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Series 3, Number 32 October 2001 Mor The A tality utopsy Statis , , tics and Copyright information

All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

Suggested citation

Hoyert D. The , medicine, and mortality statistics. National Center for Statistics. Vital Health Stat 3(32). 2001.

Library of Congress Cataloging-in-Publication Data

The autopsy, medicine & mortality statistics : an anthology of autopsy cases illustrating the value of the autopsy to the practice of medicine and the vital statistics system / Randy Hanzlick (editor) and the Autopsy Committee of the College of American Pathologists. p.; cm. — (DHHS publication ; no. (PHS) 2000-1416) (Vital and health statistics. Series 3, Analytical and epidemiological studies ; no. 32) ‘‘Articles previously published separately in archives of internal medicine’’—T.p. ‘‘August, 2001’’—T.p. Includes bibliographical references and index. ISBN 0-8406-0572-2 1. Autopsy—Case studies. I. Title: Autopsy, medicine, and mortality statistics. II. Hanzlick, Randy. III. College of American Pathologists. Autopsy Committee. IV. Archives of internal medicine. V. Series. VI. Vital & health statistics. Series 3, Analytical and epidemiological studies ; no. 32 [DNLM: 1. Autopsy—United States—. 2. Autopsy—United States—Collected Works. 3. of —United States—Case Report. 4. —United States—Collected Works. W2 A N148vc no. 32 2001] RB57 .A89 2001 616.07'59—dc21 2001044077 [362.18′0973] 2001044051

For sale by the U.S. Government Printing Office Superintendent of Documents Mail Stop: SSOP Washington, DC 20402-9328 Printed on acid-free paper. Series 3, Number 32

The Autopsy, Medicine, and Mortality Statistics

Articles previously published separately in Archives of Internal Medicine. Randy Hanzlick, M.D. (Editor) and the Autopsy Committee of the College of American Pathologists. Produced with Permission of the Archives of Internal Medicine and the American Medical Association. Published by the National Center for Health Statistics.

U.S. DEPARTMENT OF HEALTH AND SERVICES Centers for Control and Prevention National Center for Health Statistics Hyattsville, Maryland October 2001 DHHS Publication No. (PHS) 2001-1416 National Center for Health Statistics Edward J. Sondik, Ph.D., Director Jack R. Anderson, Deputy Director Jack R. Anderson, Acting Associate Director for International Statistics Jennifer H. Madans, Ph.D., Associate Director for Lawrence H. Cox, Ph.D., Associate Director for Research and Methodology Jennifer H. Madans, Ph.D., Acting Associate Director for Analysis, , and Health Promotion Edward L. Hunter, Associate Director for Planning, Budget, and Legislation Jennifer H. Madans, Ph.D., Acting Associate Director for Vital and Health Statistics Systems Douglas L. Zinn, Acting Associate Director for Management Charles J. Rothwell, Associate Director for Information Technology and Services

Division of Vital Statistics Mary Anne Freedman, M.A., Director James A. Weed, Ph.D., Deputy Director James A. Weed, Ph.D., Acting Chief, Mortality Statistics Branch The Autopsy Committee of the College of American Pathologists

The year 2001 charge statement for the Autopsy Committee of the College of American Pathologists is: ‘‘To improve the performance and reporting of the autopsy and to promote utilization of the autopsy for quality improvement, research, education, and .’’

Individuals who were members of the Autopsy Committee during the preparation of the material in this publication include:

Pamela Amato (CAP staff) Dean Havlik, M.D. Peter Baker, M.D. Grover Hutchins, M.D. Johannes Bjornsson, M.D. Eun Young Lee, M.D. Kevin Bove, M.D. Larry Nichols, M.D. John Buchino, M.D. Joseph Parisi, M.D. Steven Campman, M.D. John Sinard, M.D., Ph.D. Kim Collins, M.D. J. Thomas Stocker, M.D. Gregory J. Davis, M.D. Jessica Troup, M.T. (CAP staff) Marcella Fierro, M.D. Keith Volmar, M.D. Stephen Geller, M.D. Nancy Young, M.D. Randy Hanzlick, M.D.

Contributing Authors Individuals who served as an author for the case studies presented in this publication include:

Peter Baker, M.D. Rebecca Irvine, M.D. Allan Bennett, M.D. Eric Kiesel, M.D., Ph.D. Johannes Bjornsson, M.D. Eun Young Lee, M.D. Michael Cibull, M.D. Jeff Lee, D.O. Kim Collins, M.D. Julio Martinez, M.D. Linda Dallasta, M.D., Ph.D. Jesse McKenney, M.D. Amanda Davis, M.D. Mario Mosunjac, M.D. Gregory J. Davis, M.D. Clay Nichols, M.D. Angela Fields, M.D., Ph.D. Larry Nichols, M.D. Randy Hanzlick, M.D. Eric Pfeiffer, M.D. Dean Havlik, M.D. Ann Smith, M.D. Charles Hill, M.D. Wilbur Williams, M.D. Grover Hutchins, M.D.

iii Foreword

Comments from the National Center for Health Statistics

The series of articles in this report document the value of provides additional examples of cause-of-death autopsy in and health statistics and provides statements to supplement those available educational information about completing cause-of-death from State and Federal vital statistics programs statements. Autopsy information has long been an essential (e.g., http://www.cdc.gov/nchs/about/major/dvs/handbk.htm). tool for quality control of medical care and for enhancing the Dr. Hanzlick, the editor of the report, continues his quality of cause-of-death information reported on the death important contribution to the National Vital Statistics System certificate. Recognizing that the use of autopsy has declined and in particular to the quality of national mortality data. considerably in the past 50 years as documented in vital NCHS is pleased to assist the College of American statistics, the autopsy is nevertheless regarded as an important Pathologists in promoting the distribution of these articles, tool in medical practice and in improving the cause-of-death which previously appeared in Archives of Internal Medicine. data. An ample body of literature shows not only the medical values of autopsy, but also its importance in bench marking the quality of cause-of-death data. Harry M. Rosenberg, Ph.D. information is a major source of Special Assistant statistical data to identify public health problems, to monitor Division of Vital Statistics progress in public health, to allocate research funds, and to National Center for Health Statistics conduct scientific research. For these reasons, good reporting Centers for Disease Control and Prevention of cause of death is very important. The articles illustrate many of the basic principles in cause-of-death reporting: intellectual process of determining the best medical opinion of Donna L. Hoyert, Ph.D. cause of death, separation of contributing causes in Part 2 of Statistician (Demographer) the medical certification from the sequence of conditions Mortality Statistics Branch reported in Part 1, report of a single condition per line, Division of Vital Statistics avoidance of abbreviations, and amendment of the record if National Center for Health Statistics additional information becomes available . This report Centers for Disease Control and Prevention

iv Preface Finally, the committee wishes to thank Joe Schramm, Ayrika Gunn, and Jessica Troup of the CAP for their he Autopsy Committee of the dedicated service in producing the draft College of American Pathologists for publication. T undertook the ‘‘Autopsy and The Autopsy Committee feels that Medicine’’ series in 1997 with two this publication will be especially useful major goals in mind: for the following individuals: + To illustrate the continued value of + in medical specialties in the autopsy to the practice of which the of some medicine; and will occur, making knowledge of the + To provide educational material and autopsy and cause-of-death discussion concerning cause-of-death statements a desired attribute; statements and completion of the + Pathologists and other physicians death certificate. who have a need to educate others on the value of the autopsy; and These goals arose out of recognition + Legislators and policy makers whose that autopsy rates in the United States, duties include analysis of the especially in medical institutions, had autopsy and its role in the practice fallen to unacceptable levels for quality of medicine and public health. assurance/improvement purposes. Studies also show a need for improving Authors who reference the articles our national mortality data derived from included in this publication should cite death certificates, which, in turn, should the original reference from Archives of reflect information obtained at autopsy. Internal Medicine when possible. The committee is grateful to Dr. Complete references are included in James Dalen, Editor of Archives of ‘‘Wrapping Things Up,’’ the last case Internal Medicine, who agreed to report in this collection. publish the series which began in August of 1997 and ran through November 2000. Twenty-nine case reports and one summary article were published during that time. The committee also wishes to thank Archives of Internal Medicine and The American Medical Association for authorizing reproduction of the articles that appear in the Autopsy and Medicine Series. Some of the articles have been edited slightly or given subtitles since their original publication. Also deserving thanks is the National Center for Health Statistics (NCHS), which agreed to print the series as a freestanding publication. Comments from NCHS are printed on the following page.

v Contents

Foreword ...... iv Preface ...... v The Moribund Autopsy: DNR or CPR? ...... 1 What Killed the : The Disease or the Experimental Treatment? ...... 1 The Autopsy and New Technology: All That Glitters Is Not a ...... 3 Elder Abuse and Neglect ...... 4 The Autopsy and the Living ...... 6 Pathologic Findings in a Donor ...... 7 History Repeats Itself (Sometimes) ...... 8 Incidental and Not-So-Incidental Findings ...... 9 Outcome Analysis and Quality Assessment ...... 11 The Rest of the Story ...... 12 Education of the Pathologist ...... 16 Unavoidable Outcomes versus Misadventures ...... 17 Death and Devices ...... 18 Not-So-Obvious Uses of the Autopsy ...... 19 Death and Distraction ...... 20 Allaying Apprehension ...... 22 Making Amends ...... 23 Addressing the ‘‘Red Herring’’ ...... 24 Requesting an Autopsy ...... 25 ‘‘Negative’’ Results of Autopsy and Elusive Cause of Death ...... 26 Speculation and Competing Causes of Death ...... 28 Institutional Autopsy Rates ...... 29 Private ...... 31 Complications of , Nursing Homes, and the Elderly ...... 32 Protecting Those at ...... 34 Partial, Limited, or Restricted Autopsies ...... 35 A Tale of the Unexpected: Finding a Zebra ...... 35 An Intoxicating Case: The Importance of ...... 36 Multiple Benefits from an Autopsy ...... 37 Clarifying an Untoward Outcome ...... 38 Wrapping Things Up ...... 38

vii Series 3, No. 32 [ Page 1 The Moribund Obviously, clinical medicine has References made massive strides since 1912. Some Autopsy: DNR or clinicians may believe that our current 1. Landefeld CS, Chren MM, Myers A, sophisticated high-tech diagnostic tests Geller R, Robbins S, Goldman L. CPR? render the autopsy superfluous. Many Diagnostic yield of the autopsy in a pathologists do not agree that the university hospital and a community autopsy has been rendered superfluous hospital. N Engl J Med. he decline in the performance of 1988;318:1249–54. by modern technology. Perhaps they are autopsies in the past three 2. Hasson J, Schneiderman H. Autopsy justifiably alarmed at the imminent T decades is remarkable: from training programs to right a wrong. 41 percent of hospital deaths in 1961 (1) demise of the autopsy. Arch Pathol Lab Med. to 5 percent to 10 percent in the Landefeld, et al. (1) in 1988 found 1995;119:289–91. mid-1990s! (2) officers in the that by performing autopsies, major 3. Schatz IJ. Internal medicine residency 1960s were urged to ‘‘get the post’’ on unexpected findings were detected. A program violations of the minimum every patient dying in a teaching premortem diagnosis of these findings autopsy rate. JAMA. 1995;273:1092. hospital. Observing the postmortem would probably have improved survival 4. Cabot RC. Diagnostic pitfalls identified examination of patients whom they had in 11 percent of the cases examined at a during a study of three thousand autopsies. JAMA. 1912;59:2295–8. taken care of was a critical part of the university hospital and 12 percent of the cases at a community hospital. 5. Shanks JH, McCluggage G, Anderson training of residents in internal medicine. NH, Toner PG. Value of the necropsy Shanks, et al. (5) reported the value Currently, the residency review committee in perioperative deaths. J Clin Pathol. for internal medicine requires autopsies in of the autopsy in 213 cases of 1990;43:193–5. at least 15 percent of deaths on the perioperative death. They found major 6. Sarode VR, Datta BN, Banerjee AK, medical service in accredited residency discrepancies in clinical diagnoses that et al. Autopsy findings and clinical programs. From 1991 to 1994, less than were treatable and could survival diagnoses: a review of 1,000 cases. half of the internal medicine programs in 21 percent of the cases. Hum Pathol. 1993;24:194–8. reviewed for accreditation met these In a review of 1,000 autopsies 7. Veress B, Alafuzoff I. A retrospective minimal requirements (3). performed between 1983 and 1988, analysis of clinical diagnoses and Numerous reasons for the abrupt Sarode, et al. (6) found ‘‘major autopsy findings in 3,042 cases during two different time periods. Hum Pathol. decline in autopsies have been cited. In discrepancies’’ between the autopsy findings and the clinical diagnosis in 317 1994; 25:140–5. 1971, the Joint Commission on the 8. Manzini VP, Revignas MG, Brollo A. (32 percent) of the 1,000 autopsies. Two Accreditation of Hospitals eliminated Diagnosis of malignant tumor: autopsy requirements for hospital recent studies found major discrepancies comparison between clinical and accreditation. Autopsies have become in the diagnosis of malignant tumors. autopsy diagnoses. Hum Pathol. very expensive, and these costs are not Veress and Alafuzoff (7) reported that 1995;26:280–3. reimbursed by third-party payers. The 15 percent of all major were not process for obtaining consent for diagnosed before autopsy. Manzini, et autopsies remains cumbersome. al. (8) reported that 34 percent of tumors What Killed the However, the most likely explanation with were missed before the for the decline is that physicians do not autopsy. Patient: The Disease request autopsies because they believe Given these reports, may be more that the examinations have lost their value. appropriate to save the autopsy, rather or the Experimental The most obvious value of the autopsy is than pronounce it ‘‘DNR’’! Treatment? quality assurance: to compare the In an attempt to begin CPR of the clinician’s premortem clinical diagnosis autopsy, the Autopsy Committee of the with the precise, anatomical cause of College of American Pathologists has 38-year-old woman underwent death. Did the patient receive the correct prepared a series of brief case reports excision of a nodular malignant treatment for the correct disease? for the Archives of Internal Medicine.In A of the right scapular Cabot’s (4) classic paper in 1912 this series, ‘‘Autopsy and Medicine,’’ a region (level III; Breslow depth, based on 3,000 autopsies quantified the brief case report will be presented that 1.6 mm). Right axillary lymph node percent of correct clinical diagnoses for illustrates modern uses of the autopsy a month later showed a variety of . and for improving patient care, analyzing metastases in five of six nodes with typhoid were correctly diagnosed before potential legal and health , meeting extracapsular spread. Six months later, death in more than 90 percent of the regulations, reducing unnecessary the patient had a dental abscess cases examined after death. However, litigation, and benefiting the public. associated with a dental implant; the common diseases such as cirrhosis, abscess was treated with removal of the endocarditis, bronchopneumonia, NOTE: Volume 157, August 11/25, 1997. James E. implant and six days of antibiotic and acute nephritis were missed in more Dalen, M.D., M.P.H. Editor. therapy with metronidazole and than 50 percent of the cases. amoxicillin. The next day, the patient got a new pet dog; she already had cats. Page 2 [ Series 3, No. 32

The day after acquiring the dog, the persistent epigastric requiring patient’s epigastric pain and right upper patient was enrolled in a ganglioside progressive narcotic analgesia and quadrant tenderness. The autopsy adjuvant study (for treatment of worsening dyspnea requiring progressive findings also support the conclusion that melanoma) and received her first supplemental oxygen therapy. A decision pulmonary lymphangitic and interstitial dose (1,2). After receiving the vaccine, was finally reached to provide comfort tumor was the cause of the patient’s the patient developed progressive measures only. Terminally she had a dyspnea with pulmonary metastatic dyspnea. At first she had dyspnea only with a left shift and a white tumor being below the limits of after she walked up a flight of eight blood cell count of 30.6 109/L. The radiologic detection. Although dyspnea stairs, but it worsened until it occurred patient died on hospital day 18. initially coincided temporally with the after only minimal effort such as administration of the experimental tumor blow-drying her . vaccine and the patient’s exposure to a On the fifth day, she presented to Autopsy Findings new dog, the subsequent sequence of the outpatient . Her oxygen Postmortem examination revealed events and the autopsy findings point saturation while breathing room air was metastatic malignant melanoma toward tumor-related restriction in 96 percent, but when she was walked up involving lymph nodes, , pulmonary expansion and diffusion and down the hall on a level surface, spleen, bone marrow, , pleura, capacities as a more likely cause of the her saturation decreased to 85 percent. epicardium, myocardium, gallbladder, patient’s dyspnea, especially since Her pulse was 120 per minute, and her duodenum, pancreas, kidneys, uterus, dyspnea had worsened without was 95/60 mm Hg. Her adrenals, and left breast. There were continued exposure to the dog. Further, chest was clear. Blood hemoglobin extensive lymph node metastases with there was no morphologic evidence of concentration was 148 g/L with a nodes measuring up to 4 cm. The liver an adverse reaction, pulmonary hematocrit of 0.43. The tumor or hemorrhage, or other 9 was mildly enlarged, and metastases count was 9.2 10 /L (, 0.70; replaced approximately 70 percent of the finding to explain the progressive lymphocytes, 0.17; monocytes, 0.12; parenchyma. There were multiple spleen dyspnea. eosinophils, 0.01), and platelets The question arises whether 9 metastases up to 0.6 cm, multiple lower numbered 120 10 /L. Findings from thoracic spinal metastases up to 0.5 cm performing a might have electrocardiography revealed a normal (with extensive bone marrow necrosis), yielded the diagnosis of lymphangitic sinus rhythm with some T-wave visceral pleural metastases up to 0.8 cm, carcinomatosis. This case also suggests flattening in leads III and a VF. Chest and epicardial metastases up to 0.3 cm. that pulmonary testing, rather radiography results were negative and Histologic sections from all five lobes than radiologic imaging, may be a findings on computed tomographic of the lung each showed extensive helpful way to assess the likelihood of scan of the chest showed no evidence interstitial, lymphangitic, and lymphangitic carcinomatosis. Such of pulmonary embolus, no pulmonary perivascular tumor. Postmortem blood questions, which grew out of the nodules, no evidence of infiltrate or culture results were positive for E. coli. autopsy in this case, could prompt future effusion, and no hilar, mediastinal, or Based on these findings, a study of the clinical utility of alternative axillary adenopathy. Two deep pectoral cause-of-death statement was prepared methods of testing for the diagnosis of muscle lymph nodes were noted on as follows: lymphangitic carcinomatosis. Failure to the right, and there were multiple low recognize lymphangitic carcinomatosis attenuation throughout the (lymphangiosis carcinomatosa) as a liver. Part 1. cause for dyspnea, and its misdiagnosis The patient was hospitalized A. Pulmonary lymphangitic as pulmonary , was the subject overnight and had no dyspnea in the carcinomatosis of another ‘‘Case of the Month’’ in hospital. Her dyspnea was attributed to which the autopsy findings explained an allergic reaction to her new pet dog. Due to or as a consequence of: the lack of response to anticoagulant She was discharged the next day, but B. Metastatic malignant melanoma therapy (3). was rehospitalized the day after that (skin of back) The autopsy was also valuable in with progressive dyspnea without this particular case because it provided a Due to or as a consequence of: reexposure to the dog, so her dyspnea C. likely explanation for the patient’s was then attributed to adverse effects of that was being the ganglioside adjuvant vaccine. The Part 2. Other significant conditions: attributed to other causes, including the patient also had severe epigastric pain Escherichia coli sepsis experimental vaccine therapy she had and right upper quadrant tenderness. She received. If an adverse event occurs developed marked elevations of her following experimental therapy, the serum transaminase levels, and liver Comment may be wrongly biopsy results showed metastatic attributed to the experimental therapy melanoma. A diagnosis of Escherichia The autopsy findings suggest that (even without any hypothesis about coli urinary tract was made on stretching of the liver capsule by possible or likely pathogenetic the eighth hospital day. The patient had metastatic tumor was the reason for the mechanisms) unless a better explanation Series 3, No. 32 [ Page 3 is available. The autopsy in this case (CT) scan, she reportedly fell from the provided a much sounder explanation CT table, landing between the table and Part 1. for the progressive dyspnea: pulmonary the scanner. Computed tomographic A. Uterine leiomyosarcoma with lymphangitic carcinomatosis. Thus, the scans of her head, neck, and chest were extensive metastasis to the left lung autopsy saved an experimental therapy performed to evaluate her condition and from being falsely blamed for an determine if any were sustained Due to or as a consequence of: adverse reaction, and the patient seems from the fall. She suffered a B. to have died from progression of her cardiopulmonary arrest while still in the disease rather than a of the CT scan room. efforts Due to or as a consequence of: treatment she received. We recommend were not performed because she had C. the performance of an autopsy when been placed on do-not-resuscitate status. Part 2. Other significant conditions: experimental therapy has been used or Her death was reported to the medical Atherosclerotic coronary artery when death is suspected to have resulted examiner because of the fall and disease from a complication of treatment, even possible . When the death was if an autopsy is not required by reported to the , protocol. information obtained by the medicolegal Comment death investigator from the hospital NOTE: Volume 160, August 14/28, 2000. Larry indicated that the CT scan showed upper Because of the discrepancy between Nichols, M.D., University of Pittsburgh Medical cervical spine fracture with the autopsy findings and the initial Center, Pittsburgh, PA; Randy Hanzlick, M.D., compression. The medical examiner report of spinal column and cord injury, Emory University School of Medicine, Atlanta, GA; and the Autopsy Committee of the College of assumed jurisdiction and performed a a review of medical records was American Pathologists. complete autopsy. performed and the CT scans were reviewed with the attending radiologist. The initial interpretation of the CT scan References Autopsy Findings by the radiologist was that of a 1. Ollila DW, Kelley MC, Gammon G, The autopsy showed a small left nondisplaced fracture of the second Morton DL. Overview of melanoma frontal hematoma. There was cervical vertebral pedicles (bilateral) : active specific near total replacement of the left lung without spinal cord compression. The for melanoma patients. by hemorrhagic , which was original report of spinal cord Semin Surg Oncol. 1998;14:328–36. histologically confirmed to be compression was in error and resulted MEDLINE. leiomyosarcoma. There was evidence from misinterpretation of the ‘‘without’’ 2. Minev BR, Chavez FL, Mitchell MS. of acute hemorrhage within the tumor, symbol O as ‘‘with’’ (c). Thus, New trends in the development of which was viewed by the pathologist the lack of spinal cord compression at vaccines. In Vivo. autopsy was actually consistent with the 1998;12:629–38. MEDLINE. as a probable explanation for the acute original , and the 3. Pfeiffer EA, Bjornsson J, Hanzlick R, exacerbation of the patient’s dyspnea. Autopsy Committee of the College of Autopsy also confirmed that a apparent discrepancy was explained as a American Pathologists. Case of the hysterectomy and salpingo­ result of the autopsy and retrospective month: lymphangiosa carcinomatosa. oophorectomy had been performed, review of the case. Arch Intern Med. 1998;158:14. consistent with the reported history of The lack of vertebral fracture at MEDLINE. a uterine primary tumor site. autopsy was a second discrepancy that Examination of the neck with both needed explanation. The hospital had anterior and posterior neck recently acquired a new CT scanner The Autopsy and New revealed no fractures or soft with resolution capabilities to the hemorrhage in the paravertebral millimeter level. The CT scans of the Technology: All That tissues. The upper cervical spinal patient presented in this case report Glitters Is Not a Gold canal was easily visualized through were among the first scans performed the foramen magnum, and the spinal with the new equipment. Defects were Standard cord was unremarkable without observed with the CT scan in the lamina evidence of cord compression or of the C2 cervical spine and were spinal canal stenosis. Moderate initially interpreted by the radiologist as 66-year-old woman with atherosclerotic cardiovascular fractures. As more experience was metastatic uterine disease was also found. In the gained with the CT equipment, similar leiomyosarcoma involving nearly A absence of significant trauma, the defects were observed in other patients. the entire left lung was admitted to the cause of her death was attributed to On reevaluation of this patient’s CT hospital for evaluation of dyspnea. On the following: scans, it was determined that the defects day 3 of her hospitalization, while did not represent fractures but instead undergoing a computed tomographic Page 4 [ Series 3, No. 32 were perforating vascular foramina. References necrotic, and necrosis and These foramina could not be visualized were confirmed by microscopic with older equipment because of the 1. Sarode VR, Datta BN, Banerjee AK, et examination. A yellow-tan exudate was bone-density averaging methods used by al. Autopsy findings and clinical present within the ulcers and was the older equipment. diagnoses: a review of 1000 cases. cultured by the pathologists. Blood was As new technologies enhance our Hum Pathol. 1993;24:194–98. also drawn for culture. Both the blood abilities to visualize smaller objects and MEDLINE. culture and exudate culture were 2. Nichols L, Aronica P, Babe C. Are to detect smaller quantities of various positive for . autopsies obsolete? Am J Clin Pathol. substances, we must be careful in our 1998;110:210–18. MEDLINE. Vitreous was drawn for analysis of interpretation of the data. In some electrolytes and the results showed instances, as in this case report, we are with an increase in sodium, not detecting new or abnormal entities, chloride, and urea nitrogen levels. Other but now have the ability to measure, Elder Abuse and findings included cerebral with see, or detect ‘‘normal’’ entities that we Neglect remote ischemic previously could not. microscopically. This case highlights potential The cause of death statement was pitfalls of new technology with n elderly white woman died in prepared as follows: enhanced resolution and the continued the care of a male friend who value of the autopsy in serving as a A was her caretaker for the past ‘‘gold standard’’ for validating new and year. She was found in her bed, Part 1. emerging technology. (1,2) Regarding unresponsive, and the police were A. Pseudomonas sepsis with the present case in particular, because of notified. Upon arrival, the police found dehydration the initial diagnosis of cervical spinal her in the bed on top of dirty, soiled Due to or as a consequence of: linens. Fecal material and areas of urine fracture, the hospital was open to B. Decubitus ulcers associated with potential criticism, accidental or were present, each in excess of senile wrongful death claims, and litigation. what would be expected from agonal The confusion about the spinal cord defecation and urination. Her Due to or as a consequence of: compression also illustrates the potentially refused to sign the death certificate C. serious legal risks that may be imposed by because he had not seen her in two Part 2. Other significant conditions: a simple misinterpretation and/or years, and previously she had been miscommunication of or about the doing well. He could not think of a medical record. The retrospective medical clear cause of death since her medical record review and discussions with the history was significant only for senile Comment radiologist, done in conjunction with the dementia and osteoporosis during the autopsy and death investigation, clarified past four years. The male friend was Each year approximately 10 percent the problem and also provided useful considered the next of kin, and he of adults 65 years and over are abused, information to the radiologists. Although desperately wanted to complete the and 4 percent experience moderate to the initial misinterpretation of the CT paperwork for and insurance severe abuse (1–4). Elder abuse has scan was rectified by the radiologists, purposes. The physician agreed to sign the been recorded since the 19th century, the autopsy (by an independent agency death certificate if a complete autopsy was but it was not brought to the forefront in this case) served as the ultimate performed. was taken from the until 1980, by the U.S. House Select medical quality assurance measure, and home to the autopsy room. Committee on Aging. By 2030 the U.S. was useful to provide further knowledge population will consist of about 70 about a new technology. The autopsy million older Americans, which is more was also very valuable to the hospital in Autopsy Findings than twice the number in 1990. Thus, an increase in the number of older victims providing information that could be used At autopsy, the decedent was noted of abuse can be expected (5). to rebut or disprove legal claims that to be cachectic, with dried fecal material In 1987 the American Medical could arise about the fall and possible between her buttocks. She appeared Association’s Council on Scientific injury. dehydrated, with tenting of the skin and Affairs defined elder abuse as an act or sunken eyes. Decubitus ulcers were omission that results in harm or NOTE: Volume 160, July 10, 2000. Eric Kiesel, present over the sacral and inferior threatened harm to the health or M.D.; Randy Hanzlick, M.D., Emory University buttocks regions. The ulcers extended School of Medicine, Atlanta, GA; and the Autopsy of an elderly person (3). Elder abuse can through the skin, subcutaneous soft Committee of the College of American be classified into six categories: physical tissue, and down to the Pathologists, Northfield, IL. abuse, sexual abuse, neglect, bone. The femoral head could be psychological abuse, financial and visualized on the right side. The material exploitation, and violation of surrounding tissue was friable and rights (5). Series 3, No. 32 [ Page 5

