE, et al. Impact of http://www.post-gazette.com/news/health/2013/11/21/ n ogn n tsu poueet organiza- procurement tissue and organ and of Medical Examiners. National Association ganizations. — United States, November 2012–July 2013. 2012–July November States, United — under medical examiner jurisdiction. T BrigHthr , hfr J Criminal TJ. Shafer S, Burling-Hatcher BT, Morb Mortal Wkly Rep. 2013 Dec 13; 62(49): for valve allograft procurement. W. Pediatric heart valvedonation: The Virginia examiner/coroner practices on organ recovery examiners andcoronersinorgan transplanta- 2013 Jun 20; cited 2013 Feb 2]. Available from: documenting sudden cardiac death in hearts JK, Graham MA. Heart valve tissue donation tissue valve Heart MA. Graham JK, JK, Wetli CV, Graham MA, National Asso- National MA, Graham CV,Wetli JK, cardiac abnormalities. Working Group on Medicolegal Death Inves- release oforgans andtissuesfortransplanta- members (SWGMDI). SWGMDI’s standards for . 2002Jun;23(2):137-41. . 2010Jun;31(2):1 Examiners position paper on the medical child’s death,orhurrytosaveanother after organ/tissue donation. and prosecutionsnotadverselyaffected between medical examiner/coroner Ann 1993;§52,Chap17B§887. ASCP CheckSample.2005;47:63-75. solely . 1995Sep;16(3):215-8. JAMA. 1994Nov23-30;272(20): Act (2006). Association ofOrgan Procure- enactment status, anatomical Death Investigation; 2013 for [Internet]. Chicago: Nat- 13-6. scholarly JAMA. 1994Mar23- Am JForensic Med Am JForensic Am JForensic purposes. Am J