Physical abuse is an act carried out discussing the topic with patients. Many injuries. The interplay between external with intention of causing physical pain of these elders will even deny help. factors and intrinsic disease may be or injury, such as hitting, slapping, or Elders may deny abuse because they are explored. Information is obtained and stalking with objects. Sexual molestation ashamed of being abused or fear documented that may be used in any includes contact with genitalia, anus, or reprisal (7). Medical assessment of the legal proceedings that may follow cases mouth. Neglect is one of the more victim should include a complete of alleged abuse and neglect. common forms of abuse and is history, complete , Autopsy findings in cases of elder characterized by a failure of the and documentation of all injuries. abuse and/or neglect may be subtle, and to provide the goods or Multiple injuries at various stages of the diagnosis is often difficult for services that are necessary for optimal healing, unexplained injuries, delays pathologists to establish because of the functioning or to avoid harm. Medical between illness or injury onset and almost invariable presence of some neglect was the form of neglect in the treatment, ‘‘doctor hopping,’’ and chronic or debilitating disease that puts case reported above because there was multiple visits the patient at risk for abuse and/or failure to seek medical care appropriate are a few of the findings. Pressure neglect in the first place. The autopsy for the patient’s condition. ulcers are often present in the elderly pathologist cannot always answer Psychological abuse may include who are ill, and these should be questions or address allegations about threats, insults, harassment, harsh orders, thoroughly examined with all the abuse/neglect decisively. However, the and behavior designed to increase social dressings removed. Evidence of autopsy does provide one last chance to isolation. Stealing pension checks, not foul-smelling or necrotic pressure ulcers collect and document findings that may using funds for support of the elder, that have not been brought to the be useful not only for identifying and/or inappropriate use of the elder’s attention of the physician should raise abuse/neglect but also for refuting false personal property constitute financial suspicion of neglect (6). claims and protecting the innocent. and material abuse. This latter form of Adult Protective Services is an Whenever it is suspected that abuse/neglect could also be alleged in agency that exists by law in every State abuse/neglect may have caused or the current case since the caretaker was to investigate cases of possible contributed to the death of an elderly using the decedent’s funds, but not for abuse (6). States require the reporting of person, the medical examiner or her support. Violations of rights occur elder abuse, and the physician can be should be notified. In most such cases when the caregiver deprives the held responsible if he/she is aware of with some foundation for suspicion, a individual of his or her inalienable possible abuse but fails to report it. It is formal medicolegal death investigation, rights, such as freedom of choice, , important to understand the avenues of including autopsy, will be conducted. If or privacy. referral when elder abuse is suspected. this does not occur but suspicion Often, several types of abuse occur If an elderly victim with a possible remains, consideration should be given simultaneously. A family member who history of abuse dies, a complete to approaching the legal next-of-kin for may initially take in an elderly patient investigation is needed, including performance of an autopsy. may not be aware of the work and reporting the death to law enforcement, In the case reported, the death was involved and may become the coroner, or the medical examiner as certified as shown because it was subject to the of the situation, required by statute. believed that the decubiti were beyond which can lead to neglect or abuse (6). Abuse of the elderly occurs what would be expected with adequate The abused elder most often has a everywhere in the United States, and medical care and were the primary cognitive impairment, in close education is the key to detection. Elder cause of death, associated with senile proximity to the abuser, lives in social abuse is often difficult to identify and dementia, but also based on some isolation, and is older than 75 years (7). occurs in all races and all degree of medical neglect. Whether the Characteristics of the abuser often socioeconomic groups. In addition to certifier of death reports ‘‘neglect’’ on include a history of mental illness clinical evaluation, the autopsy can play the death certificate or classifies deaths and/or , excessive a major role in the evaluation of from neglect as ‘‘’’ varies dependence on the elder for financial suspected abuse or neglect of the among jurisdictions. In contrast, most support, and a history of violence or elderly. The nature and extent of deaths due to intentionally inflicted antisocial behavior outside the specific injury can be documented. physical abuse would be classified as family (7). Awareness of these factors Some evaluation of hydration status and homicide when the relationship between can assist health care workers in metabolic status may be performed. The physical abuse (injury) and death is identifying those individuals at risk. possibility of causes of death other than clear. However, these fine points are not Abuse is like disease: if it is not abuse/neglect may be evaluated, of major legal import because criminal considered in the it sometimes exonerating those falsely prosecution may occur if there is probably will not be diagnosed (7). accused of abuse or neglect. sufficient evidence of criminal neglect, Recognition of elder abuse/neglect is Intoxication, overmedication, or regardless of how the difficult for several reasons, such as the poisoning may be detected. Some is certified on the death certificate. The lack of structured training in screening evidence may be obtained as to the important factor is that those persons for abuse and the discomfort of duration of specific conditions, such as having knowledge of possible Page 6 [ Series 3, No. 32 abuse/neglect report the facts to the Autopsy Findings listed in Part 2, because appropriate authority so appropriate the berry aneurysm probably existed investigation and legal actions may The autopsy showed diffuse independently of hypertension but was occur. caused by a probably predisposed to rupture because ruptured berry aneurysm of the middle of the existence of hypertension. The NOTE: Volume 160, June 12, 2000. Kim A. cerebral artery. Her weight was breast carcinoma was not reported in the Collins, M.D.; Allan T. Bennett, M.D., Medical increased to 500 g, the left ventricular cause-of-death statement because it did University of South Carolina, Charleston; Randy wall thickness was increased to 2.0 cm, not cause or contribute to death. Hanzlick, M.D., Emory University School of Medicine, Atlanta, GA; and the Autopsy and both kidneys showed granular Carcinoma of the breast may be Committee of the College of American surfaces consistent with nephrosclerosis. familial or hereditary. Research has Pathologists. Microscopic examination of sections of shown that a family history of breast the heart showed hypertrophic myocytes cancer is an important for and enlarged barrel-shaped nuclei; the development of carcinoma of the References kidneys showed scarred glomerular tufts breast (3–5). The term familial breast 1. Greenberg EM. Violence and the older typical of nephrosclerosis. All of these cancer is used to describe the adult: the role of the acute care nurse findings are typical in patients with a appearance within a family of multiple practitioners. Crit Care Nurs Q. August history of hypertension. cases of breast cancer (4). Many breast 1996;19:76–84. A 1.5-cm nodule in the left breast cancers are now known to be associated 2. American Medical Association white was an incidental finding. Histologic with specific genes, notably BRCA1 and paper on elderly health: report of the analysis of sections showed the tumor to BRCA2, and some are known to be Council on Scientific Affairs. Arch be an invasive ductal carcinoma. inherited by autosomal dominant Intern Med. 1990;150:2459–72. Based on these findings, the (4,5). Therefore, the MEDLINE. cause-of-death statement was prepared diagnosis of breast cancer is important 3. Council on Scientific Affairs. Elder abuse and neglect. JAMA. as follows: not only to the patient with the disease 1987;257:966–71. MEDLINE. but perhaps to family members as well. 4. Weiler K, Buckwalter KC. Abuse In this case, the decedent had three among rural mentally ill. J Psychosoc Part 1. sisters, two daughters, and one son. The Nurs Ment Health Serv. 1992;30:32–6. A. Subarachnoid hemorrhage diagnosis of breast carcinoma in the 5. Program Resources Department, decedent should result in specific Due to or as a consequence of: American Association of Retired communication of the diagnosis to Persons (AARP) and Administration on B. Ruptured berry aneurysm of the middle cerebral artery family members so that appropriate Aging (AoA), U.S. Department of follow-up measures may be taken. Health and Human Services. A Profile Above some autopsy room entrance of Older Americans. Washington, DC: Due to or as a consequence of: doors is the phrase hic locus est American Association of Retired C. ubi mors gaudet succure vitae (this is Persons; 1993. Part 2. Other significant conditions: the place where death delights to serve 6. Schor JD, Selby A, Bertone CA. Systemic hypertension Geriatric assessment in the diagnosis the living). Indeed, the autopsy does and treatment of elder abuse. NJ serve the living, especially when Medicine. 1995;92(2)108–10. diseases are detected at autopsy that may 7. Lett JE. Abuse of the elderly. J Florida Comment be inherited or familial. In addition to the Med Assoc. 1995;82(10):675–78. breast cancer discussed in this case, other The majority of nontraumatic common examples encountered at autopsy subarachnoid hemorrhages occur include hypertrophic cardiomyopathy; The Autopsy and the sporadically, but a large proportion are serum lipid disorders; inborn errors of associated with hypertension. Heart metabolism, such as medium chain Living disease is the leading cause of death in acyl-coenzyme A dehydrogenase the United States, and hypertension is deficiency; and hereditary one of the most prevalent hemochromatosis, to name just a few. 62-year-old white woman was contributors (1,2). The autopsy provided Informing the family that such conditions found dead in her bed one good clinicopathologic correlation have been detected at autopsy can literally morning. She had gone to bed A between the decedent’s history of recent be lifesaving since appropriate diagnostic the night before complaining of a headaches and hypertension and the tests and follow-up may then be initiated. headache. Her medical history anatomic findings of berry aneurysm, For example, we have seen a case of included hypertension, mild , subarachnoid hemorrhage, medium chain acyl-coenzyme A and recent headaches; otherwise, her with left ventricular , and dehydrogenase deficiency (first diagnosed health had been good. A complete nephrosclerosis. The cause-of-death at autopsy) that caused the unexpected autopsy was requested by her family statement was prepared as shown, with death of a child. The deceased’s two and physician. siblings were then tested; both were found Series 3, No. 32 [ Page 7 to have the condition and were then 4. Radford DM, Zehnbauer I. Inherited Autopsy Findings treated. As more genetic, familial, or breast cancer. Surg Clin North Am. hereditary conditions are being 1996;76:205–20. MEDLINE. Postmortem examination confirmed elucidated, failure to detect these 5. Bertwistle D, Ashworth A. Functions of the diagnosis of bilateral internal carotid conditions at autopsy is a concern the BRCA1 and BRCA2 genes. Curr artery occlusion caused by mechanical Opin Genet Dev. 1998;8:14–20. among pathologists because of potential compression by the partially extricated MEDLINE. ramifications for family members. Also 6. Lundberg GD. Low-tech autopsies in tumor mass. Extensive subarachnoid of concern, however, is the fact that the era of high-tech medicine: hemorrhage was also confirmed. Marked necessary tests may not be readily continued value for quality assurance cerebral with cerebral uncal and available and the costs of these tests and patient safety. JAMA. cerebellar tonsillar herniation were also may be very high. Lack of 1998;280:1273–74. MEDLINE present. Microscopic and ultrastructural reimbursement for autopsy-related 7. Burton EC, Troxclair DA, Newman examination of the partially calcified procedures compounds the problem in WP. Autopsy diagnoses of malignant sellar tumor revealed high-grade today’s atmosphere of medical cost : how often are clinical fibrosarcoma extending into the nose. containment. Basically, a pathologist diagnoses incorrect? JAMA. The tumor demonstrated multiple foci of may wish to perform specific tests but 1998;280:1245–48. MEDLINE. necrosis and focally brisk mitotic may not have the necessary laboratory activity, with an MIB-1 proliferative facility or funds available. This is a index of greater than 50 percent. No particular problem outside of academic Pathologic Findings in residual was teaching hospitals and when death identified. The optic and oculomotor investigations are funded by government a Transplant Donor nerves showed marked atrophy and agencies, as commonly occurs with the fibrotic encasement. Microscopic medical examiner and coroner systems. 43-year old white man was examination of the lungs showed a Despite its ‘‘low-tech’’ nature, the admitted to the hospital with a single, small, noncaseating granuloma autopsy remains valuable as a quality A one-year history of severe but no metastatic tumor. No metastatic assurance measure in medical practice headache, extraocular muscle paresis, tumor was identified within the and as a tool in preventive upper airway obstruction, and blindness. , spleen, adrenal medicine (6,7). The autopsy’s role in Eight years previously, a nonfunctioning glands, kidneys, or bone marrow. medicolegal death investigations pituitary adenoma was diagnosed and Based on the findings, a cause-of- performed by medical examiners and the patient underwent two death statement was prepared as follows: benefits society in many ways transsphenoidal resections and radiation related to law enforcement, criminal therapy for recurrent tumor. Eight justice, and public health. The old Latin months prior to admission, the patient Part 1. A. Intraoperative bilateral internal phrase has probably never been more underwent an attempted third carotid artery compression/occlusion true; death, through the autopsy, does transsphenoidal resection for recurrent delight to serve the living. headache, followed one month later by Due to or as a consequence of: an attempted resection via an open B. Attempted resection of pituitary NOTE: Volume 159, November 8, 1999. Kim A. craniotomy. Postoperatively, the patient tumor Collins, M.D.; Allan T. Bennett, M.D.; Medical lost all vision; steroid therapy failed to University of South Carolina, Charleston; Randy Due to or as a consequence of: Hanzlick, M.D., Emory University School of restore his sight. A magnetic resonance Medicine, Atlanta, GA; and the Autopsy image scan showed a large pituitary C. Pituitary sarcoma Committee of the College of American tumor extending into the paranasal Pathologists. sinuses. During the patient’s final Due to or as a consequence of: admission, endoscopic resection was D. Radiation therapy of a previous pituitary adenoma References again attempted. The procedure was complicated by intraoperative bilateral Part 2. Other significant conditions: 1. Kannel WB. Blood pressure as a internal carotid artery compression, cardiovascular risk factor: prevention which occurred during attempts to lift and treatment. JAMA. and remove the interposing tumor mass. 1996;275:1571–76. MEDLINE. Subarachnoid hemorrhage and Comment 2. Cohn JN. The management of chronic bihemispheric also developed. Sarcoma of the sella turcica is a . N Engl J Med. Life support measures were withdrawn 1996;335:490–98. MEDLINE. rare but recognized type of malignant the following day and the patient died, 3. Lynch HT, Lynch J, Conway T, et al. neoplasm that occurs in virtually all Hereditary breast cancer and family after which the next of kin donated the reported cases after therapeutic radiation cancer . World J Surg. heart for transplantation and the liver for to a preexisting adenoma or cranio­ 1994;18:21–31. MEDLINE. research. pharyngioma (1). Following a variable latent period of 2 to 27 years, the Page 8 [ Series 3, No. 32 tumors usually grow to a substantial size interpreting autopsy findings and in Lesson of Dr. Joan Deyman (1). and cause optic nerve compression, as assessing risks of performing the autopsy. Dr. Deyman was praelector at the occurred in this patient. The autopsy Surgeon’s Guild and was also inspector procedure enabled the medical staff to NOTE: Volume 159, October 11, 1999. Linda M. of the Amsterdam medical colleges. The detect this clinically unsuspected tumor Dallasta, M.D., Ph.D.; Julio Martinez, M.D.; Larry painting showed Dr. Deyman, a group that led to the complications described. Nichols, M.D., University of Pittsburgh Medical of students, and a with the Center, Pittsburgh, PA; Randy Hanzlick, M.D., Performance of an autopsy was Emory University School of Medicine, Atlanta, calvaria removed and the exposed. valuable in this case for several reasons. GA; and the Autopsy Committee of the College of A more specific cause-of-death The transplant surgeons who American Pathologists. statement cannot be completed with transplanted the heart were alerted to the reasonable certainty because it is existence of the sarcoma and the unknown whether the man’s death possible risks of incipient cardiac References actually resulted from caused metastasis and/or granulomatous 1. Powell H, Marshall L, Ignelzi R. by neck compression or as a result of infection, illustrating the value of Postirradiation pituitary sarcoma. Acta the hangman’s fracture, involving a performing an autopsy on donors. Neuropathol (Berl). 1977;39:165–7. fracture of the odontoid process (2). We Although the timing of organ MEDLINE. also do not know how accurately causes transplantations is such that organs are of death were recorded in Amsterdam at transplanted before the availability of that time; we do know that registers of autopsy results, the autopsy does History Repeats Itself death were maintained in London in the provide information that is useful for the early 1600s. As judged by later records follow-up of the transplant recipient. (Sometimes) in London, however, when the causes of When tissues other than whole organs death were recorded, they did not are donated for transplantation (bone, always appear in a format that would be 28-year-old man was ‘‘punished skin, etc.), they may often be stored and acceptable by today’s standards. For with the rope’’ (hanged) for transplantation delayed until the autopsy example, records from the mid-1800s criminal acts. His body was then results are available. A include such causes of death as ‘‘The transferred to a local physician for The autopsy also revealed a King’s Evil’’ and ‘‘decay of nature’’ postmortem study, with emphasis on clinically unsuspected diagnosis, raising along with other, more recognizable examination of the brain, ostensibly to awareness among medical staff of a rare causes of death, such as cholera (3). search for possible reasons for the but known neoplastic complication of Even half a millennium ago deceased’s prior criminal behavior. radiation therapy. The autopsy also postmortem examination was provided the physicians and family with appreciated for its educational value; an explanation for the patient’s Autopsy Findings history repeats itself today in this sense. blindness and for the failure of steroid Although postmortem examination may therapy. Finally, the demonstration at Specific postmortem findings are have proceeded largely as an autopsy of a malignant tumor invading not available because the report cannot educational in Dr. the base of the was useful in be located. However, based on the Deyman’s case, Dr. Deyman was elucidating that the patient had a grim circumstances, a cause-of-death compensated for the specific services he , a rare and serious malignant statement could be completed as rendered. He reportedly was paid 6 neoplasm, and that the complications follows: silver spoons (valued at 31 guilders and related to would not be 19 stuyvers) (1). Today, most academic unexpected in the setting of extensive Part 1. medical institutions do not pay invasive tumor. These findings were A. Hanging case-specific professional fees for helpful in consoling the family and postmortem examination. The Health alleviating concerns of malpractice and Due to or as a consequence of: Care Financing Administration (HCFA) wrongful death. B. Judicial Execution provides some financial support for Finally, the pathologist may obtain autopsy services; Part A payments to useful information from the organ Due to or as a consequence of: medical institutions are made in the procurement and transplantation team. C. same manner that HCFA supports other Extensive serologic and laboratory testing Part 2. Other significant conditions: hospital services, such as food and is performed on donor specimens, laundry. No Part B professional payment including tests that evaluate the possibility is made to the professional staff on a of human virus and specific fee-for-service basis, however. viral hepatic . The results of Comment Furthermore, the formula for Part A such tests are usually reported to the The events described occurred in payments does not take into account the pathologist, who may not have performed 1656 and were portrayed in a painting number of autopsies performed or their these tests as part of the autopsy by Rembrandt titled The Anatomy usefulness within the institution. The procedure. The results may be useful in rationale of HCFA has been that autopsy Series 3, No. 32 [ Page 9 services do not provide useful the clinical aspects of diseases, laying Death Counts [videotape]. London, information for treating patients and the basis for the field of . In England: Health Education Video Unit therefore do not require compensation. 1858, Virchow introduced the cellular of the Leicester Royal Infirmary NHS However, autopsy findings can have a aspects of pathology and disease in his Trust; 1996. positive impact on subsequent patients. work Cellular Pathology. Other 4. Iserson KV. Death to Dust: What Happens to Dead Bodies? Tucson, AZ: To cite just a few examples, autopsy can autopsy-based publications appeared in Press; 1994:115–7. aid in the detection of nosocomial the intervening years (4). 5. Fisher R, Platt M. History of forensic infection outbreaks, determine drug Several symposia on the and related laboratory sensitivities of fatal hospital-acquired the autopsy have been published since . In: Spitz WU, ed. Spitz and infections, or detect pharmaceutical 1965 (7–10). The most recent of these Fisher’s Medicolegal Investigation of problems, such as mislabeled or includes a table of more than 80 disease Death: Guidelines for the Application defective products. Autopsy findings entities that have been ‘‘discovered or of Pathology to Crime Investigations. could be used to assess the accuracy of critically clarified through the autopsy’’ 3rd ed. Springfield, IL: Charles C. diagnostic related groups, which form since 1950 (11). More recently, autopsy Thomas Publisher; 1993:3–4. the basis of payment for medical care. has played a critical role in identifying 6. Flanagin A. The first postmortem To date, HCFA has not done this, as far the Hantavirus pulmonary , recorded in the country. JAMA. 1993;270:1891. as we know. pathologic conditions associated with 7. Symposium on the autopsy [multiple Autopsies have been done in one human immunodeficiency virus articles and authors]. JAMA. way or another since before the time of infection, and emerging infectious and 1965;193:805–14. Christ. Evidence of knowledge about environmental conditions (12). 8. The autopsy: a beginning, not an end internal anatomy is clear from Egyptian The autopsy has benefitted society [multiple articles and authors]. Am J archeological specimens; however, it is for thousands of years and continues to Clinical Pathol. 1978;69(suppl):215–65. not really known whether organ removal do so. It has not outlived its usefulness. 9. The autopsy: revitalizing the ultimate was done for any purpose other than The nature of the questions to be medical consultation [multiple articles preservation before sometime between addressed by postmortem examination and authors]. Arch Pathol Lab Med. 350 and 200 BC in , where have changed over the years, but the 1984;108:437–523. MEDLINE. anatomy and pathology were reportedly ability of the autopsy to address many 10. College of American Pathologists Conference XXIX. Restructuring taught (4). The word autopsy derives of them has not. New diseases will autopsy practice for health care reform from the Greek autopsia, which means continue to emerge. The need will [multiple articles and authors]. Arch ‘‘seeing with one’s own eyes.’’ probably always exist to evaluate Pathol Lab Med. 1996;120:700–85. Autopsies were performed in Greece as diagnostic and therapeutic effectiveness 11. Hill RB, Anderson RE. The recent early as the fifth century BC and were and disease patterns on an ongoing basis history of the autopsy. Arch Pathol Lab more formally used by Galen in Greece for quality improvement purposes. Med. 1996;120:702–12. MEDLINE. in the second century. Historical sources There is little doubt that the autopsy 12. Nolte K, Simpson GL, Parrish RG. also acknowledge the use of the autopsy will continue to be among those medical Emerging infectious diseases and the into the Middle Ages, although procedures that define significant forensic pathologist: the New Mexico autopsies were performed more often for historical landmarks in the science and model. Arch Pathol Lab Med. religious reasons (to identify , for art of medicine. 1996;120:125–8. MEDLINE. example, which was taboo) than for scientific ones (4,5). NOTE: Volume 159, September 13, 1999. Randy Before the anatomy lesson of Dr. Hanzlick, M.D., Emory University School of Incidental and Deyman was depicted in 1656, autopsies Medicine, Atlanta, GA; Grover M. Hutchins, M.D., The Johns Hopkins Medical Institutions, Not-So-Incidental had been performed in the New World. Baltimore, MD; and the Autopsy Committee of the Autopsies were performed on Siamese College of American Pathologists. Findings twins in Hispaniola in 1553; near the area of the current Maine/Canadian border in 1605 to determine why French References 63-year-old Hispanic man was a explorers were dying (of scurvy, moderate consumer with 1. Southgate MT. The Anatomy Lesson of a 50 pack per year history of apparently); and in Hartford, Conn., in Dr. Joan Deyman. JAMA. A cigarette smoking. After the onset of 1662 to assess whether an 8-year-old 1997;278:530. had died of witchcraft (4,6). 2. Spitz WU. Asphyxia. In: Spitz WU, ed. acute nonradiating , he was It was not until the 18th century Spitz and Fisher’s Medicolegal taken to the emergency department, that autopsy was used more like it is Investigation of Death: Guidelines for where his chest pain continued and he today with an emphasis on the science the Application of Pathology to Crime became restless and cyanotic. Cardiac of pathology. In 1769, Morgagni Investigations. 3rd ed. Springfield, IL: arrest occurred within 15 minutes, and published The Seats and Causes of Charles C. Thomas Publisher; resuscitative attempts were unsuccessful. Diseases Investigated by Anatomy, 1993:449. The emergency department physicians 3. British Office of National Statistics. which correlated autopsy findings with requested an autopsy to determine the Page 10 [ Series 3, No. 32 cause-of-death, which they suspected Comment may not be correctly diagnosed until was a ruptured aortic aneurysm. autopsy (8). It causes symptoms and A review of the patient’s medical Although the patient’s symptoms signs such as pulmonary hypertension, history in preparation for the autopsy suggested , the hemoptysis, and right-sided heart failure, showed a hospital admission 5 months electrocardiogram, cardiac enzyme and is usually progressive, with most earlier for substernal chest pain with levels, and dipyridamole stress test cases resulting in death (7). Treatment radiation to the neck and shoulders. results did not provide evidence of includes pneumonectomy with The pain resolved, and an coronary artery or heart disease. Death heart-lung transplantation, and one case electrocardiogram showed normal in this case serves as a sobering showed favorable results with interferon sinus rhythm and a normal axis. Neither reminder of the limitations of some alfa-2a (8,9). In the case reported herein, the electrocardiogram nor the cardiac methods in detecting serious and the was unusual because it was enzyme levels showed evidence of life-threatening . focal, the decedent was apparently myocardial , and the findings Normal dipyridamole stress test results , and the finding was of a dipyridamole stress test were do not necessarily exclude the presence basically an incidental one. interpreted as normal, without evidence of significant coronary artery disease. Nevertheless, this case shows how of significant coronary artery disease. After infusion of dipyridamole, autopsies may provide ‘‘incidental’’ adenosine concentration increases and information that may be useful in has a potent vasodilatation effect that, studying and learning about the natural Autopsy Findings although having little impact on history of some conditions or in Autopsy disclosed diffuse coronary arteries that show more than studying what might be an early stage three-vessel coronary 75 percent stenosis, may increase blood or forme fruste of a particular disease with almost complete stenosis of the left flow in normal coronary arteries three to entity. For example, a ‘‘pleural ball’’ anterior descending coronary artery. No five times baseline levels (1). Even in was described in one case in which the thrombi were seen; the heart weighed the face of significant coronary ball was attached to the lung by two 430 g; and the left ventricle showed atherosclerosis, however, dipyridamole fibrous bands, possibly providing an concentric hypertrophy. Microscopically, infusion may cause considerable explanation for how pleural balls may there was moderate perivascular and increase in blood flow to the first form and then break loose to occur interstitial myocardial fibrosis, consistent myocardium supplied by nondiseased or as free bodies in the pleural cavity (10). with chronic , but no acute lesser-diseased coronary arteries, and The autopsy was valuable in this infarction was identified. The lungs radionucleotide imaging can identify case for several reasons. It clarified the were normal except for a single focus of such areas of increased perfusion (1). As cause-of-death for death certification pulmonary capillary hemangiomatosis may have occurred in this case, purposes, provided possible explanations within the right lower lobe, false-negative dipyridamole test results for why diagnostic tests during life did characterized by proliferation of small may occur in patients with global not detect the fatal condition, disclosed capillaries in alveolar septal walls and coronary artery disease, because there an unusual incidental finding of some interstitium, along with proliferating will not be heterogeneity of regional academic interest, and provided capillaries within small pulmonary myocardial blood flow and the results information with a firm foundation for veins. The capillary lining consisted of may appear to be normal (1). The explaining more fully to the family the uniform, small, flat to cuboidal dipyridamole stress test has a reported patient’s clinical course and endothelial cells without atypia. No sensitivity of 86 percent and a cause-of-death. The autopsy provided aortic aneurysms were found, but the specificity of 71 percent in predicting both incidental and not-so-incidental, and major arteries showed the presence of coronary artery disease, very relevant information and atherosclerosis of moderate degree. but results may vary on the basis of exemplifies why the autopsy remains the Based on these findings, a cause-of- several factors, including the type of ‘‘gold standard’’ in determining causes death statement was prepared as follows: radionucleotide imaging agent of death, clarifying clinical issues, and used (2,3). resolving enigmas. Also, in this case, the autopsy Part 1. disclosed the rare finding of localized NOTE: Volume 159, August 9/23, 1999. Dean M. A. Atherosclerotic cardiovascular pulmonary capillary hemangiomatosis, Havlik, M.D., University of New Mexico School disease which is characterized by a proliferation of Medicine, Albuquerque; Wilbur L. Williams, M.D., University of New Mexico School of of small capillaries within peribronchial, Medicine and Albuquerque Veterans Affairs Due to or as consequence of: perivascular, septal, and subpleural Medical Center; Randy Hanzlick, M.D., Emory B. regions of the lungs. Most of the 23 University School of Medicine, Atlanta, GA; and cases reported in the literature showed the Autopsy Committee of the College of Due to or as a consequence of: diffuse involvement throughout both American Pathologists. C. lungs (4–7). The condition may be Part 2. Other significant conditions: misdiagnosed as pulmonary veno-occlusive disease during life and Series 3, No. 32 [ Page 11 References Outcome Analysis and Comment 1. Braunwald E, ed. Braunwold’s Heart Quality Assessment The cause-of-death statement as Disease: a Textbook of Cardiovascular shown is appropriate because the limited Disease. 3rd ed. Philadelphia, PA: WB autopsy hampered the ability to fully white male infant was born at 37 Saunders Co; 1997:288–90. evaluate possible factors that caused or weeks’ gestation. Soon after 2. Chou TM, Amidon TM. Evaluating contributed to death. No doubt, the coronary artery disease noninvasively: delivery, hypoplastic left heart A underlying cause-of-death was which tests for whom? West J Med. syndrome was diagnosed. A Norwood hypoplastic left heart syndrome. 1994;161:173–80. MEDLINE. procedure was performed (a palliative However, the specific nature of the 3. MaHmarian JJ, Verani MS. Myocardial procedure with of the aorta immediate cause-of-death could not be perfusion imaging during to the right ventricle for systemic pharmacological stress testing. Cardiol fully explained because of the limited circulation and an atrial septectomy Clin. 1994;12:223–45. MEDLINE. autopsy. The conditions cited in Part 2 formed to avoid pulmonary venous 4. Al-Fawaz IM, Al Mobaireek KF, certainly played a significant role and hypertension). Reexploration was Al-Suhaibani M, Ashour M. Pulmonary were therefore reported as ‘‘other required for postoperative , capillary hemangiomatosis: a case significant conditions.’’ report and review of the literature. which was controlled surgically. Despite its limited nature, the Pediatr Pulmonol. 1995;19:243–8. Urosepsis and disseminated intravascular autopsy showed that the infant’s surgical MEDLINE. coagulopathy complicated the clinical procedure was done without obvious 5. Masur Y, Remberger K, Hoefer M. course and the infant died. The surgeons complications, such as breakdown of Pulmonary capillary hemangiomatosis requested permission for autopsy from as a rare cause of pulmonary anastomosis sites, suturing closed a the family so that the surgical procedure coronary artery, or thrombosis of hypertension. Pathol Res Pract. could be reassessed, but the family 1996;192:290–5. MEDLINE. anastomosed vessels. The pediatric declined and stated that the infant had 6. Jing X, Yokoi T, Nakamura Y, et al. cardiothoracic surgeons, pediatric been ‘‘cut on enough.’’ However, when Pulmonary capillary hemangiomatosis: cardiologists, residents, and medical a unique feature of congestive the option of a limited autopsy was students involved in the care of the vasculopathy associated with discussed, the family consented to a infant attended the autopsy and were hypertrophic cardiomyopathy. Arch postmortem examination limited to the able to see the outcome of their work Pathol Lab Med. 1998;122:94–6. heart and lungs. and treatment. They examined their MEDLINE. surgical work and explained their 7. Humbert M, Maitre S, Capron F, Rain B, Musset D, Simonneau G. Pulmonary Autopsy Findings decision-making processes and edema complicating pulmonary techniques to the pathologists and others capillary hemangiomatosis. Am J Autopsy showed that all suture sites at the autopsy; the pathologist was then Respir Crit Care Med. were intact; there were no sutures that able to demonstrate and explain the 1998;157:1681–5. MEDLINE compromised vessels or other critical pathological changes to the clinicians. 8. Faber CN, Yousem SA, Dauber JH, structures, and there were no vascular Based on the autopsy findings, treatment Griffith BP, Hardesty RL, Paradis IL. thromboses. However, there were modalities were discussed, as well as Pulmonary capillary hemangiomatosis: unexpected of both cardiac options available for future patients. The a report of three cases and a review of ventricles and infarction and lobular cardiologists educated all those the literature. Am Rev Respir Dis. pneumonia within the right lower lung attending regarding hypoplastic left 1989;140:808–13. MEDLINE. lobe. heart syndrome and its clinical findings, 9. White CW, Sondheimer HM, Crouch Based on these findings, a EC, H, Fan LL. Treatment of correlating clinical features, and pulmonary hemangiomatosis with cause-of-death statement was prepared: postmortem results. Pathology residents recombinant interferon alfa-2a. N Engl gained experience in the dissection of a J Med. 1989;320:1197–1200. pediatric heart as well as an MEDLINE. Part 1. understanding of the issues related to 10. Hanzlick R, Zaki S, Ross W. Pleural A. Hypoplastic left heart syndrome the examination of such . Thus, pearl: an immature pleural ball? Am J everyone involved learned more about Forensic Med Pathol. 1988;9:159–60. Due to or as a consequence of: B. hypoplastic left heart syndrome, MEDLINE. acquired useful information about the Due to or as a consequence of: course and treatment of the infant, and C. broadened the scope of their medical experience to the extent that it may Part 2. Other significant conditions: affect the care of future patients. These Biventricular ; right lower lung infarction and benefits exemplify the value of outcome lobular pneumonia analysis and quality assessment, to Page 12 [ Series 3, No. 32 which the autopsy contributed much in References during a hospital-based autopsy and this case. permission has been granted by the legal The autopsy findings were 1. Aiello VD, Ho SY, Anderson RH, custodian of the body), the wording discussed at subsequent conferences, Thiene G. Morphologic features of the caused the resident to wonder whether with additional discussion of treatment hypoplastic left heart syndrome: a the physician understood and conveyed modalities and outcomes. The reappraisal. Pediatr Pathol. to the next of kin the nature of routine conferences were attended not only by 1990;10:931–43. MEDLINE. autopsy procedures. A review of other 2. Nichols L, Aronica P, Babe C. Are the infant’s clinicians, but also by others autopsy authorization forms showed that autopsies obsolete? Am J Clin Pathol. who did not attend the autopsy or had 1998;110:210–8. MEDLINE. similar wording was common, such as no direct involvement in the treatment 3. Burton EC, Troxclair DA, Newman WP ‘‘keep the head intact,’’ ‘‘be gentle, of this patient. These individuals also III. Autopsy diagnoses of malignant would like open-casket ,’’ ‘‘keep benefitted from the information gathered neoplasms: how often are clinical facial features natural,’’ and ‘‘be careful from this autopsy and the thorough diagnoses correct? JAMA. to do nice surgical incisions.’’ review of hypoplastic left heart 1998;280:1245–8. MEDLINE. Shortly thereafter, at an introductory syndrome. Patients with hypoplastic left 4. Kumar P, Taxy J, Angst DB, Mangurten session about the autopsy for new heart syndrome are at risk for acidosis, HH. Autopsies in children: are they still internal medicine interns and residents, shock, and multiorgan dysfunction useful? Arch Pediatr Adolesc Med. the participants were asked to raise their secondary to hypoxia. In complicated 1998;152:558–63. MEDLINE. hands if they had ever received 5. Grunberg SM, Sherrod A, Muellenbach cases, infarctions may occur in various instruction in about how R, Renshaw M, Zaretsky S, Levine organs, as in the heart and lungs of this AM. Analysis of physician attitudes an autopsy is performed. Very few infant (1). concerning requests for autopsy. Cancer participants raised their hands; fewer Finally, the analysis of the facts and Invest. 1994;12:463–8. MEDLINE. participants had actually seen an autopsy findings was useful in discussions with 6. Wilkes MS, Link RN, Jacobs TA, performed; and even fewer participants the patient’s family, providing them with Fortin AH, Felix JC. Attitudes of house had received any instruction on how to peace of mind and a sense of closure. officers toward the autopsy. J Gen ask a family member for permission to They were assured that everyone Intern Med. 1990;5:122–5. MEDLINE. perform an autopsy or how to explain involved in the antemortem and 7. Stolman CJ, Castello F, Yorio M, how an autopsy is performed. postmortem care of the infant had been Mautone S. Attitudes of pediatricians The pathology resident and his thoughtful, diligent, and thorough; that and pediatric residents toward obtaining supervisor had a discussion in which the permission for autopsy. Arch Pediatr what could have been done was done; idea was put forth that some (or perhaps Adolesc Med. 1994;148:843–7. and that the institution’s staff was MEDLINE. many) clinicians may be reluctant to comprehensive, professional, and caring request permission to perform an in the services provided. autopsy because they are uncomfortable As illustrated by this case, the The Rest of the Story with their lack of knowledge about limited autopsy can be an excellent tool autopsy-related issues. If they do not to help physicians perform quality know how the procedure is performed, assessment and analyze outcomes. 78-year-old woman with they may not be comfortable addressing Despite major advances in medical hypertension presented with a questions that may be asked by the technology, recent studies validate the A gangrenous foot that had kept family members. If the clinician is not continued contributions of the her from ambulating. During the aware of the routine sequence of events, autopsy (2–4). When possible, it is surgical closure following above-the- clinicians may be hesitant to answer desirable to perform a complete autopsy. knee she developed questions about the logistics of autopsy Attitudes and approach can play a major precipitous hypotension followed by performance (such as, How long does it role in how the results of the autopsy cardiopulmonary arrest and death. take to perform an autopsy? Will the are used (5–7). The preference for The pathology resident on call to autopsy preclude viewing the body at complete autopsy should be discussed perform autopsies received an the ? Will it cost the family with families and the possibility of a authorization to perform an autopsy that any money if an autopsy is performed?). limited autopsy should be offered to had been completed by the patient’s Clinicians may unknowingly answer them if they do not wish to consent to physician and the legal next of kin. In questions incorrectly or provide the performance of a complete autopsy. the area of the form for notation of misleading information. restrictions (such as ‘‘autopsy to be The pathology resident’s supervisor NOTE: Vol 159, July 12, 1999. Allan T. Bennett, limited to chest and abdomen only’’) thought that it might be helpful to M.D.; Kim A. Collins, M.D., Medical University were the words ‘‘please do not disfigure describe some of the basic features of of South Carolina, Charleston, SC; Randy the face.’’ Because the face is almost autopsy performance so that clinicians Hanzlick, M.D., Emory University School of never disfigured during an autopsy Medicine, Atlanta, GA; and the Autopsy who are unaware of specific details may Committee of the College of American (unless dissection is required in a be better prepared to have discussions Pathologists. forensic autopsy for medicolegal with families. This article includes such purposes or special needs have arisen information. Series 3, No. 32 [ Page 13

Autopsy Findings provided as a model for adaptation to a What Is Done With the particular practice setting. Organs? The autopsy showed extensive bilateral pulmonary thromboemboli that How Long Does It Take to The answer varies with the institution. In the hospital setting, originated in the lower extremities. Perform an Autopsy? There was no evidence of fat especially if there is a pathology embolization or adverse reaction to The time required depends on the training program, the internal organs . case. In most cases, the part of the may be retained by the pathology Based on autopsy findings, a autopsy dissection in which the organs department. They may be saved cause-of-death statement could be are removed and examined indefinitely for teaching purposes or completed as follows: macroscopically requires 2 or 3 hours at they may ultimately be disposed of, most. Usually, the body will be usually by incineration. In some available for transport to the funeral institutions, the bulk of the organs are Part 1. home a few hours after the autopsy is returned to the body cavity (in a plastic A. Bilateral pulmonary begun. In efficient settings, the bag) after the necessary samples have thromboembolism preparation and examination of been taken. The latter procedure is microscopic slides, review of the especially common in medicolegal Due to or as a consequence of: (forensic) autopsies. In most hospital B. Deep vein thrombosis associated medical record, performance and review settings, however, the organs are with immobility of laboratory tests performed as a result of the autopsy, and preparation of the retained. If the organs are retained, the Due to or as a consequence of: final autopsy report may require a week autopsy authorization form should C. Peripheral vascular disease or less; however, a few weeks is often clearly indicate that the hospital has the required. If there is compliance with the right to retain, use, and dispose of the Part 2. Other significant conditions: organs in compliance with applicable Hypertensive cardiovascular disease inspection and accreditation requirements of the College of American laws. Pathologists, most cases will be completed within 30 working days What Parts of the Body Are Comment unless the case is complicated. Incised? Preliminary autopsy results should be The autopsy findings in this case available within 2 to 3 working days. Typically, only two incisions are were useful for completing the death made on the body surfaces. To remove certificate, answering questions that What Is a Complete Autopsy? the brain, an incision is made that were posed by the patient’s physician extends from behind one ear across the and family, and ruling out untoward A complete autopsy generally top of the head posterior to the vertex effects that could potentially have been includes removal and examination of the and downward behind the other ear. directly related to the surgical procedure brain and the organs of the neck, , This incision is such that when it is or anesthesia. However, another major abdomen, and pelvis, with microscopic repaired at the funeral home, even in a value of the autopsy was that it brought sections prepared for major viscera and bald person, it is not visible when the an important issue to light that some other tissues, as required (2). Specific body is in the supine position with the clinicians may not be fully prepared to postmortem laboratory tests are head on a pillow in the casket. The top explain the autopsy procedure or answer performed as indicated by the clinical of the skull (calvaria) is removed by questions about autopsy performance. history and autopsy findings. sawing circumferentially after the scalp Information about autopsy-related has been reflected anteriorly and procedures is provided below in the What Is a Limited Autopsy? posteriorly and at an obtuse angle in the form of commonly asked questions with posterior skull to keep the skullcap from answers. The comments are related In a limited autopsy, one or more of rotating when it is replaced after mainly to autopsies that are performed the components of a complete autopsy removal of the brain. After removal of in hospitals, with the consent of the next are not performed. Limited autopsies are the brain and inspection of the inside of of kin. usually performed because the family the skull, the skullcap is replaced and has restricted the extent of the autopsy. the scalp margins are reapproximated. How Does One Ask for Sometimes, however, the pathologist or The other incision is a Y-shaped incision Permission to Perform an clinician may restrict the extent of that extends from each anterior shoulder Autopsy? autopsy; this might occur, for example, region toward the midline over the in a suspected case of Creutzfeldt-Jakob lower , then downward in the Guidance on how to request disease for which professional midline toward the pubis. The soft tissue permission for an autopsy was provided guidelines advise that only the brain be can then be reflected upward to the previously (1). Templates and pocket removed (3,4). underside of the mandible, which allows cards with specific language have been inspection and removal of the soft tissue Page 14 [ Series 3, No. 32 of the neck, and laterally, which allows Is the Spinal Cord Routinely prepared for the funeral home within removal of the anterior chest wall in one Removed? one to two hours of starting time. This piece (sternum and adjacent ribs to the allows for release of the body promptly, costochondral junction), making the The spinal cord is not routinely while the organs may be retained for organs of the thorax, abdomen, and removed, although it is removed later dissection and examination. Such pelvis accessible for removal. After the routinely in some institutions. The spinal procedures may be used, for example, if autopsy, the chest plate is replaced and cord may be removed in three ways. In occurs late in the day and the the soft tissue flaps are reapproximated. one method, pathologists use a special family does not want to delay transport Usually, the major autopsy incisions are spinal cord extractor consisting of a of the body to the funeral home until loosely sewn together; at the funeral long rod with a sharp forked blade on the following day. home, the incisions are tightly repaired one end, which can be inserted through with suture and other agents, such as the foramen magnum to cut the spinal Are Autopsies Performed 24 roots. The spinal cord can then be special glue and sealers. Other incisions Hours a Day, 7 Days a Week? may be made (for example, in the legs withdrawn through the foramen to look for venous thrombi), but such magnum. The advantage is that Most pathology departments incisions are not routine and may, in additional incisions are not required; perform autopsies during normal some institutions, require special however, the extractor should not be business hours during the week. Thus, if permission depending on the wording in used if subtle changes in the spinal cord a death that occurs late in the afternoon, the autopsy authorization form. or roots are being evaluated. Another the autopsy may not be performed until method is to remove the vertebral the following day unless a special Are Any Other Incisions Made? bodies with an anterior approach (after request is made to expedite procedures the organs have been removed) by as described in the preceding paragraph. In general, effort is made not to sawing through the pedicle of the Many pathology departments have staff incise areas of the body that are visible vertebral arch, which allows the anterior on call to perform autopsies on at a viewing of the body at the funeral spine to be lifted away from the spinal weekends, but some do not. It is home (such as the hands and face). canal from which the spinal cord may important to be familiar with the Whether such incisions are made then be removed. The posterior staffing procedures at the institution depends on how the autopsy approach involves a midline posterior where you work. authorization (and its ) incision, with reflection of the soft is worded. Without clearly worded tissues away from the spinous processes Where Is the Autopsy consent for such incisions when needed, and posterior vertebral arches, which are most pathologists would not make then sawed through, allowing the Performed? incisions in unusual areas unless specific posterior portion of the spine to be lifted Most hospitals have a and permission has been obtained from the away to remove the spinal cord. Either an autopsy room, and the autopsy is family. of the latter two procedures leaves performed in the hospital. However, enough spine and soft tissue in place so some hospitals do not have autopsy Are the Eyes Removed? that the body does not distort or rooms. In such cases, the body may be foreshorten. transferred to another location for the Again, whether the eyes are autopsy, such as another hospital or a removed is based on the needs and the How Are the Organs Removed? funeral home. Physicians should be wording in the autopsy authorization familiar with the practice in their and informed consent. Many The brain is removed intact. The institution so that questions by the pathologists require specific thoracic and abdominal organs may be family may be adequately addressed. It permission from the family for removed en masse (in one large block is helpful when autopsies are performed removal of the eyes. In most hospital that may include everything from the in the hospital where death occurred so autopsies, the eyes are not routinely tongue to the anus), in sections (in that the physician’s ability to observe or removed for diagnostic purposes. The which organ systems are removed in review the findings is facilitated. corneas or globes may be removed by blocks, such as the heart and lungs an eye bank if the eye bank has together), or individually. The method obtained permission from the family chosen depends on the needs of the case How Long Are the Organs, or if other laws permit their removal. and the pathologist’s preference. Tissues, and Other Items The eyes may be removed as Retained? needed in forensic autopsies performed What If There Is a Rush to Unless the organs are specifically under the authority of the medical Have Funeral Services? kept for teaching purposes, the dissected examiner or coroner (for example, to organs are usually disposed of when the assess the possibility of shaken baby In most instances, the body may be autopsy report has been finalized or syndrome). externally examined, the organs within a short time thereafter. removed (eviscerated), and the body Series 3, No. 32 [ Page 15

Microscopic slides and the paraffin In general, research on specimens appropriate to levy such additional fees. blocks from which they are prepared are removed during the autopsy does not The family may be instructed to check usually kept for a number of years and require approval by an institutional with their if they are may be kept indefinitely. Stock tissue or review board, although there are concerned about possible autopsy-related small pieces of organs and tissues that exceptions. However, the major fees imposed by the funeral home. are preserved in formalin may be kept determining factor is the specific for months or years before they are language contained in the autopsy disposed. Finalized autopsy reports are authorization and informed consent. In Conclusions usually kept indefinitely. the medicolegal (forensic) setting, in We hope that the information which the family’s permission is not provided herein will be helpful to What If the Family Members usually required to perform an autopsy, clinicians who request permission to Want Some or All of the the use of organs and tissues is often perform autopsies, explain autopsy restricted to determining the cause and Specimens? procedures, and answer questions related manner of death, and the procurement of to autopsy performance. When needed, Technically, the remains of the tissues specifically for research purposes questions may be directed to a deceased belong to the family (legal often requires special permission. pathologist in the institution where the next of kin). Thus, the family has a autopsy will be performed or to the legal right to the various specimens, When Is funeral director, if questions are related although such requests are rare. Usually, Performed? to body preparation and other aspects of the wording in the autopsy authorization funeral services (5,6). either implicitly or explicitly transfers If the body is embalmed, the ownership of the specimens to the procedure is usually done at the funeral NOTE: Volume 159, June 14, 1999. Randy institution or the pathology department. home after the autopsy has been Hanzlick, M.D.; Mario I. Mosunjac, M.D., Emory If specimens are transferred out of the performed and the body has been University School of Medicine, Atlanta, GA; and institution, it is important that such transported out of the hospital. However, the Autopsy Committee of the College of American Pathologists. transfer and storage of body parts or embalming may be done prior to the specimens be done in accordance with autopsy either inadvertently because the State laws that pertain to the ownership body was taken to the funeral home References and storage of anatomical specimens. before the autopsy was performed or intentionally because there is a known 1. Hutchins GM, Hanzlick R, and the Autopsy Committee of the College of Are Implanted Devices infectious disease that may pose some risk to the autopsy . Some American Pathologists. Case of the Removed During an Autopsy? hospitals have embalming equipment month. Arch Intern Med. 1998;158:219–20. MEDLINE. and may routinely embalm bodies prior Pacemakers and other implanted 2. Hutchins GM, ed, and the Autopsy devices (such as orthopedic appliances) to autopsy. Committee of the College of American are usually removed, when feasible and Pathologists. Autopsy Performance and when their presence is known or a Is There a Cost to the Family? Reporting. Northfield, IL: College of specific request to remove them has American Pathologists; 1990. been made. Responsibility for Most hospitals do not charge a fee 3. Hanzlick R, and the Autopsy documentation of the disposition of such for an autopsy when an autopsy is Committee of the College of American devices usually rests with the physician performed on a patient who died in the Pathologists. Case of the month: (or institution) who implanted the hospital. However, some hospitals familial olivopontocerebellar atrophy. Arch Intern Med. 1997;157:2557. device. Thus, devices that are removed charge a fee if the autopsy is requested by the family but the hospital does not MEDLINE. may be forwarded to the appropriate 4. Crain B. Safety tips for anatomic institution or with the body for return to have a particular interest in performing an autopsy. Other hospitals charge a fee studies of possible Creutzfeldt-Jakob the family, who may then transfer the disease. CAP Today. 1996;10:56. to perform an autopsy if the deceased device to the appropriate agency or MEDLINE. institution. was a patient at the hospital but died 5. Mayer RG. Embalming: History, outside the hospital. Because billing Theory, and Practice. East Norwalk, practices for autopsies vary among How Are Specimens Used for CT: Appleton & Lange; 1990. institutions, it is important for 6. Hanzlick R. Embalming body Research? physicians at a given institution to know preparation, burial, and disinterment: an In most hospitals, the autopsy what those practices are. On occasion, overview for forensic pathologists. Am J Forensic Med Pathol. authorization form specifically states some funeral homes will charge 1994;15:122–31. MEDLINE. that organs and tissues removed during additional fees for body preparation the autopsy may be used by the hospital when an autopsy has been performed. for teaching, research, or other purposes. However, this is not common, and some funeral directors believe it is not Page 16 [ Series 3, No. 32 Education of the following the head injury, and multiple opinions about the relative contribution blood cultures at autopsy yielded of injury and disease in causing death. Pathologist Acinetobacter anitratus without He also learned more about the evidence of postmortem contaminants, importance of reporting appropriate supportive of the antemortem diagnosis deaths to the medical examiner, and also 47-year-old man was admitted to of sepsis. There was residual subdural gained additional experience with the the hospital with complaints of hematoma over one cerebral hemisphere. practical aspects of performing the A leg swelling and shortness of Because of the patient’s accelerated and autopsy and preparing the autopsy breath. His medical history included continual downhill course after the fall, report. Adequate experience at autopsy chronic alcohol abuse and diabetes. the medical examiner concluded that the performance and reporting are critical Serologic testing indicated hepatitis C head injury was a significant factor in for the pathology resident to become infection. Evaluation also showed causing death. Thus, a cause-of-death competent and proficient at autopsy probable cirrhosis and spontaneous statement could be prepared as follows: performance prior to finishing bacterial peritonitis due to culture- pathology residency training and Escherichia coli. proven infection with entering independent practice. In Antibiotic therapy was administered. Part 1. recognition of this need, the American While in the hospital, the patient fell A. Acinetobacter anitratus sepsis Board of Pathology requires a resident from his bed and sustained a head injury to perform a minimum of 50 autopsies Due to or as a consequence of: on the sixth hospital day. He was as part of the qualifications to take the conscious and responsive when B. Complications of subdural hematoma board examination in anatomic discovered on the floor near his bed, but pathology (1). within an hour he required intubation Shortly after this case, the autopsy after a sudden deterioration in mental Due to or as a consequence of: C. Blunt force head injury sustained in training director was contacted by the status. Neuroimaging showed a subdural fall from bed pathology training program hematoma with midline shift. There was administrator, who asked if some Part 2. Other significant conditions: transient clinical improvement, but adjustments could be made to allow , increasing leukocytosis, and a Alcohoholic cirrhosis, hepatitis C infection pathology residents in their last year gradual decline in his condition ensued of training to spend additional time on and he died on hospital day 14. the autopsy service. The reason was The patient’s physician obtained that residents needed additional permission for postmortem examination. Comment autopsy experience to qualify for the The pathology resident who was on duty board examination, and time was became aware that deaths involving The conditions in Part 2 were running short. This problem occurred, injury are reportable to the medical reported because the cirrhosis and at least in part, because the examiner, and he reported the death hepatitis C infection were ongoing and institutional autopsy rate had declined accordingly because he realized that the coagulation disturbance related to liver as it has in many other institutions (2). patient’s physician had not notified the disease was thought to have predisposed Autopsy rates have declined in some medical examiner. Because permission the patient to subdural hematoma training institutions to the point that for autopsy at the hospital had been following head injury. Listing these the number of autopsies is barely obtained, the medical examiner assumed conditions in Part 2 is appropriate adequate to provide pathology jurisdiction of the case for the purpose because the conditions did not, in and of residents with the required number of of death certification, but permitted the themselves, result in the fall, which may autopsies. In fact, the required number autopsy to be performed at the hospital. well have been an independent event of autopsies for board qualification The death certificate was not completed that could have occurred if cirrhosis and was 75 a few years ago, but the by the medical examiner until the peritonitis had not existed. number was reduced to 50 because of hospital autopsy findings were available The attribution of death to a fall in insufficient autopsy rates in many several days after the autopsy. the hospital may raise the concern that training institutions. It is now the cause-of-death statement puts the permissible for two pathology Autopsy Findings hospital at potential risk for some legal residents to share in the performance action, but the cause-of-death as stated of an autopsy for the purpose of board At autopsy, liver findings were is the truth to the best of the certifier’s qualification, another adjustment consistent with hepatitis C infection and knowledge and the truth should not be necessitated by low autopsy rates. additional autopsy findings included skirted for fear of litigation. Also, the Joint Commission for cirrhosis and resolving peritonitis (the The pathology resident learned Accreditation of Health Care E. coli infection apparently responded to much from the performance of this Organizations and the Residency antibiotic treatment). There had been autopsy. He learned about correlating Review Committee for internal clinical evidence of systemic sepsis autopsy findings with the clinical history medicine residency programs each had while in the and practical approaches to formulating minimum autopsy requirements at one Series 3, No. 32 [ Page 17 time. No longer is that the case, References into the surrounding soft tissues and however, and the tail seems to have substernal soft tissue. An ‘‘wagged the dog.’’ Rather than 1. The ABP Examiner. December aortoesophageal fistula existed between enforcing the requirements, the 1993;15:2. the posterior aortic arch and the anterior requirements were dropped, 2. Hanzlick R, Baker P, and the Autopsy mid-upper esophagus. Two additional presumably because too few Committee of the College of American posterior esophageal perforations were institutions were in compliance. Thus, Pathologists. Institutional autopsy rates present: one near each end of the stent. [Autopsy and Medicine]. Arch Intern autopsy rates are now almost The stent was intact and there was no Med. 1998;158:1171–2. MEDLINE. exclusively dependent on the interest 3. Hill RB, Anderson RE. Contributions evidence that the stent itself had caused of clinicians, the institution, or the of the autopsy to modern medical a traumatic perforation of the esophagus. patient’s family, and regulations no science and practice. In: The Autopsy: The did not contain longer foster autopsy performance. Medical Practice and Public Health blood but the esophagus and Clinicians need to recognize that Policy. Newton, MA: Butterworth- contained copious blood and blood performance of an adequate number of Heinemann; 1988:43–6. clots. Microscopic sections of each autopsies is not only needed as part of perforation site showed extensive tumor an intellectually honest institutional necrosis with multiple areas of tumor quality assurance and improvement Unavoidable ulceration and an acute inflammatory program, but where pathology training infiltrate. Malignant tumor cells were programs exist, also because there must Outcomes versus identified at all levels of the esophagus be a sufficient number of autopsies to that were sampled. The aortic fistula site afford pathologists adequate training and Misadventures showed acute inflammation extending experience. Even if the pathologist ends from the intima through the wall and up in a practice where autopsies are 48-year-old man presented at the into the periadventitial soft tissues and rarely performed, it is still important hospital and described a 22.5-kg tumor infiltrate. that the autopsies that are performed are A and progressive Based on these findings, a performed and reported well. Adequate difficulty swallowing over the past 6 cause-of-death statement could be exposure to the autopsy during months. The following day, an prepared as follows: pathology residency training is required esophageal biopsy showed squamous to ensure such an outcome, and cell carcinoma. Radiographic studies adequate autopsy rates are an integral indicated liver metastases. The tumor Part 1. part of the equation. was judged to be inoperable and A. Esophageal hemorrhage Internal medicine and surgical palliative treatment included placement Due to or as a consequence of: residents would have a suboptimal of an esophageal endoprosthesis (a B. Aortoesophageal fistula training experience if the number of metallic metal mesh tube) and patients they could evaluate and treat with fluorouracil and Due to or as a consequence of: was severely restricted. The same cisplatin. One week later the patient had C. Squamous cell carcinoma of the applies to pathology residents and the an episode of major hematemesis and esophagus quality of their training relative to the cardiopulmonary arrest that could not be Part 2. Other significant conditions: number of autopsies they can perform. reversed with resuscitation. It was Physicians and the public need to apparent that the underlying recognize that education of the cause-of-death was most likely pathologist is one of the many benefits esophageal squamous cell carcinoma, Comment that the autopsy affords to society and but the patient’s physician requested an the practice of medicine (3). A autopsy to determine the immediate The autopsy in this case was well-trained autopsy pathologist can be cause-of-death and the cause of the valuable for several reasons. First, the of great value to the clinician and terminal gastrointestinal hemorrhage, specific reason for the fatal hemorrhage medical practice by providing complete, with special interest in evaluating was identified and the immediate thorough, and accurate documentation whether death resulted from a (esophageal hemorrhage) and and interpretation of autopsy findings, mechanical complication of the stent or intermediate (aortoesophageal fistula) which are used in conjunction with the its placement. causes of death were accurately clinical history. determined and reported. Second, it was determined that the esophageal NOTE: Volume 159, May 10, 1999. Randy Autopsy Findings perforations were due to tumor necrosis Hanzlick, M.D.; Jesse K. McKenney, M.D., Emory rather than mechanical perforation University School of Medicine, Atlanta, GA; and Autopsy showed an ulcerating related to the stent or its placement. the Autopsy Committee of the College of tumor mass in the mid-esophagus with Without an autopsy, the hemorrhage American Pathologists. hepatic metastases and local infiltration may have been erroneously attributed to Page 18 [ Series 3, No. 32 a misadventure or product defect References Autopsy Findings involving the stent or its placement. Instead, it was established that the 1. Siersema PD, Tan TG, Sutorius FF, et The results of the autopsy revealed perforation and hemorrhage was an al. Massive hemorrhage caused by a marked biventricular hypertrophy (heart unavoidable outcome of appropriate perforating Gianturco-Z stent resulting weight, 720 g) and moderate-to-severe therapy. The information obtained from in an aortoesophageal fistula. dilation of all four cardiac chambers. autopsy not only disclosed what actually Endoscopy. 1997;29:418–20. The coronary arteries had atherosclerosis 2. Raijman I, Siddique I, Lynch P. Does happened to the patient, but at the same with 80 percent luminal narrowing in the chemoradiation therapy increase the time, it showed that potential claims of of complications with right artery, 60 percent luminal misadventure and culpability would not self-expanding coated stents in the narrowing in the left anterior descending be well-founded. Third, the autopsy management of malignant esophageal artery, and 25 percent luminal narrowing demonstrated that the chemotherapeutic stricures? Am J . 1997; in the left circumflex coronary artery. agents were probably effective in 92:2192–6. The ablation site had endocardial causing tumor necrosis, but that tumor 3. Ludwig D, Dehne A, Burmester E, ulceration and underlying hemorrhage. necrosis can cause untoward effect such et al. Treatment of unresectable Histological sections showed myocyte as the fatal hemorrhage that occurred in carcinoma of the esophagus or hypertrophy and mild fibrosis of the this case. the gastroesophageal junction by ventricles. The atrioventricular node Although rare, aortoesophageal and mesh stents with or without region had coagulation necrosis and radiochemotheray. Int J Oncology. esophagorespiratory fistulas have been granulation tissue consistent with the 1998;13:583–8. reported in patients after palliative 4. Burton JC. Tumor lysis syndrome in recent ablation. The sinoatrial node treatment with metallic stents and nonhematopoietic neoplasms. Cancer. appeared normal. As requested by the chemotherapy and/or radiotherapy (1). 1989;64:738–40. family, the pacemaker was released to One retrospective study of 60 patients, 5. Shamseddine AI, Khalil AM, Wehbeh an attorney according to established however, did not show an association WH. Acute tumor lysis syndrome with institutional procedures. The results of between previous chemotherapy and squamous cell carcinoma of the vulva. the pacemaker testing were perforation (2). Another study reported Gynecol Oncol. 1993;51:258–60. communicated to the cardiologist and that the addition of irradiation and MEDLINE. showed no defects in pacemaker chemotherapy in conjunction with stent function. placement resulted in longer Based on these findings, the survival (3). Regardless, tumor Death and Devices cause-of-death statement could be lysis/necrosis secondary to prepared as follows: chemotherapy has been reported to occur as quickly as 38 hours after 49-year-old man had a history of administration (with great variability), idiopathic cardiomyopathy and Part 1. but consistent with the 1-week interval A had been receiving A. Dilated cardiomyopathy observed in our cases (4,5). It could be antiarrhythmic for the past Due to or as a consequence of: argued that mechanical pressure of the several years. He was admitted to the B. stent may have accelerated tumor hospital for evaluation of atrial fibrillation with a rapid, uncontrolled necrosis by compression of Due to or as a consequence of: ventricular response. Partial ablation of esophageal/tumor vasculature. If so, the C. outcome could still be regarded as an the atrioventricular node was performed, unavoidable outcome of an appropriate and a pacemaker was implanted. He was Part 2. Other significant conditions: Coronary artery atherosclerosis treatment, and thus, could be considered discharged from the hospital on the next a complication of therapy that would not day with a stable heart rate of 50 to 60 fall in the domain of the ‘‘therapeutic beats/min. He was found unresponsive misadventure.’’ at home 10 days after discharge, and Comment resuscitative efforts were unsuccessful. NOTE: Volume 159, April 12, 1999. Amanda The family, in cooperation with the The family was considering Davis, M.D.; Angela Fields, M.D., Ph.D.; Charles decedent’s cardiologist, requested that medicolegal action against the Hill, M.D.; Randy Hanzlick, M.D., Emory an autopsy be performed to determine if cardiologist, the electrophysiologist who University School of Medicine, Atlanta, GA; and there had been a complication related to performed the atrioventricular node the Autopsy Committee of the College of the pacemaker placement or ablation ablation and pacemaker placement, and American Pathologists. procedure and if the pacemaker had the manufacturer of the pacemaker. The malfunctioned. cardiologist and electrophysiologist were contacted by the family’s attorney. The autopsy results disclosed significant Series 3, No. 32 [ Page 19 pathologic changes in the heart radioactive materials, so that appropriate Not-So-Obvious Uses consistent with dilated cardiomyopathy, precautions may be taken. Another along with high-grade stenosis of one potential risk is the presence of of the Autopsy coronary artery. No complications were ‘‘implanted’’ material of a different identified from the ablation or nature, such as fragments of bombs and 33-year-old black man was pacemaker placement. The autopsy also explosives, which are sometimes admitted with second- and allowed the pacemaker to be removed encountered during an autopsy and may third-degree over and submitted for testing. It seems likely cause a serious catastrophe (explosion A 50 percent of the total body surface that the autopsy results and pacemaker and/or injury) if not recognized and area. The burns were not considered testing demonstrated to the family that handled correctly (3). life-threatening and were treated with medical care for the decedent had been Implanted medical devices, once fluid replacement, debridement, and appropriate, and indications are that no removed, may be tested by a local silver sulfadiazine. Neither fasciotomies medicolegal actions are being pursued. electrophysiology laboratory or by the The autopsy may be the only source manufacturer. The manufacturer can nor skin grafts were required. The of information about implanted medical probably provide the most thorough patient’s condition improved initially but devices and the body’s reactions to testing, but there is an inherent concern then deteriorated slowly during a them. Such information may be crucial about possible conflicts of interest. 3-week course. Chest x-ray films in understanding the course in individual Ideally, a disinterested independent showed increasing bilateral infiltrates patients. An autopsy-based series may testing agency should be used. It may be with some focal nodularity, and the provide a better understanding of necessary, however, to release the device mediastinum was also perceived to be function and to an attorney who can arrange for widened. On the 23rd hospital day, the complications for many types of devices testing on behalf of the interested party, patient died. There was no clinical and implanted materials, such as especially if medicolegal action seems evidence of local wound infection synthetic grafts. Other medical devices imminent. In such cases, it would be or systemic sepsis. frequently assessed during autopsy prudent to involve the attorney for the include catheter, endotracheal, institution to assure that testing is Autopsy Findings nasogastric, and feeding tube placement thorough and unbiased. Institutions and and the location and status of devices, pathology departments should have The autopsy showed second- and such as intravenous filters inserted to policies and procedures that address the third-degree burns that were healing. prevent pulmonary embolism. release of medical devices to attorneys Minimal bacterial colonization was Pacemaker units and wires can be or other third parties while protecting identified microscopically. The lungs evaluated and recovered during the the interests of the institution and were heavy and weighed 750 g (left) autopsy for further testing (1). A department. and 800 g (right) and were firm to transistor radio placed near a pacemaker palpation, both findings suggestive of may allow detection of an audible click NOTE: Volume 159, January 11, 1999. Peter B. pneumonia. Focal spherical lesions as when the pacemaker discharges, Baker, M.D., Ohio State University College of large as 15 mm in diameter with allowing assessment of pacemaker rate Medicine, Columbus; Randy Hanzlick, M.D., hyperemic rims were identified Emory University School of Medicine, Atlanta, throughout the lung parenchyma. at the postmortem examination. GA; and the Autopsy Committee of the College of Postmortem radiographs may enable American Pathologists. Examination of the mediastinal lymph detection of gross breaks in pacemaker nodes showed marked enlargement as wires, and when wires have been high as 10 cm in some locations. The implanted for long periods, careful References spleen and liver were enlarged, weighing 800 g and 3200 g, autopsy dissection may be required to 1. Wilson CJ. The pathology of cardiac remove the wires from adherent fibrous pacing. In: Silver MD, ed. respectively. The results of microscopic tissue without damaging the wires. Cardiovascular Pathology. New York, examination of the lungs showed the Automatic implantable cardioverters NY: Churchill Livingstone Inc; spherical lesions to be early or defibrillators pose a hazard to the 1991:1429–64. balls. A Gomori methenamine-silver autopsy pathologist (2). Some of these 2. Prahlow JA, Guileyardo JM, Barnard stain was performed and showed acutely devices must be inactivated prior to JJ. The implantable cardioverter­ branching, septate filaments typical of autopsy to prevent discharge of electric defibrillator: a potential hazard for Aspergillus species. During the current and potential electric shock. In autopsy pathologists. Arch Pathol Lab histological staining process, a tissue some cases, the wires can be removed Med. 1997;121:1076–80. MEDLINE. specimen known to contain fungal 3. Clark MA. Autopsy guidelines for from the power unit or cut close to the hyphae and a tissue specimen lacking explosion fatalities. In: Froede R, ed. fungal elements, both obtained from power unit before beginning the autopsy. Handbook of . The autopsy pathologist appreciates Northfield, IL: College of American previous autopsies, were also stained to advance notification that a body Pathologists; 1990:205–15. serve as controls for the procedure. In contains implanted or exogenous addition, multiple sections of lymph material of potential risk, including nodes, spleen, and liver showed Page 20 [ Series 3, No. 32 numerous Reed-Sternberg cells with a specimens from previous autopsies may References typical background milieu of Hodgkin be used in the pathological workup of disease. other cases, including not only autopsy 1. Hanzlick R, ed. Options for writing Based on the autopsy findings, the cases, but also clinical specimens. cause-of-death statements by including cause-of-death statement was reported as Autopsy specimens may serve as injury events, trauma, and fatal follows: positive or negative controls for special derangements. In: Cause-of-Death histological, immunohistochemical, and Statements and Certification of Natural and Unnatural Deaths. Northfield, IL: immunocytochemical stains. The College of American Pathologists; Part 1. autopsy also offers an opportunity to A. Aspergillus pneumonia 1997:33–48. retain tissues for educational slide sets 2. Wilkes MS, Link RN, Jacobs TA, for students of and pathology. Due to or as a consequence of: Fortin AH, Felix JC. Attitudes of house Tissue from tumors obtained during an B. Hodgkin disease officers toward the autopsy. J Gen autopsy may be used for special Intern Med. 1990;5:122–5. MEDLINE. Due to or as a consequence of: and gene studies, to obtain 3. Feldman H, Sanchez A, Morzonov S, et C. genetic material for synthesis of biologic al. Utilization of autopsy RNA for the substances, and postmortem serum synthesis of the nucleocapsid antigen of Part 2. Other significant conditions: samples can be saved for exploration of a newly recognized virus associated Thermal burns serological markers of neoplasia (3–6). with hantavirus pulmonary syndrome. Virus Res. 1993;30:351–67. Control specimens are needed in MEDLINE. cytogenetic analysis for procedures, such 4. Amedee-Manesme O, Furr HC, Olson Comment as fluorescence in situ hybridization (6), JA. The correlation between liver and these specimens may be obtained vitamin A concentrations in The pathologist prepared the during autopsy. Prospective collection of micro-(needle biopsy) and cause-of-death statement as shown selected tissues and the measurement of macrosamples of human liver because she believed that the Aspergillus environmental toxins may also be specimens obtained at autopsy. Am J pneumonia would probably not have performed in some settings. When Clin Nutr. 1984;39:315–9. MEDLINE. occurred had the patient not had the appropriate permission is obtained, 5. Suvarna SK, Start RD. Cytodiagnosis underlying Hodgkin disease, but she tissues, such as bone and cardiac valves, and the autopsy. J Clin Pathol. also believed that the stress of the can be obtained during autopsy for 1995;48:443–6. MEDLINE. 6. Trask BJ. Fluorescence in situ healing thermal burns probably transplantation. The autopsy provides an hybridization: applications in contributed to the development of opportunity for health care profession pneumonia. The thermal burns were cytogenetics and . Trends trainees to learn procedures, such as Genet. 1991;7:149–54. MEDLINE. healing with no evidence of significant fine-needle aspiration, cytology 7. Nolte K, Simpson GL, Parrish RG. local or systemic infection. Because an preparations, bone marrow aspiration, Emerging infectious diseases and the injury (burns) was involved, the death and biopsy, and to further refine forensic pathologist: the New Mexico was reported to and certified by the knowledge of anatomy and dissection model. Arch Pathol Lab Med. medical examiner, and the injury-related methods required for surgical and other 1996;120:125–8. MEDLINE. information on the death certificate was invasive procedures. Anatomical variants also completed specifying how and and anomalies may be studied, and when the burns occurred (1). clinical imaging techniques may be Death and Distraction The autopsy is an excellent mode of correlated with anatomical findings. The quality control within the hospital autopsy may also be useful for because it may be used to assess the surveillance of emerging infectious 13-year-old black youth was accuracy of disease diagnosis and the diseases (7). living in a foster home. effectiveness of treatment (2). There are, In addition to providing information A According to the foster mother, however, other uses of the autopsy for about the cause-of-death and nature and he fell in the tub and sustained an injury medical education, research, technology, extent of disease, the autopsy has many to the right hip. The boy was described and other applications that may not be not-so-obvious uses that can provide as being sarcastic, belligerent, and a so obvious (2). numerous benefits to the medical poor historian during the examination at The standard autopsy authorization profession and the practice of medicine. the hospital. He also accused the form used by hospitals usually allows physician of trying to play with him. the hospital to retain and dispose of NOTE: Volume 158, December 7/21, 1998. Kim The results of radiography of the right autopsy tissue at its discretion and A. Collins, M.D.; Clay A. Nichols, M.D., Medical hip were negative for fracture. His includes specific provisions that samples University of South Carolina, Charleston; Randy temperature was 37.6oC; pulse rate, 82 derived from an autopsy may be used Hanzlick, M.D., Emory University School of beats/min; respiration rate, 20/min; and for the purpose of teaching, diagnosis, Medicine, Atlanta, GA; and the Autopsy Committee of the College of American blood pressure, 110/62 mm Hg. The and research. As occurred in conjunction Pathologists. examination was not prolonged, and the with this case, tissues or other boy was sent home with the diagnosis Series 3, No. 32 [ Page 21 of a right-hip contusion. Ibuprofen was uncooperative. Third, it reminds us that prescribed for pain. Two days later at a Part 1. it is not uncommon for the deceased to follow-up visit, the boy denied any A. Bilateral Staphylococcus aureus have been examined by a physician a problems other than some tenderness in pneumonia few days before death. Usually, the the right hip. The foster mother reported causes of death in such cases involve an a productive cough in the child. Again, Due to or as a consequence of: infectious process that was more he was difficult to examine and had a B. aggressive than was recognized nonchalant attitude. Examination clinically or cardiovascular causes, such revealed the following: temperature, Due to or as a consequence of: as coronary artery disease. The former 38.7oC; pulse rate, 108 beats/min; and C. situation emphasizes the need for respiration rate, 24/ min. A complete Part 2. Other significant conditions: thorough evaluation of patients with blood cell count showed a white blood symptoms and signs that are possibly cell count of 0.01 109/L (11.7/mL). attributable to infectious causes, and the Lungs were described as clear by latter situation points out that auscultation. He was described as in no Comment cardiovascular examination may only acute distress and sent home with a During the past century, the reflect the status of the patient at the diagnosis of right-hip strain. Two and a epidemiologic, clinical, and pathologic time of examination. Such unexpected half days later, he was found dead in findings of staphylococcal pneumonia deaths following a recent visit to a bed. An autopsy was requested by the have been extensively researched and physician frequently result in coroner, who had been notified of the documented (1–4). This potentially fatal consternation and litigious thoughts death pursuant to State death disease is associated with fever, an among family members and survivors, investigation statutes. elevated white blood cell count, pleural but it is important to recognize that a involvement, necrosis, and often a blood given death may not have been related Autopsy Findings culture positive for S aureus (1–4). In to a medical oversight or error in this case, the staphylococcal pneumonia clinical judgment. At autopsy, the right and left lungs was florid in both lungs, with severe weighed 600 and 520 g, respectively. pleural involvement, marked necrosis, NOTE: Volume 158, November 9, 1998. Kim A. and hematologic spread to both kidneys. Collins, M.D.; C. Jeff Lee, D.O., Medical University Numerous white-tan nodules ranging of South Carolina, Charleston; Randy Hanzlick, from 0.1 to 1.0 cm in greatest The boy had a fever, an increased M.D., Emory University School of Medicine, dimension covered the pleural surfaces respiration rate, an elevated white blood Atlanta, GA; and the Autopsy Committee of the of both lungs. Several of the nodules cell count, and was certainly in College of American Pathologists. were surrounded by a hyperemic rim. discomfort. The critical diagnosis was not Patches of green-gray, fibrinous material made probably because the examination References were over the diaphragmatic surfaces of was focused on the hip injury and the both lungs. On sectioning, similar patient was difficult to examine. 1. Eichwald HF, Shinefield HR. The white-tan nodules were present Across the country, many children problem with staphylococcal infection throughout both lungs, with focal are in foster homes and temporary living in newborn infants. J Pediatr. necrosis. The surrounding pulmonary situations. Interviewing these children 1960;56:665–74. parenchyma was dark red and firm. The can be extremely difficult due to learned 2. Huxtable KA, Tucker AS, Wedgwood process involved the majority of the behavior and coping mechanisms (5,6). RJ. Staphylococcal pneumonia in childhood. AJDC. 1964;108:262–9. lungs. Several similar-appearing nodules Defensive barriers allow such children 3. Fang GD, Fine M, Orloff J, et al. New to claim absence of illness and involved both renal cortices. The results and emerging etiologies for of the remainder of the autopsy, symptoms (5). When presented with community-acquired pneumonia with including the examination of the right such cases, the examiner must be implications for therapy. Medicine hip, were unremarkable. Microscopic perceptive beyond the usual (Baltimore). 1990;69:307–16. MEDLINE. sections of the lungs showed acute interviewing of an adolescent (5). 4. Torres A, Serra-Batlles J, Ferrer A, et pneumonia with hemorrhage, segmented The autopsy in this case was a al. Severe community-acquired neutrophils, fibrin, necrosis, and learning experience for several reasons. pneumonia. Am Rev Respir Dis. bacterial colonies. Similar findings were First, it allowed excellent clinicopatho­ 1991;144:312–8. MEDLINE. seen in the sections of the kidneys. logical correlation between the child’s 5. Schenck BR. Understanding Teenagers: Lung cultures were taken and revealed presentation and examination and the Emotional and Social Changes. Halifax: Virginia Cooperative Extension heavy growth of Staphylococcus aureus. autopsy findings of pneumonia. Second, Service;1983:1–4. Publication 350–014. the autopsy findings emphasized the Based on these findings, the 6. Phares V, Lum JJ. Family cause-of-death statement was prepared challenge of interviewing troubled demographics of clinically referred as follows: adolescents, a growing segment of our children: what we know and what we population (6–8), as well as that fatal . J Abnorm Child Psychol. outcomes may result when a patient is 1996;24:787–801. MEDLINE. Page 22 [ Series 3, No. 32

7. Hibbs ED. Child and adolescent tonsils and the cervical and para-aortic cases is a balanced translocation disorders: issues for psychosocial lymph nodes were enlarged and between 15 and 17. There treatment research. J Abnorm Child microscopically showed reactive is a high rate of when treated Psychol. 1995;23:1–10. MEDLINE. lymphoid . A peripheral with conventional chemotherapy, but 8. Kovacs M, Lohr WD. Research on smear of antemortem blood showed a this therapy often exacerbates the with children and slightly increased white blood cell count coagulopathy (1). adolescents: an overview of evolving (1.5 109/L) and decreased platelet Autopsy was important in this case trends and current issues. J Abnorm 9 Child Psychol. 1995;23:11–30. count (5.0 10 /L). A manual differential for several reasons. It alleviated the MEDLINE. blood cell count exhibited 0.03 blasts, emergency department physicians’ 0.87 promyelocytes, 0.03 myelocytes, concerns about the possibility of and 0.07 lymphocytes. The infectious disease and the potential for promyelocytes were characterized by infection transmission to close contacts. Allaying large nuclei and cytoplasm that Autopsies are extremely helpful in Apprehension contained small eosinophilic granules identifying or excluding infectious and multiple fine Auer rods. The results diseases and potential outbreaks. The of bone marrow examination showed information in this case was shared with 39-year-old white man noticed a 0.10 blasts and 0.50 promyelocytes. the emergency department personnel and rash on his legs 10 days before These findings are diagnostic of acute family after the major disease process A death, but he did not seek myelogenous leukemia, was identified, which was on the same medical attention. He also experienced French-American-British class M3 day of death. It is important for an increasing . Two days before (acute promyelocytic leukemia). autopsy pathologist to convey specifics death, he went to a primary care Bacterial and viral cultures of blood, about a case in a timely manner so the physician with complaints of a sore lungs, and cerebrospinal fluid were information can be used effectively. throat. At this time, he was diagnosed as without growth. The results of a latex Procedures, such as sections, having tonsillitis and pharyngitis and agglutination test on cerebrospinal fluid touch preparations of tissues for was sent home with a prescription for for Neisseria species were negative. histological examination, and blood or antibiotics. The medical records did not Based on these findings, the cause-of- marrow smears, have rapid turnaround indicate the presence of a skin rash. On death statement was prepared as follows: times, are often applicable to the the day of death, he came into the autopsy, and may enable rapid answers emergency room with a fever and to questions regarding the death. weakness. He quickly became Part 1. This autopsy also revealed an unresponsive to stimuli. The emergency A. Intracerebral hemorrhage in basal unsuspected diagnosis. In retrospect, the department physicians noted lower ganglia patient had classic symptoms of acute extremity petechiae and localizing promyelocytic leukemia, but these neurological signs on the right side. Due to or as a consequence of: symptoms are nonspecific and could also Approximately 2 hours after presentation, B. Thrombocytopenia be seen in many other disease processes. he was pronounced dead. The patient had Probably the most important aspect of this no notable medical history. The family Due to or as a consequence of: autopsy, and of most autopsies in general, C. Acute myelogenous leukemia and emergency department physicians is that the family received an explanation requested an autopsy to determine the Part 2. Other significant conditions: for the sudden demise of their relatively cause-of-death. The physicians were young relative. This important aspect of justifiably concerned about meningococcal the autopsy in extending the continuum of and the possibility of infectious care to survivors is sometimes overlooked exposure of the staff and community. Comment in a busy medical practice or medical Hematopoietic malignancies are a institution. Autopsy Findings recognized but relatively rare cause of sudden natural death. Patients with acute NOTE: Volume 158, October 12, 1998. Dean M. The results of an autopsy performed promyelocytic leukemia typically have Havlik, M.D.; Rebecca Irvine, M.D., University of under isolated conditions revealed a New Mexico School of Medicine, Albuquerque; coagulopathy at presentation with Randy Hanzlick, M.D., Emory University School of 4.5-cm hemorrhage within the left basal decreased platelet counts and laboratory Medicine, Atlanta, GA; and the Autopsy Committee ganglia that extended into the tests suggestive of disseminated of the College of American Pathologists. surrounding white matter. There were intravascular coagulation. There is a external petechial hemorrhages on the dramatic increase in the numbers of head, chest, forearms, and legs. promyelocytes and blasts within the Reference Internally, petechial hemorrhages were bone marrow that spill over into the 1. Foucar K. Bone Marrow Pathology. identified within the lungs and trachea. peripheral blood. The classic cytogenetic Chicago, IL: American Society of (480 g) was noted. The finding seen in at least 80 percent of Clinical Pathologists Press; 1995. Series 3, No. 32 [ Page 23 Making Amends hilar lymph nodes, perirenal soft tissue, The clinician sent a copy of the and peripancreatic and periportal lymph letter to the family and the office of nodes. The pancreas also showed vital statistics, which made the requested 60-year-old man was diagnosed hemorrhagic cystic spaces consistent amendment. Both the family and the as having recurrent idiopathic with abscesses and pseudocysts with vital statistics system benefitted because A pancreatitis for 3 years. Other hemorrhage. The location and the cause-of-death was accurately medical history included morphologic characteristics of the tumor recorded after the amendment. mellitus, nephrolithiasis that required indicated that it had obstructed the In this case, the family’s initial lithotripsy, and cholecystitis that pancreatic duct, which probably refusal to authorize an autopsy led to required cholecystectomy. He had accounted for the pancreatitis and the clinician’s prompt completion of the abdominal symptoms that led to pseudocyst formation. death certificate based on information diagnoses of pancreatic abscesses and that was available at the time, which is peritonitis. Medical management and the correct procedure to follow. Then, surgical drainage led to the culture of Comment the unexpected reversal of the family’s multiple organisms from the After receiving the results of the wishes and unexpected autopsy findings inflammatory process, then systemic autopsy, the family member contacted led to the need for death certificate sepsis and coagulopathy developed and the clinician and requested that the amendment. In such instances, resulted in death. The family initially death certificate be changed. The knowledge of death certificate correction declined to have an autopsy performed, clinician agreed to make a change but procedures is required. and the cause-of-death statement on the did not know the correct process, so he When it is known that an autopsy is death certificate was prepared by the asked the attending pathologist. The going to be performed and the attending physician as follows: pathologist pleaded ignorance on the cause-of-death is not known prior to matter but offered to find out the autopsy, it is prudent to delay filing of appropriate way to change a death the death certificate until the provisional Part 1. autopsy findings are available, which is A. Intra-abdominal abscess certificate. She consulted available publications that included generic usually a matter of only a day or two. If the provisional autopsy findings are Due to or as a consequence of: information on what is referred to as the insufficient to complete the death B. Peripancreatic abscess death certificate amendment process (1,2). She took the advice in the certificate, a certificate may then be Due to or as a consequence of: publications and contacted the State’s filed as pending further study. Then, C. Chronic pancreatitis office of vital statistics and learned that when the final autopsy report is completed, a supplemental report must Part 2. Other significant conditions: in her jurisdiction, death certificate amendments within 3 years of the then be filed with the office of vital patient’s death simply require that the statistics so the death certificate can be The following day the responsible original certifier of death submit a letter finalized (1). family member contacted the clinician to the vital statistics office requesting If a death certificate with a stated and requested that an autopsy be and specifying the desired changes. cause-of-death has been filed but is later performed. The family member was Accordingly, a letter was composed discovered to be in error (such as the referred to the autopsy service and making the request and indicating that case reported herein), the correction arrangements were made to receive a the cause-of-death statement be process is referred to as death certificate facsimile transmission of a signed and amended to read as follows: amendment. witnessed autopsy permission form The regulations for filing stating the restrictions of autopsy which, supplemental reports and making in this case, specified that no Part 1. amendments are determined by each examination of the head or brain was to A. Sepsis state. The vital statistics office can be performed. provide the specific details and Due to or as a consequence of: procedures for the state it serves. It may B. Peritonitis be useful for the institution or office to Autopsy Findings develop a standard letter or in-house Due to or as a consequence of: procedure to file supplemental reports or Autopsy revealed widespread C. Pancreatic abscess intra-abdominal abscesses. The head of make amendments. the pancreas contained a 3-cm mucinous Due to or as a consequence of: Although there was initial cystic neoplasm, which was micro­ D. Metastatic cystadomocarcinoma of speculation that the family’s request for scopically proved to be an infiltrating the pancreas a death certificate change may have been based on their pursuing of a mucinous cystadenocarcinoma. Part 2. Other significant conditions: Metastatic adenocarcinoma was found in possible lawsuit for failure to diagnose the lungs, subcarinal and pulmonary the malignant neoplasm, three years have passed and nothing further has Page 24 [ Series 3, No. 32 been heard from the family or their The results of echocardiography showed The results of the autopsy uncovered a attorneys. Apparently, the concerns were right ventricular dilatation. An electron rare (and in this case clinically unwarranted; as is often the case, the beam computed tomographic scan was unsuspected), but well described entity family simply wanted to know what interpreted as negative for pulmonary of tumor microemboli to the lungs, happened and have the record accurately embolism. which caused pulmonary hypertension, reflect the circumstances and details of Despite the interpretation, the cor pulmonale, and death (1,2). The death. patient was diagnosed as having metastatic route to the lungs was Finally, this case shows that the pulmonary thromboembolism and was probably via the vertebral metastatic autopsy may answer many questions given anticoagulant therapy. She died of deposits. even when a complete autopsy has not progressive respiratory failure 2 weeks Performance of this autopsy was been performed (permission to examine after admission to the hospital. valuable because the results showed the the head or brain was not granted). reason for the patient’s failure to Limited or partial autopsies were the respond to anticoagulant thrombolytic topic of discussion in an earlier Case of Autopsy Findings therapy for suspected pulmonary the Month (3). Right cardiac ventricular dilatation, thromboembolism. The case was chronic passive visceral congestion, and analyzed for similarities and differences NOTE: Volume 158, September 14, 1998. Ann E. microscopic metastases in the vertebral to previous institutional experience with Smith, M.D.; Grover M. Hutchins, M.D., The column, liver, and pancreas were the disease entity, and these data were Johns Hopkins Medical Institutions, Baltimore, forwarded to the referring clinicians as MD; Randy Hanzlick, M.D., Emory University observed during the autopsy. Careful School of Medicine, Atlanta, GA; and the Autopsy dissection of the lungs failed to show part of the autopsy interpretation. The Committee of the College of American either pulmonary thromboembolism or postmortem examination provided Pathologists. metastases. The results of microscopic information of immediate value in examination disclosed numerous small several respects. First, the patient’s References pulmonary arterial and arteriolar lumens relatives were able to understand the that were occluded by neoplastic extent of tumor and resultant limitations 1. National Center for Health Statistics. microemboli. In some vessels, fibrin or of possible therapeutic measures. Physician’s Handbook on Medical platelet thrombi were present with tumor Second, the physicians obtained an Certification of Death. Hyattsville, MD: cells, and some pleural pulmonary explanation for the lack of response to National Center for Health Statistics; lymphatics contained tumor therapy. Third, the imaging analysis 1996. U.S. Dept of Health and Human (‘‘lymphangiosis carcinomatosa’’). better appreciated the limitations of Services publication PH97–1108. imaging technique resolution in the face 2. Hanzlick R, ed, and the Autopsy Based on these findings, a cause-of-death statement was prepared of neoplastic pulmonary microembolism. Committee of the College of American Fourth, an accurate and complete cause- Pathologists. The Medical as follows: of-death statement could be prepared. Cause-of-Death Manual: Instructions for Writing Cause-of-Death Statements for Deaths Due to Natural Causes. Part 1. NOTE: Volume 158, January 12, 1998. Eric A. Northfield, IL: College of American A. Cor pulmonale Pfeifer, M.D., Johannes Bjornsson, M.D., Mayo Clinic and Foundation, Rochester, MN; Randy Pathologists; 1994. Due to or as a consequence of: Hanzlick, M.D., Emory University School of 3. Hanzlick R, and the Autopsy Medicine, Atlanta, GA; and the Autopsy B. Pulmonary arterial carcinomatous Committee of the College of American Committee of the College of American Pathologists. Case of the month. Arch microemboli Pathologists. Intern Med. 1997;157:2557. MEDLINE. Due to or as a consequence of: C. Metastatic ductal adenocarcinoma References of breast 1. Schriner R, Ryu J, Edwards W. Addressing the Part 2. Other significant conditions: Microscopic pulmonary tumor Lymphangiosis carcinomatosa of microembolism causing subacute cor ‘‘Red Herring’’ lungs and pleura pulmonale. Mayo Clin Proc. 1991;66:143–8. 2. Shields D, Edwards W. Pulmonary 53-year-old white woman was hypertension attributable to neoplastic admitted to the hospital with a Comment emboli. Cardiovasc Pathol. 3-day history of cough and A The pathologists concluded that 1992;1:279–87. dyspnea. Two years previously, a ductal occlusion of the peripheral pulmonary carcinoma of the breast (already with vasculature led to cor pulmonale and widespread metastases) had been that respiratory failure was in part diagnosed. On this admission, caused by lymphangiosis carcinomatosa. significant arterial hypoxia was noted. Series 3, No. 32 [ Page 25 Requesting an it to accurately complete the death caused the patient’s death. For quality certificate. However, the house officer, assurance, medical education, and the Autopsy also beginning his postgraduate work, advancement of medical knowledge, had not received formal training in complications of therapy as factors medical school on how to write a causing or contributing to death may be 28-year-old man with cause-of-death statement. He was as important to document and evaluate long-standing asthma was provided with an instruction manual (2) as the underlying disease conditions. A admitted to the hospital in and, after reading relevant portions, Publications are available for status asthmaticus. Necessary treatment discussed the cause-of-death with the purchase from the College of American modalities included high-dose attending pathologist and completed the Pathologists Publications Department, methylprednisolone, sedation, and cause-of-death statement as follows: 800-323-4040. The authors have no succinylcholine-induced paralysis for financial affiliation with the College of intubation. Pulmonary infiltrates were American Pathologists. noted on a chest radiograph, and the Part 1. patient could not be weaned from A. Disseminated aspergillosis NOTE: Volume 158, February 9, 1998. Grover M. ventilation use. Decreasing Hutchins, M.D., The Johns Hopkins Medical consciousness was observed, and the Due to or as a consequence of: Institutions, Baltimore, M.D.; Randy Hanzlick, results of a computed tomographic scan B. Steroid therapy M.D., Emory University School of Medicine, of the head showed ring-enhancing Atlanta, GA; and the Autopsy Committee of the lesions in the right frontal and left Due to or as a consequence of: College of American Pathologists. parietal cerebral lobes. After rapid C. Asthma neurologic decline, the patient died. The Part 2. Other significant conditions: References attending physician asked the medical house officer, who had recently started 1. Autopsy Committee of the College of her internship, to obtain permission to American Pathologists. Autopsy: Aiding perform an autopsy. However, the house Comment the Living by Understanding Death. Northfield, IL: College of American officer had never been taught in medical After the laminated card was Pathologists; 1996. school how to request permission to introduced at the institution, the autopsy 2. Hanzlick R, ed, and the Autopsy perform an autopsy, had never seen an rate rose approximately 30 percent Committee of the College of American autopsy performed, and was unfamiliar above the previous rate. Obtaining Pathologists. The Medical with the procedures involved, making permission to perform an autopsy Cause-of-Death Manual: Instructions her unsure of how to field questions depends, of course, on asking for for Writing Cause-of-Death Statements from family members. The institution permission, and knowledge of how to for Deaths Due to Natural Causes. had prepared and distributed to the ask for permission in a professional and Northfield, IL: College of American Pathologists; 1994. house officers a small laminated card compassionate way may facilitate the 3. Hanzlick R, ed, and the Autopsy with instructions for obtaining process. Complete and accurate permission from the legal next of kin to Committee of the College of American completion of the cause-of-death Pathologists. Cause-of-Death perform a postmortem examination. The statement and death certificate has been Statements and Certification of Natural house officer reviewed the information compromised because of a lack of and Unnatural Deaths. Northfield, IL: on the card and spoke with the formal teaching of physicians. In College of American Pathologists; responsible family member, the patient’s response to that problem, the College of 1997. mother. In addition, an informational American Pathologists has produced 4. Hanzlick R, and the Autopsy brochure on the autopsy was made several publications with instructions Committee of the College of American available to the mother, similar to one and examples of how to write Pathologists. Practice protocol for that has been published (1). The cause-of-death statements (2–4). writing cause-of-death statements for natural causes. Arch Intern Med. patient’s mother consented to the The autopsy was valuable in this 1996;156:2526. performance of a complete autopsy. case because it established the immediate cause-of-death (disseminated Autopsy Findings aspergillosis) and documented that a recognized potential complication of a The results of the autopsy showed necessary and accepted medical therapy disseminated aspergillosis with fungal (methylprednisolone treatment) had brain abscesses, which had formed in occurred in this patient. Reporting the the setting of high-dose adverse effects of a medical treatment in methylprednisolone treatment of asthma. the cause-of-death statement does not The pathology house officer wanted to necessarily connote inappropriate include a cause-of-death statement in the therapy or misadventure but simply autopsy report so the clinician could use explains the sequence of events that Page 26 [ Series 3, No. 32 ‘‘Negative’’ Results of PROTOCOL FOR AUTOPSY REQUEST Autopsy and Elusive When a patient dies, determine if the Medical Examiner/Coroner (phone #) must be Cause-of-Death notified. If the case is declined or is not an ME/C case, we are obligated to offer the family an autopsy. When you pronounce a patient dead, it is your responsibility to inform the patient’s family about the autopsy examination. This should not be perceived as an emotionally 91-year-old man was a nursing charged issue. The following information should be communicated to the family: home resident mainly due to mild dementia. He died suddenly The person taking responsibility for the body (usually the next of kin) may give A permission for autopsy. after taking his evening meal. The staff reported that he had The family is not charged for the autopsy. been in his usual state of health when The autopsy may confirm the clinical diagnosis or uncover additional contributory he suddenly collapsed; death was causes for the patient’s death. pronounced within minutes of the The autopsy contributes toward physician education, research, and improved patient care. collapse. His medical history included An autopsy will not delay the funeral or interfere with viewing of the body. nodular goiter diagnosed 27 years prior to death, a 6-year history of atrial A packet of forms is available on the wards. Assistance with previous or pending fibrillation, and a 4-year history of an autopsies (e.g., facilitating the process or arranging a gross review) can be directed to the unspecified type of mild dementia. Mild Pathologist-on-call. For further information and reports: Autopsy room (phone #), Pathologist-on-call (phone #), Admitting Office (phone #), Autopsy Pathology Division mitral regurgitation was also noted 2 Office (phone #). years before death. Notably absent from the clinical history was any evidence of systemic hypertension, ischemic heart disease, , or diabetes mellitus.

SAMPLE VERBAL AUTOPSY REQUEST Autopsy Findings I am Dr. ______, and I am covering for Dr. ______. I’m sorry to inform you that ______, your _____, has just died. We believe that death was ______. It is my Atherosclerotic luminal responsibility to inform you that you have the right to have an autopsy performed in order to stenosis (70 percent) was identified in be more certain about the cause of death and to learn more about this type of disease. the distal circumflex branch of the left (If this is unacceptable, a partial autopsy should be recommended, i.e., ‘‘I recommend that coronary artery. Other coronary arteries we at least examine the ______.’’) Although it is an expensive procedure, the hospital does had 40 percent to 50 percent maximum not charge the patient’s account or the family for autopsy examinations. stenosis. Mild floppiness of the mitral We are grateful when the family gives consent for an autopsy because the hospital valve was present. The heart weighed physicians will be able to learn more about the disease that caused your ____’s death, and 340 g (expected mean, 290 g). No gross we will be able to evaluate or improve our treatment. An autopsy will not delay the funeral or interfere with viewing of the body. or microscopic evidence of acute or As the responsible person, do you want an autopsy (or partial autopsy) to be performed? chronic myocardial ischemia was If yes, you will need to sign this form (autopsy consent form) and I will explain it to you identified. Other findings included before you sign. nodular goiter, moderate centrilobular OR pulmonary emphysema, a diaphragmatic If yes, you may give consent by telegram, facsimile, or by phone. Arrangements for this hernia, moderate aortic atherosclerosis, type of consent may be made with the Admitting Office (phone #) or through the hospital and moderate arterial nephrosclerosis. operator (phone #). The brain weighed 1195 g (expected mean, 1270 g) and appeared slightly atrophic. Microscopic examination of Sample laminated card that may be distributed to house officers or those physicians the brain revealed mild, nonspecific who request permission for autopsy performance. The card may be sized to fit in a neurodegenerative changes, including pocket and has general information on one side (upper frame) and sample text for scattered neuritic plaques in the requesting permission on the other side of the card (lower frame). Specific wording neocortex. Evidence of must be designed with institutional needs, policies, and local laws in mind. angiopathy was absent. A blood screen yielded negative toxicologic results. Based on these findings, a cause-of-death statement could be prepared as follows: Series 3, No. 32 [ Page 27

contributed to death and may have been However, the performance of an autopsy Part 1. the basis of the dysrhythmia, but a allows better assessment of likely causes A. Sudden witnessed death specific cause of the dysrhythmia could and enables exclusion of many possible not be determined with reasonable causes. The results of an autopsy also Due to or as a consequence of: probability. enable assessment of , the B. Presumed cardiac dysrhythmia Atherosclerosis, floppy mitral valve, identification of conditions that existed Due to or as a consequence of: and atrial fibrillation may each be but were not the cause of the patient’s C. associated with a fatal cardiac rhythm death. For research, epidemiological disturbance, but fatal rhythm studies, and elucidation of the courses of Part 2. Other significant conditions: disturbances may also occur without disease and treatments, it may be just as Atherosclerosis, floppy mitral valve, these conditions. The word ‘‘presumed’’ valuable to know the diagnoses existing atrial fibrillation was included because the results of an at death (DEAD) as it is to know the autopsy cannot confirm the occurrence cause-of-death. of a cardiac rhythm disturbance, which Comment is a functional rather than anatomical NOTE: Volume 158, July 13, 1998. Johannes derangement. Bjornsson, M.D., Mayo Clinic and Foundation, The results of the autopsy were Each of the causes listed in Part 2 Rochester, Minn; Randy Hanzlick, M.D., Emory University School of Medicine, Atlanta, GA; and remarkable for the absence of organ will be included and coded in multiple changes specific enough to cite with the Autopsy Committee of the College of cause mortality data that are used for American Pathologists. reasonable probability a specific single statistical purposes. A user of the condition or sequence of conditions that original cause-of-death statement or accounted for death. Coronary stenosis death certificate will realize from the References was of marginal significance, evidence wording and structure of the of acute or chronic myocardial ischemia 1. Kohn RR. Cause of death in very old cause-of-death statement that a clear cut people. JAMA. 1982;247:2793–97. was absent, and other vital organs cause-of-death was not identified, even 2. Gloth FM III, Burton JR. Autopsies and lacked sufficient changes to explain after performing an autopsy. Both death certificates in the chronic care death without tenuous assumptions. practical and statistical needs were met setting. J Am Geriatr Soc. Biochemical or toxicologic by writing the cause-of-death statement 1990;38:151–5. derangements may certainly cause death as shown. There is bias in some forms 3. Klatt EC, Meyer PR. Geriatric autopsy without corresponding morphologic of mortality data derived from death pathology in centenarians. Arch Pathol changes, but there was no clinical or certificates as a result of nosologic Lab Med. 1987;111:367–9. postmortem evidence of such coding procedures, but certifiers of 4. The Autopsy and Forensic Pathology Committees of the College of American disturbances. death can avoid confounding the bias by Pathologists. Cause-of-death statements The absence of autopsy findings reporting the cause-of-death as sufficient to explain death may pose a and the elderly. In: Hanzlick R. ed. accurately, specifically, and completely Cause-of-Death Statements and dilemma for the physician completing as possible and, when needed, in Certification of Natural and Unnatural the death certificate: this dilemma is not less-specific terms to avoid Deaths: Protocol and Options. uncommon when causes of death in the overreporting conditions for which there Northfield, IL: College of American elderly are at issue (1–3). Because death is little or no basis (5,6). Pathologists; 1997:15–24. certificate data may ultimately be used Definitive proof of a cause-of-death 5. National Center for Health Statistics. for epidemiological purposes, it is is not needed to report it on the death Instruction Manual Part 2a: Instructions important that death not be attributed to certificate. Adequate evidence may for Classifying the Underlying specific causes that are arbitrarily consist of a cause being more likely Cause-of-Death. Hyattsville, MD: National Center for Health Statistics; selected, speculative, or nonexistent. In than not. In this case, sufficient 1993:1–106. the case presented herein, it is likely evidence was lacking to cite a specific that had autopsy not been performed, 6. Hanzlick R. The relevance of queries condition or sequence of conditions in and coding procedures to the writing of death might have been erroneously Part 1 as being more likely than not, so cause-of-death statements. Am J attributed to myocardial infarction or the cause-of-death statement was Forensic Med Pathol. 1996;17:319–23. some other form of ischemic heart prepared using nonspecific terminology disease. Unfortunately, due to the low in Part 1. In most cases, however, a national autopsy rate, especially among specific condition or sequence of the elderly nursing home population, conditions may be stated in Part 1 with erroneous reporting of the reasonable probability of accuracy based cause-of-death is undoubtedly frequent. on the clinical history, available medical The cause-of-death statement shown records, and autopsy findings when herein states the facts: death appeared to needed. result from a cardiac dysrhythmia, and The results of an autopsy do not there were other conditions that likely always reveal the cause-of-death. Page 28 [ Series 3, No. 32 Speculation and Comment cause-of-death on the death certificate, seemed to support the widow’s initial Competing Causes of The widow consulted an attorney; a lawsuit. However, the autopsy results lawsuit was instigated against several provided histologic samples that could Death health care providers who had treated be reviewed and that ultimately the decedent, alleging that they had provided an alternative explanation for man in his late forties had been failed to diagnose and treat coronary the cause-of-death. If an autopsy had not in good general health. He had artery disease, which was reported as been performed, death might have been A smoked two packs of cigarettes the cause-of-death. The attorneys for the attributed to coronary artery disease, and per day but had recently stopped. He defendants engaged a pathologist to the same legal action may have resulted. had become an avid exerciser, running review the case, and the consulting However, in that scenario the about 24 to 32 km and swimming 1.6 to pathologist noted that was information obtained from the autopsy 3.2 km each week. Paroxysmal atrial present focally in the histologic sections, would not have been available to fibrillation developed and was initially including an area with myocyte necrosis address relevant issues and adjudicate controlled by the use of digitalis. in the atrioventricular node. There was the case. Also, if an autopsy had not However, during a 2-year period, the no histologic evidence of acute been performed, the additional expense episodes of atrial fibrillation became myocardial ischemia typical of coronary of exhumation might have been more frequent and required insufficiency or of the type sometimes necessary to perform an autopsy, in cardioversion and trials of several other seen in unstable angina. There was no which case the findings may have been antidysrhythmic . Atrial flutter was evidence of sudden changes in the more difficult to interpret because of noted during an office visit with his coronary arteries, such as plaque postmortem artifacts. cardiologist. The next day, he staggered fissuring, hemorrhage, or thrombosis. This case points out the need for and fell on a jogging path. Emergency Based on these findings, the certifiers of death to realize the possible services were called, but an attempt to consulting pathologist indicated that an ramifications of the wording in the resuscitate the patient was unsuccessful. alternative cause-of-death could be cause-of-death statement as well as the reported as follows: need to evaluate possible competing Autopsy Findings causes of death. One does not need to be absolutely certain about a An autopsy was performed under Part 1. cause-of-death to report it on the death the authority of the local medicolegal A. Myocarditis, undetermined type certificate. In fact, in many cases it is death investigation system because death sufficient if a cause-of-death is ‘‘more was sudden, unexpected, and Due to or as a consequence of: likely than not (5)’’ and one should not unexplained. The heart weighed 450 g B. skirt the responsibility of reporting a (average normal weight about 345 g for reasonable and likely specific weight and height). There was calcific Due to or as a consequence of: cause-of-death, when possible. However, atherosclerosis of the left anterior C. a reported cause-of-death should consist descending coronary artery with luminal Part 2. Other significant conditions: of more than speculation, especially narrowings estimated at 70 percent. Atrial fibrillation/flutter when other competent and equally There was no significant alteration in likely (i.e., competing) causes of death the left main, left circumflex, or right The consulting pathologist advised may exist. coronary arteries. The brain was not the attorneys that coronary artery Medicolegal death investigations examined. The remaining organs and disease, especially in the face of performed under the jurisdiction of a tissues showed nothing that was demonstrable myocarditis, may not have medical examiner or coroner, as was reported as significant. been the actual cause-of-death in this done in this case, are often geared Based on the gross and microscopic case. Although coronary artery disease toward differentiating natural autopsy findings and negative results of was reasonably included in the deaths (due to disease) from unnatural a toxicologic screen, the cause-of-death differential diagnosis based on the deaths (due to injury or poisoning). For was reported as follows: autopsy findings and circumstances of a variety of reasons, including Part 1. death, the patient’s previous athletic workforce, funding, available resources, A. Calcific coronary artery sclerosis activity and exercise tolerance, lack of and operational strategies and priorities, anatomical and clinical evidence of medicolegal death investigation systems Due to or as a consequence of: myocardial ischemia, marginally may not pursue a full and B. significant coronary artery stenosis, and comprehensive pathologic workup once histologic evidence of myocarditis Due to or as a consequence of: death has been determined to be natural C. indicated that myocarditis may have in manner. Whether tissue samples are been a more likely cause-of-death (3,4). retained for histologic examination and, Part 2. Other significant conditions: The results of the autopsy in this if retained, processed only to paraffin Cardiomegaly case, used as a basis to report the blocks (and not routinely reviewed) or to Series 3, No. 32 [ Page 29 glass slides (which may or may not be angina pectoris. J Am Coll Cardiol. typical of pseudomembranous colitis, routinely reviewed), varies from place to 1996;28:910–4. normally distributed ganglia (i.e., no place. Also, some medicolegal death 3. Aretz HT, Gillingham ME, Edwards evidence of congenital megacolon), and investigation systems may be limited by WD, et al. Myocarditis: a no features suggestive of ulcerative law or other regulation in the extent to histopathological definition and colitis, regional enteritis, ischemic bowel classification. Am J Cardiovasc Pathol. which a death may be investigated when disease, or other infectious bowel 1986;1:3–14. there is no evidence of injury, 4. Lieberman EB, Hutchins GM, disease. The brain showed organizing poisoning, or foul play (6). Thus, it is Herskowitz A, Rose NR, Baughman abscesses consistent with recently not surprising that cases like the one KL. A clinicopathologic description of treated toxoplasmosis. reported herein sometimes occur. myocarditis. J Am Coll Cardiol. Based on the autopsy findings, a It is also important to realize that 1991;18:1617–26. cause-of-death statement could be experienced medical examiners and 5. Hanzlick R, ed. Cause-of-Death prepared as follows: coroners are used to investigating deaths Statements and Certification of Natural with anatomical findings that do not fit and Unnatural Deaths: Protocol and precisely with well-established concepts Options. Northfield, IL: College of Part 1. and pathophysiologic patterns. Such American Pathologists; 1997. A. Toxic megacolon 6. Combs DL, Parrish RG, Ing RT. Death cases may result in the need to report a Investigation in the United States and Due to or as a consequence of: cause-of-death in rather generic terms . 1995. Atlanta, GA: Centers for B. Pseudomembranous colitis because demonstrable evidence of a Disease Control and Prevention; 1996. specific fatal derangement, immediate Due to or as a consequence of: cause-of-death, or mechanism of death is C. Clindamycin therapy for cerebral lacking. For example, simply attributing toxoplasmosis death to coronary artery atherosclerosis (or Institutional Autopsy to a somewhat vague condition, such as Rates Due to or as a consequence of: cardiomegaly, anesthesia-related death, or D. Acquired immune deficiency homicidal violence) without further syndrome explanation is appropriate and necessary 35-year-old man with end-stage Part 2. Other significant conditions: in some situations. acquired immune deficiency Pneumonia due to cytomegalovirus When a lawsuit involves A syndrome was admitted to the information derived from the hospital for severe abdominal pain, cause-of-death on a death certificate or abdominal tenderness, and fever. A autopsy report, a first step should be to computed tomographic scan showed Comment colonic distension, thickening of the ascertain the basis and likely accuracy Although clindamycin-associated colonic wall, and a possible rectal of the reported cause-of-death so that pseudomembranous colitis due to mass. Death occurred within 24 hours valuable time and resources are not difficile is a well-known of admission to the hospital, and wasted and possible misinformation is entity (1), it is not commonly associated permission to perform an autopsy was not perpetuated. with toxic megacolon. The findings in requested to evaluate the this case prompted the pathologist to gastrointestinal tract. Recently, he had NOTE: Volume 158, August 24, 1998. Grover M. consider a retrospective review of Hutchins, M.D., The Johns Hopkins Medical been given clindamycin for autopsy cases at the institution to a Institutions, Baltimore, MD; Randy Hanzlick, empirically suspected central nervous search for similar cases among the M.D., Emory University School of Medicine, system toxoplasmosis. Atlanta, GA; and the Autopsy Committee of the patients with acquired immune College of American Pathologists. deficiency syndrome who had been Autopsy Findings treated with clindamycin. Unfortunately, References the number of autopsies performed in The results of the autopsy showed such cases was too small to enable such 1. Kitzman DW, Scholz DO, Hagen PT, pneumonia due to cytomegalovirus an analysis. This problem prompted the Ilstrup DM, Edwards WD. Age-related infection and massive dilatation of the pathologist to review the overall autopsy changes in normal human hearts during entire colon, which had a diameter rates in the institution. the first 10 decades of life, Part approximately three times the normal A review of annual institutional II (maturity): a quantitative anatomic size. The colonic wall was thickened mortality and autopsy data showed that study of 765 specimens from subjects and edematous, the mucosa of the distal the annual deaths of inpatients remained 20 to 99 years old. Mayo Clin Proc. colon was necrotic, and the remaining relatively constant between 1986 and 1998; 63:137–46. mucosa showed numerous ulcerative 2. Dominitz I, Boruchow IB, Hutchins 1995 but the number of autopsies lesions and a thick fibropurulent GM. Focal myocardial ischemic performed had progressively declined necroses associated with unstable pseudomembrane. Microscopically, the from 250 in 1986 to 105 in 1995, colon showed morphologic changes resulting in an autopsy rate that declined Page 30 [ Series 3, No. 32 from 17 percent to 7 percent of autopsy, and no opportunity to view an the autopsy (11–12). These studies in-hospital deaths. A review of the autopsy in progress or the inside of a indicate that the autopsy continues to be literature (2) showed that similar trends cadaver. Perhaps as a result of decreased a valuable resource for education and have occurred nationally and that emphasis, it has been shown that quality assurance. The positive nationwide autopsy rates gradually clinicians frequently do not ask for contributions of the autopsy have also declined from 41 percent in 1964 to permission to have an autopsy been recognized by the American about 15 percent in 1983. A 1994 survey performed. Medical Association (2). One of of 244 hospitals conducted by the Technological advances—The us (R.H.) has educated physician house College of American Pathologists (3) dramatic and rapid advancements in staff about these data, and the showed that half of hospitals had diagnostic modalities such as computed institution’s autopsy rate rose nearly autopsy rates at or below 8.5 percent tomography and magnetic resonance 30 percent in one year. and 75.0 percent had autopsy rates imaging have improved the ability to Several reasons cited herein for below 13.5 percent. Interestingly, view images of internal bodily aspects, declining autopsy rates could be accreditation programs (4) in internal resulting in the perception among addressed by regionalization of recommend an autopsy rate of clinicians that the autopsy may be autopsies to medical centers with at least 15 percent. replaced by imaging and other methods. interest in performing autopsies, Why have autopsy rates fallen so Changing nature of disease experience in performing autopsies dramatically? This question and other patterns—Changing disease patterns involving infectious and complex issues have been discussed extensively affect the autopsy in two ways. First, conditions, and adequate facilities for for 35 years at various symposia in the some pathologists have become recommended and regulated infection United States (5–8). In brief, the concerned about the increased risk of control practices (8). following are the most commonly occupational exposure to potentially mentioned reasons: fatal and/or drug-resistant, blood-borne, NOTE: Volume 158, June 8, 1998. Randy Lack of reimbursement—In general, respiratory, and other , causing Hanzlick, M.D., Emory University School of hospitals do not charge families for them to take a closer look at the Medicine, Atlanta, GA; Peter Baker, M.D., Ohio State University School of Medicine, Columbus; autopsy services, insurers do not usually risk-benefit ratio of autopsy and the Autopsy Committee of the College of pay for autopsy costs, and the Health performance. Second, the increase in American Pathologists. Care Financing Administration’s deaths involving human immuno­ Medicare reimbursements do not deficiency virus infection and survival provide payments (Part B) for specific among patients with terminal diseases of References autopsy services. Part A reimbursements, many types have changed the mortality 1. Cotran RS, Kumar V, Robbins SL. according to the Health Care Financing patterns in some institutions. More Robbins Pathologic Basis of Disease. Administration, include nonline item patients have lengthy illnesses and 4th ed. Philadelphia, PA: WB Saunders money to support autopsy services, but prolong hospitalization during which Co: 1989;360–1. the payment is not based on autopsy many of their disease processes may be 2. AMA Council on Scientific Affairs. rate, autopsy use, outcomes assessment, elucidated. Autopsy; a comprehensive review of or actual autopsy costs. In essence, the Negative feedback—Many current issues. JAMA. 1987;258;364–9. lack of reimbursement makes the pathologists are not interested in the 3. Baker PB, Zarbo RJ, Howanitz PJ. autopsy a ‘‘loss leader,’’ which hospital autopsy and have attitudes of Quality assurance of autopsy permit financial managers and pathology indifference, avoidance, and in some form information, timeliness of performance, and issuance of departments must manage. cases, antagonism resulting in preliminary report: a College of Lack of incentive—The autopsy is a half-hearted autopsy performance. These American Pathologists Q-Probes labor-intensive and expensive procedure. attitudes and practices may negatively study of 5434 autopsies from 462 In most hospital settings, pathologists affect the attitudes and practices of institutions. Arch Pathol Lab Med. are not paid on a fee-per-case basis. clinicians in the institution who are the 1996;120:346–52. Managed care has resulted in fewer suppliers of autopsy authorizations and 4. Program requirements for residency pathologists who have to work longer users of autopsy information. education in internal medicine. and harder, and the autopsy poses Despite the use of sophisticated Accreditation Council for Graduate workforce burdens with little incentive. imaging technologies and other new Medical Education Web site. Available Decreased emphasis in medical diagnostic tools, recent studies (9–11) at http://www.acgme.org/acgme/ school—Medical schools have moved demonstrate that 32 to 42 percent of progreq/lm.htm. Accessed March 27, 1998. toward clinical problem-solving autopsies reveal at least one major 5. Agnrist A. What remedies for the curricula and away from basic sciences. unexpected or clinically unconfirmed failing autopsy? In: Symposium on the Time allocated to pathology curricula finding that contributed to the patient’s autopsy. JAMA. 1965;193:805–14. has dwindled. Many medical students death. In addition, approximately 6. Williams MJ, Peary TM. The autopsy, a now graduate with no training in 93 percent of clinical questions made beginning, not an end. Am J Clin autopsy procedure, no instruction on known to the pathologist prior to Pathol. 1978;69 (suppl 2):215–6. how to request permission for an autopsy are answered in the results of 7. College of American Pathologists Series 3, No. 32 [ Page 31

Foundation Conference on the Autopsy. compensation. However, they were told Comment Revitalizing the ultimate medical that they did not have a claim because consultation. Arch Pathol Lab Med. there was no evidence that the death It is unclear why the medical 1984;108:437–512. resulted from the work-related injury examiner did not accept jurisdiction and 8. College of American Pathologists since the death was certified as being perform an autopsy in this case because Conference XXIX. Restructuring due to a specific natural cause. The the possibility of death due to injury autopsy practice for health care reform. Arch Pathol Lab Med. family was perplexed and contacted an existed based on the close temporal 1996;120:700–85. attorney, who recommended that an relationship between injury and death. It 9. Sarode VR, Datta BN, Banergee AK, et autopsy be performed to evaluate is also unclear why an autopsy was not al. Autopsy findings and clinical whether the stated cause-of-death was performed at the hospital where the diagnoses: a review of 1000 cases. correct and whether the fall and death occurred. Oversight, Hum Pathol. 1993;24:194–8. vertebral fracture somehow caused or miscommunication, or misunderstanding 10. Veress B, Alafuzoff I. A retrospective contributed to death. by one or more parties may have played analysis of clinical diagnoses and The attorney contacted a pathologist a role. Fortunately, an autopsy was autopsy findings in 3,042 cases during and discussed the case. After executing eventually performed, which allowed the two different time periods. Hum Pathol. a legal authorization for autopsy, signed family to proceed with their personal 1994;25:140–5. by the legal next of kin, the body was and financial matters. Unfortunately, 11. Baker PB, Saladino AJ. Autopsy Contributions to Quality Assurance: exhumed and a pathologist performed an however, the family had to expend effort Data Analysis and Critique. Northfield, autopsy for an agreed upon fee, using a and money to arrange and pay for a IL: College of American Pathologists; local morgue and paying a user’s fee to private autopsy when an autopsy might 1993. Q-Probes series No. 93–06. cover supplies and overhead expenses in have been performed earlier in a 12. Fowler EF, Nicol AG, Reid IN. the morgue. different setting. In cases such as this Evaulation of a teaching hospital one in which the correct cause-of-death necrospy service. J Clin Pathol. was determined after the original death 1977;30:575–8. Autopsy Findings certificate was incorrectly completed The results of the autopsy did not and filed, effort should be made to Private Autopsies confirm the presence of a coronary amend (i.e., update or correct) the artery aneurysm, , or original death certificate, which usually reason for a hemopericardium to exist. requires contacting the original certifier. white man in his thirties fell Because of the body cavity trocar and When an injury is involved, the medical from a ladder at work and broke aspiration procedure performed during examiners or coroners could be A his back (lumbar vertebral the embalming process (1), which contacted (in the jurisdiction where the fracture). He was taken to a local introduces puncture-like artifacts and injury or death occurred, depending on hospital where he was given supportive can remove abnormal fluid the laws of that State), and they can treatment while being evaluated for collections (1), a specific explanation for then assume jurisdiction of the case and surgical repair of the fracture. About 4 blood having been obtained during the amend the death certificate. days after admission, he suddenly subxiphoid aspiration could not be In other cases, the family (or the became dyspneic, underwent determined; aspiration of intracardiac patient’s physician) may need or want to cardiopulmonary arrest, and died. blood was one explanation. The results have an autopsy performed, but the During resuscitation, subxiphoid of the autopsy showed lumbar vertebral death clearly does not come under the aspiration using a pericardial needle was fracture and the presence of multiple, jurisdiction of the medical examiner or performed, revealing blood. The bilateral, pulmonary emboli. coroner and, for one or more of several clinicians felt that death resulted from Based on these findings, a reasons, an autopsy cannot be performed hemopericardium probably due to a cause-of-death statement could be at the hospital. Such reasons include the ruptured coronary artery aneurysm and prepared as follows: following: the patient did not die in the certified the cause-of-death as such. The hospital; the family was not informed in medical examiner was notified of the a timely fashion that an autopsy could Part 1. be performed in the hospital; the facility death but did not investigate, A. Pulmonary embolism presumably because a natural in which death occurred does not have cause-of-death was reported by the Due to or as a consequence of: formal provisions for autopsy services; clinicians. An autopsy was not B. Lumbar spine fracture sustained in or the family wants an autopsy to be performed at the hospital. The body was a fall from a ladder performed but does not want the buried a few days following death. hospital to do it because of perceived The patient’s family assumed that Due to or as a consequence of: conflicts of interest or concern about death was related to the back injury, C. possible coverups. Some hospitals will which occurred on the job, and they Part 2. Other significant conditions: only perform autopsies when patients attempted to process a claim for Page 32 [ Series 3, No. 32 die in the hospital, although some will Regardless of the ultimate Complications of perform one even if the patient dies arrangement, the autopsy service outside the hospital if the patient has an provider will probably require a legally Therapy, Nursing active medical record or has recently executed authorization for autopsy, been admitted and discharged. completed and signed by the legal next Homes, and the Procedures and arrangements vary of kin and/or their authorized attorney. Elderly among hospitals with respect to such A sample, generic authorization form circumstances. has been published (3). It may be For all the reasons cited, the necessary to transport the body across ollowing several cerebrovascular physician of a patient who dies may be long distances or State lines, which may , an elderly man was called upon or desire to arrange for a require embalming before transport. F placed in a nursing home for private autopsy performed on a Most hospitals do not bill the family long-term care because of his fee-for-service basis. The following are when an autopsy is performed, but few immobility and paresis. Regular sessions several approaches to finding such a private autopsies are performed free of in a heated whirlpool were part of his service: charge, and the fee may be considerable. therapeutic regimen. One day, shortly Financial arrangements should be clear after being placed in the whirlpool, he + If the family has an attorney, the to all parties prior to the performance of moaned and thrashed. He was promptly attorney may be aware of a a private autopsy. removed from the whirlpool and noted pathologist who will perform Organized, commercial autopsy to have erythematous skin extending autopsies on a private basis on service enterprises are relatively new from the nipples to the feet. The on-call behalf of the family. and growing in number. How they physician was notified and observed + The pathology department at a local perform and interface with medical blistered and erythematous skin. hospital may be contacted. In many professional guidelines and standards, Treatment consisted of burn wound instances, the pathologist may be facility inspections, and accreditation management, and death occurred several able to provide such services or and certification procedures remains to days later from burn wound sepsis. recommend a pathologist who be seen. provides such services. + The office of the medical examiner Autopsy Findings NOTE: Volume 158, May 11, 1998. Randy or coroner may be contacted. Many Hanzlick, M.D., Emory University School of The results of the autopsy showed pathologists who work in the offices Medicine, Atlanta, GA; Grover M. Hutchins, patterned thermal injury (burns) of the medical examiner or coroner M.D., The Johns Hopkins Medical Institutions, involving most of the skin surface of the provide private autopsy services Baltimore, MD; and the Autopsy Committee of the trunk and extremities below the level of independently from their duties as College of American Pathologists. the nipples and included erythema medical examiner, coroner, or sloughed epithelium in a distribution coroner’s pathologist or will be able References typical of an immersion scald burn. to recommend a pathologist who Autopsy results also showed old provides such services. 1. Hanzlick R. Embalming. Body cerebral infarcts, nonspecific changes + The College of American preparation, burial, and disinterment; an related to aging; and no apparent Pathologists (800-323-3040) may be overview for forensic pathologists. Am immediate cause-of-death other than the able to provide names of several J Forensic Med Pathol. 1994;15:122–31. burns. An investigation of the scene and pathologists who practice in the area 2. Glabmar, M. Breathing new life into an examination of the whirlpool where the service is needed. autopsies. American Medical News. disclosed that the hot coming into + There are an increasing number of March 9, 1998; Business section: 13–5. the whirlpool could exceed scalding commercial and private autopsy 3. Geller SA. Autopsy permission and temperature (the thermostat on the hot service companies that have a consent. In: Hutchins GM, ed, Autopsy water heater was set too high) and that nationwide network of people who Performance and Reporting. Northfield, the temperature sensor on the whirlpool will provide autopsy services on a IL: College of American Pathologists; measured the temperature of the water private basis (2). Information about 1990:27. in the incoming water pipe, not the some companies can be obtained water in the whirlpool basin. Thus, the through the Internet or perhaps from water faucet could be operated in such a a local pathologist, medical way that the temperature indicator examiner, or coroner’s pathologist would indicate a safe temperature (when who may be familiar with cool water was running in the line) advertisements for such services. when, in fact, the tub contained scalding water that had previously been run into the tub. There was no indication that the burns were intentionally inflicted. Series 3, No. 32 [ Page 33

Based on the results of autopsy and make them safe, including a reduction in to requesting permission for autopsy, as investigation, a cause-of-death statement the thermostat setting on the water does the lack of an established method could be prepared as follows: heater to below 48.8oC. Information of payment or reimbursement for from the autopsy and investigation was autopsy services related to nursing home used by the State licensing board (which patients. Part 1. conducted an investigation) and also In the case presented herein, an A. Burn wound sepsis forwarded to the whirlpool manufacturer autopsy was performed because the and could be used for training medical examiner was notified and Due to or as a consequence of: employees on whirlpool and water death involved an injury. In many cases, B. Scald burns of and extremities temperature safety. Data in the literature however, death may clearly have Due to or as a consequence of: about the relationship of time, resulted from natural disease processes, C. Whirlpool treatment with temperature, and thermal scald burns and even if reported to the medical overheated water were validated in that the ultimately examiner or coroner, the death may not fatal burns occurred within seconds of be investigated. Whenever injury (such Part 2. Other significant conditions: immersion in the scalding water. (Water as falls, fractures, burns, etc.), abuse, or Remote cerebral infarctions, o cerebral artery atherosclerosis temperature of 54.4 C can scald within foul play are suspected, or the death a few seconds (2).) Because the seems sudden, unexpected, and not information discovered through the explained with reasonable certainty, performance of the autopsy and medical examiners or coroners should Comment investigation was thorough, potential be notified and they will usually accept legal claims could be promptly and the case for investigation. In cases that Because death was related to an accurately addressed. do not involve medical examiners or injury, the medical examiner was There is little doubt that the autopsy coroners, those caring for the elderly are notified of the death and assumed is underused as a method for evaluating responsible for arranging for an autopsy jurisdiction for the investigation and mortality patterns, the health of the with the legal next of kin. autopsy. The manner of death was aging population, and the subset of such Gerontologists and nursing home classified as accidental because the patients in nursing homes or long-term physicians need to recognize that death was caused by an unintentional care facilities. Approximately 20 percent performing an autopsy may be valuable injury (i.e., burns, an external condition). of deaths occur in nursing homes; in selected cases, and it may be useful An appropriate cause-of-death statement however, in New York State, for to pursue planned arrangements for the is shown, which reports the injury example, the autopsy rate for nursing provision of pathology and autopsy information in Part 1. The home patients during a 5-year period services when they are indicated. cerebrovascular conditions are was only 0.8 percent (3). During a This case also points out that appropriately reported in Part 2 because 7-year period in a teaching nursing patients may die of medical procedures they explain why the man was in the home, the autopsy rate was only and . Such cases need to be whirlpool; however, these conditions 3.5 percent, but it did increase to fully evaluated and pose special needs were not directly linked in a causal 10.8 percent after an extensive when completing the death certificate, relationship with the thermal burns, educational effort (4). The Centers for including the reporting of the which essentially were an independent Disease Control and Prevention’s complication in the cause-of-death event (1). Had the burns not occurred, National Center for Health Statistics statement (1). the man most likely would not have data tapes indicate that in the United died when he did. States autopsies were performed on NOTE: Volume 158, April 13, 1998. Randy Performance of the autopsy was fewer than 1 percent of patients who Hanzlick, M.D., Emory University School of valuable because it allowed died in nursing homes between 1990 Medicine, Atlanta, GA; and the Autopsy documentation of the event of injury Committee of the College of American and 1994. Deaths in nursing homes and evaluation for the presence of other Pathologists. We thank Norman W. Staehling, sometimes raise concerns about plausible, competing causes of death M.S., and Steven S. Yoon, Sc.D., M.P.H., of the unsuspected injury, patient management, Centers for Disease Control and Prevention, that were ruled out. The autopsy and possible abuse or neglect. The Atlanta, GA, for their assistance in accessing and provided information that could be used performance of an autopsy can address tabulating the nursing home autopsy data. to confidently address issues of injury these issues. Unfortunately, many and death without relying on nursing homes lack full-time physician incomplete information or speculation. References staff, autopsy rooms, pathology services, The associated investigation of the or formal affiliations with hospital-based 1. Hanzlick R. ed., and the Autopsy and scene and circumstances provided autopsy services, posing some obstacles Forensic Pathology Committees of the information that was potentially valuable to autopsy performance. The fact that College of American Pathologists in in preventing subsequent patient the patient was old and seemed to die of conjunction with the National injuries. The whirlpool and water Association of Medical Examiners. or other ill-defined natural heating system could be modified to Cause-of-Death Statements and causes (5) may also serve as a deterrent Page 34 [ Series 3, No. 32

Certification of Natural and Unnatural eroded into pulmonary arteries and to provide information in advance to the Deaths: Protocol and Options. bronchi causing massive hemorrhage pathologist who will perform the Northfield. IL: College of American into the pulmonary airways. autopsy on likely or known infectious Pathologists; 1997. Based on the autopsy findings, a conditions and the specific nature of the 2. Moritz AR, Henriques FC. Studies of cause-of-death statement could be conditions. thermal injury: the relative importance written as follows: Following the demonstration of of time and temperature in causation of thermal burns. Am J Pathol. Mycobacterium infection in 1947:23:695–720. the results of the autopsy in this case, Part 1. 3. Katz PR. Seidel G. Nursing home the hospital infection control department A. Pulmonary hemorrhage autopsies: survey of physician attitudes was notified of the findings so that and practice patterns. Arch Pathol Lab appropriate followup could occur with Due to or as a consequence of: Med. 1990:114:145–7. the county health department, as B. Broncial- fistula 4. Gloth FM 111, Burton JR. Autopsies required, potentially exposed physicians, and death certificates in the chronic Due to or as a consequence of: hospital staff, and family members. The care setting. J Am Geriatr Soc. C. Pulmonary tuberculosis autopsy enabled a definitive diagnosis 1990:36:151–5. that was suspected but not confirmed 5. Kohn RR. Cause of death in very old Part 2. Other significant conditions: clinically because death occurred before people. JAMA. 1982;247:2793–97. sputum analysis was performed, emphasizing the potential value of Comment promptly identifying patients who Protecting Those at harbor M tuberculosis infection. The Risk In the institution where this death autopsy findings were forwarded to the occurred, a considerable number of department of medicine for mortality patients with human immunodeficiency and management review processes in 59-year-old woman presented virus, mycobacterial, and opportunistic light of the patient’s earlier admission with a 13.5kg weight loss, infections are treated. Of concern is a with pneumonia of the left upper lobe. A malaise, and chronic cough of trend toward tuberculosis infection 2 months’ duration. The results of a among patients who are not known to NOTE: Volume 158, March 9, 1998. Randy chest x-ray examination suggested a be immunocompromised. An autopsy Hanzlick, M.D., Emory University School of cavitary lesion of the left upper lobe, may be necessary to establish such Medicine, Atlanta, GA; Larry Nichols, M.D., diagnoses when a patient dies before a University of Pittsburgh Medical Center, and based on empirical evidence, she Pittsburgh, PA; and the Autopsy Committee of the was given antituberculous medications. definitive diagnosis can be made College of American Pathologists. Sputum cultures had not yet been clinically. obtained when, 2 days after admission, The emergence and re-emergence of she was found dead on the floor in the fatal infectious diseases and unexplained References deaths due to possibly infectious causes bathroom of her hospital room with 1. Schwartz DA, Herman CJ. The should cause a resurgence in the use of copious amounts of blood emanating importance of the autopsy in emerging from the nose and mouth. A family the autopsy as a diagnostic and reemerging infectious diseases. member with human immunodeficiency procedure (1–3). Although the usefulness Clin Infect Dis. 1996;23:248–54. virus infection had been living in her of postmortem cultures is sometimes 2. Perkins BA, Flood JM, Danila R, et al. home, but the deceased patient had no limited because of postmortem growth for The Unexplained Deaths Working serologic or clinical evidence of human of bacterial contaminants or antibiotic Group. Unexplained deaths due to immunodeficiency virus infection. Six treatment during life (which may result possibly infectious causes in the United months earlier, she had been admitted in cultures negative for infectious States: defining the problem and for respiratory symptoms and was agents), new methods, such as designing surveillance and laboratory approaches. Emerg Infect Dis. diagnosed as having bacterial DNA-based tests and immunohistochemical studies, will 1996;2:47–53. pneumonia in the left upper lobe, which 3. Nolte KB, Simpson GL, Parrish RG. facilitate and improve the identification was treated with antibiotics during a Emerging infectious agents and the short hospital stay. of infection causing agents in forensic pathologists: the New Mexico postmortem specimens. However, model. Arch Pathol Lab Med. cultures will still be required to identify 1996;120:125–8. Autopsy Findings many infectious agents and test for drug sensitivities, when indicated, to fully The results of an autopsy showed evaluate the nature of an important excessive involvement of the left upper infectious agent. Although universal lobe of the lung with tuberculosis, precautions dictate that all cases be including an apical lesion (Simon foci) regarded and managed as potentially that infiltrated into the chest wall and infectious, it is helpful for the clinician Series 3, No. 32 [ Page 35 Partial, Limited, or chest and abdomen, which could have References enabled anterior removal of the spinal Restricted Autopsies cord was also not obtained. Thus, 1. Davis G. Organ limited autopsies: examination of the spinal cord was obtaining permission for postmortem complicated in this case. examination of the urinary tract. Arch 17-year-old girl had a 7-year Limited (restricted or partial) Pathol Lab Med. 1995;119:1092. Letter. history of neurologic decline that autopsies are appropriate in some cases, 2. Hutchins GM, ed., and the Autopsy Committee of the College of American A appeared to be related to a such as cases that necessitate identifying Pathologists. Autopsy Performance and familial degenerative neurologic the nature of a lesion lacking definitive disorder. She developed chronic Reporting. Northfield, IL: College of diagnosis before death when other American Pathologists; 1990. , decubitus ulcers, aspects of the clinical course and death marasmus, and repeated episodes of are well explained or cases when the aspiration pneumonia. Her status was next of kin will give permission for a placed on do not resuscitate, and she limited autopsy but not a complete one. A Tale of the died with a clinical picture of acute Effort should be made in cases of a Unexpected: Finding a respiration distress syndrome. limited autopsy to ensure that all parties realize that information derived from a Zebra Autopsy Findings limited autopsy will also be limited. ‘‘Partial autopsies, partial answers’’ is 56-year-old woman was The extent of the autopsy was the phrase sometimes quoted to make admitted for nausea and restricted by the family to removal and the point (1). When arranging for an projectile vomiting of several examination of the brain and spinal autopsy, it may be appropriate for the A days’ duration. A review of her medical cord. The permit also restricted making clinician or family member who is history failed to provide significant incisions into the back or torso. The requesting the autopsy to discuss with information, and the physical findings of an extensive neuropathologic the pathologist whether the autopsy can examination showed only marked workup of the brain were most address specific issues that have arisen obesity. During the course of the compatible with a familial and, if a limited autopsy is being patient’s workup, a computed olivopontocerebellar atrophy. considered, to what extent the ability to tomographic scan of her head indicated Based on these findings, a address relevant issues in the case might ring-enhancing lesions in the frontal and cause-of-death statement could be be limited (2). Regardless of its limited parietal lobes of the brain, each 2.5 cm prepared as follows: nature, the autopsy in this case did in greatest dimension and reported as provide information that could be used being consistent with metastases. The to further define the pathologic basis of patient was transferred to the Part 1. the familial nervous system atrophy that neurosurgical service, where she A. Familial olivopontocerebellar affected this patient and others in her atrophy suddenly died. An autopsy was family. However, because the lack of a requested by the physician with the goal complete autopsy precluded Due to or as a consequence of: of determining the primary site of the identification of a specific immediate B. patient’s presumed carcinoma. cause-of-death (such as pneumonia, Due to or as a consequence of: pulmonary embolism, diffuse alveolar C. damage, metabolic derangement, or Autopsy Findings other plausible cause), the Part 2. Other significant conditions: cause-of-death statement was prepared Postmortem fine-needle aspiration using the single line, Part 1 format biopsy of the cerebral lesions showed shown herein (i.e., only the underlying only neutrophils and necrotic debris. Comment cause-of-death is stated). The evaluation Cerebral herniation was evident. of visceral and other nervous system Subsequent histological study indicated Although the spinal cord may be changes was also precluded. that the lesions were abscesses, not removed during an autopsy through the metastases. An assiduous postmortem foramen magnum using a special tool, NOTE: Volume 157, December 8/22, 1997. search for a source of infection revealed the removal may be difficult without Randy Hanzlick, M.D., Emory University School suppurative gingivitis and no other causing considerable artifactual damage. of Medicine, Atlanta, GA; and the Autopsy source of infection. Removal of the spinal cord from a Committee of the College of American Based on these findings, the posterior or anterior approach was not Pathologists. cause-of-death statement was prepared possible because a request by the next as follows: of kin to avoid incision into the back was specifically stated on the autopsy permit and permission for opening the Page 36 [ Series 3, No. 32 References Comment Part 1. A. Cerebral herniation 1. Hill RB, Anderson RE. Contributions The postmortem alcohol studies of the autopsy to modern medical indicated that the patient consumed Due to or as a consequence of: science and practice. In: The Autopsy: alcohol at the hospital (1). Alcohol had B. Intracerebral abscesses Medical Practice and Public Health not been prescribed, and it was Policy. Newton, Mass: presumably provided by a visitor. Butterworth-Heinemann; 1988:43–66. Due to or as a consequence of: Findings from an examination of the C. Bacteremia liver at autopsy were consistent with long-term alcohol use. There was no Due to or as a consequence of: history of posttraumatic or other seizure D. Suppurative gingivitis An Intoxicating Case: disorder. Acute intoxication from Part 2. Other significant conditions: The Importance of alcohol consumption can lead to cardiac Toxicology rhythm disturbance (and seizures), and the timing of death in regard to alcohol Comment consumption suggested that alcohol 60-year-old man had a history of consumption may have played some role Although the clinical and imaging hypertensive heart disease with in this death. Furthermore, long-term studies in this case clearly were A congestive heart failure, chronic alcohol use is associated with consistent with a carcinoma, the autopsy alcohol abuse, prior pontine lacunar hypertension and unexplained proved that an infectious, rather than infarcts, and remote head trauma from dysrhythmias. A seizure due to alcohol neoplastic, process was responsible for an auto accident that occurred 30 years withdrawal was viewed as extremely the patient’s death. before. He complained of decreased unlikely because of the blood alcohol Performance of this autopsy was urine output and suprapubic tenderness concentration, which was probably valuable for several reasons. First, and was admitted with a diagnosis of rising based on the blood vitreous although sophisticated imaging prostatism and possible pyelonephritis. humor alcohol ratio (1). technology is available and continually About 24 hours following admission, he Although the autopsy did not improving in quality, an autopsy often experienced a cardiac rhythm clearly identify a cause-of-death, many indicates clinically unsuspected or disturbance and a seizure and then died. conditions were ruled out, and the unobserved findings or clarifies the Concern was expressed by the survivors findings confirmed the clinical nature of lesions known to exist that there had been some mistake on the diagnoses except for pyelonephritis, clinically. Second, the class of disease part of the hospital staff or physicians which was included in the clinical causing death was different from that since his death was perceived to be differential diagnoses. clinically suspected, and the death sudden. The medical examiner was The discovery that the patient had certificate could be accurately notified but declined to investigate consumed alcohol shortly before the completed. Third, information useful to because of the patient’s significant fatal events provided information that the medicine and medical history. The permission to could be used to address some legal departments and hospital quality perform an autopsy was obtained from claims that might arise. The tests for improvement offices was generated. the legal next of kin. alcohol could not have been performed The autopsy findings were legally in the jurisdiction of the hospital immediately reported to the medicine Autopsy Findings without permission to conduct a and neurosurgery departments at an postmortem examination since invasive afternoon postmortem conference and Autopsy findings included prostatic procedures were required to obtain the more formally presented at respective hyperplasia with chronic prostatitis, specimens. As illustrated by this case, morbidity/mortality conferences the hepatic with early cirrhosis, a toxicologic tests may play an important following month. At those conferences, 570 g heart with concentric left role in evaluating hospital deaths. When the fact was reiterated that 10 to ventricular hypertrophy and dilatation, deaths occur suddenly or unexpectedly 41 percent of autopsies reveal previously and old pontine lacunar infarcts with no in the hospital, it is prudent (or perhaps unsuspected diagnoses (1). demonstrable acute central nervous legally required) to report the death to system findings. Pyelonephritis was not the local medical examiner or coroner. NOTE: Volume 157, November 10, 1997. Gregory present. The postmortem blood alcohol Although the medical examiner declined J. Davis, M.D., University of Kentucky College of level was 24 mmol/L (112 mg/dL), and to investigate this case, the hospital Medicine, Frankfort; Randy Hanzlick, M.D., the postmortem vitreous humor alcohol fulfilled its legal obligation to report the Emory University School of Medicine, Atlanta, concentration was 1 mmol/L death. GA; and the Autopsy Committee of the College of American Pathologists. (30 mg/dL). Based on all the available information, the most likely explanation for death was that the patient’s Series 3, No. 32 [ Page 37 underlying hypertensive heart disease The patient died 8 hours following Performance of this autopsy was caused a cardiac rhythm disturbance the lumbar puncture. The patient’s valuable because it enabled accurate with agonal seizure disorder, probably medical history included an completion of the death certificate; influenced to some degree by alcohol appendectomy 30 years previously and a alleviated clinical concern about consumption. Thus, a cause-of-death hiatal hernia repair in 1994. An autopsy possible brain herniation; explained the statement could be prepared as follows: was requested by the physician, with the patient’s nausea and vomiting; and major goal of assessing the possibility provided information that should be of opportunistic meningitis or brain useful in the medical department and Part 1. herniation following lumbar puncture. hospital quality improvement programs. A. Hypertensive heart disease A copy of the autopsy report was forwarded to the medical department Due to or as a consequence of: Autopsy Findings and hospital quality improvement offices B. The major autopsy findings because in the institution where this Due to or as a consequence of: included multiple abdominal adhesions death occurred deaths resulting from C. resulting in small bowel obstruction, unexpected findings or complications of perforation, and peritonitis; bacterial medical procedures are subject to Part 2. Other significant conditions: quality assessment review, even if Acute , bronchopneumonia; and no evidence of management seems appropriate. Such a long-term alcohol (ethanol) use, meningitis, brain herniation, or HIV agonal seizure . program helps meet the requirement of Based on these findings, a the Joint Commission on Accreditation cause-of-death statement was prepared of Healthcare Organizations (2) that NOTE: Volume 157, September 7, 1997. Randy as follows: institutions have a policy stating how Hanzlick, M.D., Emory University School of autopsy findings are used to improve Medicine, Atlanta, GA; and the Autopsy care in the institution. Committee of the College of American Part 1. Pathologists. A. Perforation of jejunum with NOTE: Volume 157, August 11/25, 1997. Randy peritonitis Hanzlick, M.D., Emory University School of References Medicine, Atlanta, GA; and the Autopsy Due to or as a consequence of: Committee of the College of American Pathologists. 1. Caughlin JD. Correlation at postmortem B. Obstruction of jejunum blood and vitreous humor alcohol concentrations. Can Soc Forensic Scr J. Due to or as a consequence of: References 1983;16:61–8. C. Postoperative intra-abdominal 2. Schuekit MA. Alcohol and alcoholism. adhesions 1. Hanzlick R, and the Autopsy In: Wilson JD, Braumunld E, Committee of the College of American Isselbacher KJ, et al., eds. Harrison’s Due to or as a consequence of: Pathologists, eds. The Medical Principles of Internal Medicine. 12th D. Delayed complications of Cause-of-Death Manual: Instructions ed. New York, NY. McGraw Hill Book appendicitis for Writing Cause-of-Death Statements Co; 1991:2148. Part 2. Other significant conditions: for Deaths Due to Natural Causes. Human immunodeficiency virus Northfield, IL: College of American infection, bacterial pneumonia Pathologists: 1994. 2. Joint Commission on Accreditation of Healthcare Organizations. Accreditation Multiple Benefits Manual for Hospitals: 1995. Oak Comment Brook, IL. Joint Commission on from an Autopsy Accreditation of Healthcare The pathologist thought that the Organizations: 1994. 47-year-old white man, location of adhesions corresponded to diagnosed as having human the appendectomy procedure rather than A immunodeficiency virus (HIV) the hiatal hernia repair. Pneumonia and in 1989, was admitted in 1996 for HIV infection were listed as other nausea and vomiting of 4 days’ significant conditions because duration. He had several previous pneumonia was thought to have episodes of pneumonia and cutaneous contributed to death and HIV infection Kaposi lesions. During hospitalization, may have increased susceptibility to he became confused. A lumbar puncture peritonitis and/or pneumonia, but these was performed: following the procedure, conditions did not result in the the headache and confusion worsened underlying cause-of-death reported in with development of hypotension. Part 1 (1). Page 38 [ Series 3, No. 32 Clarifying an considered and explained when Part 1. prescribing medications. Untoward Outcome A. myocarditis NOTE: Volume 157, October 13, 1997. Eun Due to or as a consequence of: Young Lee, M.D., Michael L. Cibull, M.D., 20-year-old man who was a B. Drug-related hypersensitivity— University of Kentucky College of Medicine, college baseball player in specific drug unknown Lexington; Randy Hanzlick, M.D., Emory excellent health complained of University School of Medicine, Atlanta, GA; and A the Autopsy Committee of the College of back pain and malaise. His symptoms Due to or as a consequence of: American Pathologists. became progressively worse despite C. being prescribed several medications. Part 2. Other significant conditions: Nausea, bloody , submandibular Disseminated intravascular References , hemoptysis, blurred coagulation vision, and dizziness developed. On 1. Kounis NG, Zavras GM, Soufras GO, Kitrou MP. Hypersensitivity presentation to an emergency myocarditis. Ann . department, the results of laboratory 1989;62:71–5. studies showed marked leukocytosis and Comment 2. Burke AP, Saenger J, Mullick F, disseminated intravascular coagulation. The autopsy findings not only Virmani R. Hypersensitivity The patient was transferred to a confirmed the clinical diagnosis of myocarditis. Arc Pathol Lab. university hospital, where the possibility 1991;115:764–9. disseminated intravascular coagulation, of an unusual viral illness was but also indicated the clinically considered. He appeared stable on unsuspected origin of disseminated admission to the hospital but suddenly intravascular coagulation, a severe drug Wrapping Things Up became unresponsive and apneic 4 hours hypersensitivity reaction. Several of the later. A cardiac monitor indicated drugs the patient took have been electromechanical dissociation, and the implicated in such hypersensitivity drug advanced cardiac life support protocol Introduction reaction so it is impossible to determine was unsuccessful. An autopsy was which drug or combination of drugs was This is the 30th and final requested by the physician primarily to responsible. The cardiac findings were installment in the Autopsy and Medicine identify the etiologic agent of the typical of hypersensitivity myocarditis, a Case of the Month series, which has presumed fatal viral illness. condition associated with a variety of been published in Archives since the drugs. Hypersensitivity myocarditis is first Case Report of August 1997. The Autopsy Findings rarely recognized clinically and is often Autopsy Committee of the College of first discovered in the results of a American Pathologists is grateful to Major autopsy findings included postmortem examination. Most patients Archives Editor James Dalen for severe hypersensitivity myocarditis, with this condition do not appear providing the opportunity to acute syndrome, critically ill but may die suddenly, re-emphasize the value of the autopsy to interstitial nephritis, and centrilobular presumably because of an the practice of medicine and society. hepatic necrosis. All the organs arrhythmia (1,2). The autopsy in this In his editorial titled ‘‘The examined showed marked case was useful for important reasons. Moribund Autopsy: DNR or and features of disseminated First, it provided an explanation of the CPR?’’ (August 1997), Editor Dalen intravascular coagulation. Bacterial and cause-of-death to the family, eliminating introduced the series and correctly viral cultures and the results of serologic to some extent the attendant frustration pointed out the moribund condition of tests and a drug abuse shown were and bewilderment in such a death. autopsy utilization in the United States negative. A review of the drug use Second, it dispelled the fear of an in virtually all spheres but the history indicated that the patient had exotic, fatal within medicolegal (forensic) one (1). He been taking several medications the community in this well-publicized advocated CPR for the autopsy rather including cephalexin, case. Third, information was disclosed than letting the last several decades of trimethoprimsulfamethoxazole, that is appropriate for reporting to the declining autopsy rates and utilization phenylbutazone, and an unknown Food and Drug Administration’s relegate the autopsy to DNR status. We antihistamine, for approximately MedWatch Reporting System for agree with his recommendation and we 2 months. adverse drug reactions and problems hope that the series has convinced Based on these findings, the with medical devices and for review by others to think and act similarly. cause-of-death statement was prepared the patient’s physicians. The case also Over the past 3 years, numerous as follows: illustrates how commonly prescribed values and contributions of the autopsy drugs can be associated with fatal have been emphasized in the series adverse reactions that need be using a Case Report presentation. The cases presented are only a small sample Series 3, No. 32 [ Page 39 of those encountered in everyday 6. explanation that lymphangiosis certificate that was incomplete or practice in which the autopsy provides a carcinomatosa of lungs and pleural originally in error (15); benefit to the practice of medical existed rather than pulmonary 15. recognition that autopsy findings science and society. We cannot touch on thromboemboli, thus explaining to can be used to allay concern every point made, but in this article, we clinicians and survivors the among medical professionals and present a capsule summary of the major patient’s lack of clinical response the public when a death presents issues addressed in the series. to anticoagulant thrombolytic as one that could have public therapy (7); health ramifications (such as 7. provision of suggested wording for meningococcemia), but is proven Case Report Summary use by physicians who request to be of other causes that are of The various case reports in the permission for autopsy from the little or no concern (16); Autopsy and Medicine Series legal next-of-kin (8); 16. illustration of how the autopsy emphasized the following information 8. detection of previously allows excellent clinico-pathologic about the autopsy and/or the value and undiagnosed tuberculosis in a correlation when the clinical contributions made by the autopsy: hospitalized patient who died course is atypical or involves suddenly from a unusual causes (17); 1. improvement in the accuracy and bronchial-pulmonary fistula, with 17. discussion of autopsy utilization completeness of the cause-of-death discussion of the use of the for not-so-obvious procedures such as reported on the death autopsy for diagnosing emerging as providing control tissue for certificate; alleviation of concern infectious diseases and infectious special histologic stains, or to about possible untoward outcomes disease of concern to obtain genetic material from that could have adversely impacted institutions (9); neoplasms, for example (18); upon the institution or physician in 9. provision of information about the 18. discussion of the use of the terms of potential liability; cause and circumstances of death autopsy to investigate deaths that elucidation of findings that more when death possibly results from involve implanted medical devices precisely explain the patient’s medical devices that malfunction such as pacemakers (19); symptoms and signs; and the value or which are not used 19. recognition that the autopsy may of autopsy findings for required appropriately (10); be used to distinguish whether and voluntary hospital quality 10. discussion of the ‘‘private death resulted from an unavoidable improvement programs (2); autopsy’’ in which a pathologist, outcome (20); 2. detection of undesirable, for an agreed-upon fee, may 20. recognition that the autopsy is not unacceptable, or contraindicated perform an autopsy for a third only a valuable teaching tool for patient behavior (such as drinking party (such as the family) outside clinicians, but is also needed as an nonprescribed alcoholic beverages of the usual institutional setting for educational and training tool for in the hospital) which may have hospital deaths or medicolegal pathologists who are training in a contributed to death, and, if (forensic) cases (11); pathology residency program (21); undetected, might allow erroneous 11. listing of possible reasons for the 21. presentation of answers to conclusions or unfounded decline in institutional autopsy numerous commonly asked allegations (3); rates over the past several decades questions about the autopsy, which 3. detection of drug hypersensitivity in the United States (12); may be helpful to clinicians who reaction causing fatal myocarditis 12. recognition that the autopsy may are often asked such questions by that provided information for be ‘‘negative’’ (i.e., not family members (22) reporting to the FDA and allayed demonstrate specific findings) and 22. discussion of the use of the clinical and public concern about a not necessarily answer questions autopsy for outcome analysis and possible fatal exotic infectious that have arisen, or identify a quality assessment of therapeutic process in the community (4); specific cause-of-death (13); interventions (23); 4. clarification that cerebral ring- 13. recognition that the autopsy 23. recognition of the value of the enhancing lesions observed on CT provides reports, tissues, and other autopsy in detecting findings were abscesses rather than specimens that may be incidental to the cause-of-death, metastases as suspected and that re-examined at a later time if legal and findings that may better the cause-of-death was suppurative or other controversial issues arise; explain to the family the patient’s gingivitis that had not been that such information helps avert clinical course or lack of detection recognized clinically (5); the need for speculation; and that of serious disease by routine 5. recognition that ‘‘limited autopsy’’ some findings and their diagnostic tests (24); may sometimes be needed and significance can be interpreted in 24. discussion and historical review of appropriate but that the more than a singular way (14); the use of the autopsy, including information obtained is also 14. discussion of the use of autopsy considerations that deal with limited (6); findings to amend (correct) a death inadequate financial support from Page 40 [ Series 3, No. 32

health care payment agencies (25); testimony to its place as an essential in which there is a need to perform 25. recognition of the value of the component of the practice of medicine. autopsies, steps need to be taken to autopsy in evaluating transplant Take, for instance, the recent growth in ensure that pathology departments donors and in evaluating the clinical use of laparoscopic include pathologists who are not only complications of radiation procedures, which are not always willing, but who take professional treatment for neoplasms (26); without untoward complication. interest and pride in performing 26. discussion of how the autopsy may Information has been obtained from autopsies. Regionalized (or centralized, disclose previously undiagnosed autopsy that has prompted rethinking depending on how one looks at it) conditions that may have impact about the safe uses of laparoscopic autopsy centers, established through on survivors, such as breast cancer surgery. Thus, an old procedure (the partnerships or consortia, may be one that may have a familial autopsy) remains valuable to evaluate workable option. occurrence (27); newer ones. Clinicians, through their informing 27. discussion of the value of the Recent reports of large numbers of of families about the autopsy and autopsy in evaluating suspected or in-hospital deaths due to complications requesting permission to perform one, alleged elder abuse and neglect, of diagnostic and therapeutic procedures play a key role in the use of the autopsy which serves to protect patients, provide good reason to perform more to investigate deaths which occur in institutions, and health care autopsies if for other than to medical institutions. We believe that workers (28); enable the collection and documentation families should always be offered the 28. discussion of the use of the of objective postmortem findings to opportunity for an autopsy when death autopsy in bringing about clinical refute or support claims that arise. Who occurs in the hospital and that one recognition of limitations, knows, we could find out that many should be performed if the family idiosyncrasies, or possible such deaths are being incorrectly requests or consents to it, even if the interpretive errors when new attributed to medical procedures and physician or medical staff has minimal technologies are implemented (29); treatments. Of course, we could find out or no interest in the case. This may even and otherwise. Regardless, there would be include autopsies on patients who die 29. discussion of autopsy utilization to some objective information available outside the hospital but who have an help determine the relative roles of beyond that which would exist if an ongoing medical record in the the underlying disease and/or its autopsy were not performed. institution. treatment in causing or Even if technologies were to Part of medical practice is to help contributing to death (30). emerge (let’s call it an ‘‘autopsy prepare families and patients for death. machine’’) which could replace part or It seems reasonable to recommend that all of the autopsy procedure, such as physicians discuss the role of the Comments scans or other imaging procedures, autopsy with patients and their families, The autopsy has been used in North robotic procedures, or less invasive and to encourage family members to America for nearly 400 years. Although methods such as fiber-optic scope discuss, prior to death, the patient’s disease patterns have changed and new procedures, classical autopsies will still wishes regarding autopsy. Remember, technologies have emerged during that need to be performed as the standard to family consent is usually needed to time, human anatomy, cellular, and which these emerging methods are perform an autopsy after the death of a subcellular structure and function have compared, and in cases where the newer hospitalized patient. If the family does not changed much to our knowledge. technologies may have limitations. not know the patient’s wishes, their Although our understanding of these Certain lesions or objects will still need decision is made more difficult. Many things continues to deepen, there is still to be physically removed for analysis. patients desire that their death bring much to learn from the scientific And, in the foreseeable future, an about some good. That’s why many are standpoint. On the practical side, there autopsy performed by a pathologist will willing to donate their bodies for study are often relatively simple questions that probably remain more reliable and or to donate organs and tissue for arise when death occurs which the cost/time effective than automated or research or transplantation. The autopsy autopsy may easily and reliably answer. hands-off procedures. is another way for a patient or family to Thus, from both the scientific and It’s easy to advocate the use of the contribute to medicine and society, or to practical viewpoints, the autopsy autopsy. But what specific things can be provide information that may be helpful remains a useful tool to ‘‘see things for done to revitalize its use? We have a to the family or other survivors. one’s self.’’ few suggestions. Agencies and organizations who Many medical technologies To be sure, not all pathologists wish pay for health care need to shift their (diagnostic and therapeutic devices and to perform autopsies, and that fact is thought process from one which only methods) have come and gone undoubtedly part of the reason for the recognizes treatment of living patients completely, yet the autopsy persists. Its historical decline in autopsy utilization. toward one which recognizes that the withstanding of the test of time—albeit In fact, an autopsy attitude adjustment is autopsy can contribute to the overall on occasional shaky ground—is probably indicated within parts of the quality of medical practice. The autopsy pathologist community. For institutions could provide information that might be Series 3, No. 32 [ Page 41 used to rethink certain treatments or References autopsy rates (#11, June 1998). Arch procedures to modify their use, redefine Int Med. 1998;158:1171–2. the indications for certain procedures, or 1. Dalen JE. The moribund autopsy: DNR 13. Bjornsson J, Hanzlick R, and the even evaluate payment strategies for or CPR? Arch Int Med. 1997;157:1633. Autopsy Committee of the College of clinical procedures. These agencies 2. Hanzlick R, and the Autopsy American Pathologists. Autopsy and Medicine: Case of the Month: Negative would be wise to come up with a Committee of the College of American results of autopsy and elusive cohesive plan to ensure that pathology Pathologists. Autopsy and Medicine: Case of the Month (#1, Aug). Arch Int cause-of-death (#12, July 1998). Arch departments and pathologists are Med. 1997;157:1645. Int Med. 1998;158:1399–1400. adequately funded and staffed to 3. Hanzlick R, and the Autopsy 14. Hutchins GM, Hanzlick R, and the perform an appropriate number of Committee of the College of American Autopsy Committee of the College of autopsies based on the number and Pathologists. Autopsy and Medicine: American Pathologists. Autopsy and types of deaths at a particular institution, Case of the Month (#2, Sept). Arch Int Medicine: Case of the Month: or in a particular region. Med. 1997;157:1798. Speculation and competing causes of 4. Lee EY, Cibull ML, Hanzlick R, and death (#13, August 1998). Arch Int the Autopsy Committee of the College Med. 1998;158:1593–4. Summary of American Pathologists. Autopsy and 15. Smith AE, Hutchins GM, Hanzlick R, Medicine: Case of the Month (#3, Oct). and the Autopsy Committee of the Having not changed in recent Arch Int Med. 1997;157:2044. College of American Pathologists. history, the human body continues to 5. Davis GL, Hanzlick R, and the Autopsy Autopsy and Medicine: Case of the lend itself well to the autopsy procedure Committee of the College of American Month: Making amends (#14, and the documentation and interpretation Pathologists. Autopsy and Medicine: September 1998). Arch Int Med. of postmortem morphologic, cellular, Case of the Month (#4, Nov). Arch Int 1998;158:1739–40. and chemical changes. The use of Med. 1997;157:2296. 16. Havlik DM, Irvine R, Hanzlick R, and autopsy findings in conjunction with 6. Hanzlick R, and the Autopsy the Autopsy Committee of the College of American Pathologists. Autopsy and other scientific methods and Committee of the College of American Medicine: Case of the Month: Allaying investigative techniques remains as Pathologists. Autopsy and Medicine: Case of the Month (#5, Dec). Arch Int apprehension (#15, October 1998). valuable today as it was centuries ago, Med. 1997;157:2557. Arch Int Med. 1998;158:1971–2. both in daily practice and for scientific 7. Pfeifer EA, Bjornsson J, Hanzlick R, 17. Collins KA, Lee J, Hanzlick R, and the endeavor. Although the rate of our and the Autopsy Committee of the Autopsy Committee of the College of learning through the autopsy may have College of American Pathologists. American Pathologists. Autopsy and slowed, the quality of information Autopsy and Medicine: Case of the Medicine: Case of the Month: Death obtained remains high. The values and Month (#6, Jan). Arch Int Med. and distraction (#16, November 1998). uses of the autopsy are limited mainly 1998;158:14. Arch Int Med. 1998;158:2183–4. by our lack of imagination or our 8. Hutchins GM, Hanzlick R, and the 18. Collins KA, Nichols CA, Hanzlick R, passive or active unwillingness to find Autopsy Committee of the College of and the Autopsy Committee of the College of American Pathologists. facts in pursuit of scientific truth. American Pathologists. Autopsy and Autopsy and Medicine: Case of the CPR or DNR for the autopsy? DNR Medicine: Case of the Month (#7, Feb). Arch Int Med. 1998;158:219–20. Month: Not-so-obvious uses of the status is reserved for those situations in 9. Hanzlick R, Nichols L, and the autopsy (#17, December 1998). Arch which hope has been lost and the Autopsy Committee of the College of Int Med. 1998;158:2429–30. chance for meaningful survival seems American Pathologists. Autopsy and 19. Baker PB, Hanzlick R, and the Autopsy over. The autopsy meets neither Medicine: Case of the Month Committee of the College of American criterion. CPR, therefore, seems (#8, March). Arch Int Med. Pathologists. Autopsy and Medicine: indicated. Successful CPR for the 1998;158:426. Case of the Month: Death and devices. autopsy will require the effort of 10. Hanzlick R, and the Autopsy Arch Int Med. 1999;159:21–2. pathologists, clinicians, institutions, and Committee of the College of American 20. Davis A, Fields A, Hill C, Hanzlick R, payers. It is our ethical, scientific, and Pathologists. Autopsy and Medicine: and the Autopsy Committee of the College of American Pathologists. medical obligation to revive the autopsy Case of the Month: Complications of Autopsy and Medicine: Case of the to an appropriate level of utilization. Let therapy, nursing homes, and the elderly (#9, April 1998). Arch Int Med. Month: Unavoidable outcomes versus the CPR begin! Breathing life into the 1998;158:695–6. misadventures. Arch Int Med. autopsy will also revitalize the practice 11. Hanzlick R, Hutchins GM, and the 1999;159:646–7. of medicine. Autopsy Committee of the College of 21. Hanzlick R, McKenney J, and the American Pathologists. Autopsy and Autopsy Committee of the College of NOTE: Volume 160, November 13, 2000. Randy Medicine: Case of the Month: Private American Pathologists. Autopsy and Hanzlick, M.D., Emory University School of autopsies (#10, May 1998). Arch Int Medicine: Case of the Month: Medicine, Atlanta, GA; and the Autopsy Med. 1998;158:947–8. Education of the pathologist. Arch Int Committee of the College of American 12. Hanzlick R, Baker P, and the Autopsy Med. 1999;159:907–8. Pathologists, Northfield, IL. Committee of the College of American 22. Hanzlick R, Mosunjac MI, and the Pathologists. Autopsy and Medicine: Autopsy Committee of the College of Case of the Month: Institutional American Pathologists. Autopsy and Page 42 [ Series 3, No. 32

Medicine: Case of the Month: The rest of the story. Arch Int Med. 1999;159:1173–6. 23. Bennett AT, Collins KA, Hanzlick R, and the Autopsy Committee of the College of American Pathologists. Autopsy and Medicine: Case of the Month: Outcome analysis and quality assessment. Arch Int Med. 1999;159:1399–1400. 24. Havlik D, Williams W, Hanzlick R, and the Autopsy Committee of the College of American Pathologists. Autopsy and Medicine: Case of the Month: Incidental and not-so-incidental findings. Arch Int Med. 1999;159:1655–6. 25. Hanzlick R, Hutchins GM, and the Autopsy Committee of the College of American Pathologists. Autopsy and Medicine: Case of the Month: History repeats itself (sometimes). Arch Int Med. 1999;159:1837–8. 26. Dallasta LM, Martinez J, Nichols L, Hanzlick R, and the Autopsy Committee of the College of American Pathologists. Autopsy and Medicine: Case of the Month: Pathologic findings in a transplant donor. Arch Int Med. 1999;159:2115–6. 27. Collins KA, Bennett AT, Hanzlick R, and the Autopsy Committee of the College of American Pathologists. Autopsy and Medicine: Case of the Month: The autopsy and the living. Arch Int Med. 1999;159:2391–2. 28. Collins KA, Bennett, Hanzlick R, and the Autopsy Committee of the College of American Pathologists. Autopsy and Medicine: Case of the Month: Elder abuse and neglect. Arch Int Med. 2000;160:1567–8. 29. Kiesel E, Hanzlick R, and the Autopsy Committee of the College of American Pathologists. Autopsy and Medicine: Case of the Month: All that glitters is not a gold standard. Arch Int Med. 2000;160:1901–2. 30. Nichols L, Hanzlick R, and the Autopsy Committee of the College of American Pathologists. Autopsy and Medicine: Case of the Month: What killed the patient—the disease of the experimental treatment. Arch Int Med. 2000;160:2253–4. Vital and Health Statistics series descriptions

SERIES 1. Programs and Collection Procedures—These reports SERIES 14. Data on Health Resources: Manpower and Facilities— describe the data collection programs of the National Center Discontinued in 1990. Reports on the numbers, geographic for Health Statistics. They include descriptions of the methods distribution, and characteristics of health resources are now used to collect and process the data, definitions, and other included in Series 13. material necessary for understanding the data. SERIES 15. Data From Special Surveys—These reports contain statistics SERIES 2. Data Evaluation and Methods Research—These reports are on health and health-related topics collected in special studies of new statistical methods and include analytical surveys that are not part of the continuing data systems of the techniques, objective evaluations of reliability of collected data, National Center for Health Statistics. and contributions to statistical theory. These studies also SERIES 16. 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