LifeBridge Health - Northwest Hospital Center
A: GENERAL POLICY STATEMENT
The Department of Pathology encourages the Medical Staff to obtain autopsy authorization on deceased patients 1) to determine cause of death, 2) to establish a quality assurance mechanism to evaluate the accuracy of clinical diagnoses, and 3) to assess patient management and the results of medical/surgical therapy. However, it is recognized that performing an autopsy on every death may not be feasible. Cases in which an autopsy should be especially encouraged are:
- death in which autopsy may help to explain unknown or unanticipated medical complications to the attending physician.
- all deaths in which the cause of death or a major diagnosis is not known with certainty on clinical grounds;
- cases in which autopsy may help to allay concerns of and provide reassurance to the family and/or the public regarding the death;
- unexpected or unexplained deaths occurring during or following any dental, medical, or surgical diagnostic procedures and/or therapies, if jurisdiction has not been assumed by the Office of the Chief Medical Examiner of the State of Maryland (see section B.2.);
- deaths of patients who have participated in clinical trials (protocols) approved by institutional review boards;
- natural deaths occurring within 24 hours of hospital admission
- obstetric deaths of natural cause
- neonatal and pediatric deaths;
- deaths in which it is believed that an autopsy would disclose a known or suspected illness that may have a bearing on survivors.
Postmortem examinations provide a valuable mechanism for teaching the pathogenesis and pathophysiology of disease entities and advancing medical knowledge. If an anatomic finding warrants an inspection of the organs by the clinicians or if specifically requested, the clinician will be notified by the pathologist. If attendance of the contacted clinicians is not possible at that time, every practical measure will be taken to preserve the organs of interest for a later review, when requested.
The performance of a postmortem examination requires a joint effort on the part of clinicians, nursing staff and personnel of the Pathology Department. Interdepartmental cooperation and an understanding of the correct protocol are essential.
B. ROUTINE AUTOPSY PROTOCOL
1. DETERMINATION OF MEDICAL EXAMINER JURISDICTION
The initial consideration should include an assessment of whether a post-mortem examination falls under the jurisdiction of the State of Maryland Office of the Chief Medical Examiner. This assessment is the initial responsibility of the attending clinician. If the attending clinician feels that the case may fall under such jurisdiction, he/she must contact the Investigator's Office at the Office of the Chief Medical Examiner (410-333-3271), before attempting to obtain autopsy permission from the family of the deceased.
In addition, the attending pathologist has both the prerogative and the responsibility to assess whether a case may fall under the Medical Examiner's jurisdiction, even if the case has already been reported by the clinician. The Medical Examiner has the authority to take custody of a body for postmortem examination in any case falling under his legal jurisdiction, regardless of the wishes of the next of kin.
The following categories of death are reportable to the Office of the Chief Medical Examiner regardless of where or when the initial injury event occurred:
- Any death that occurs suddenly or unexpectedly, that is, when the person has not been under medical care for significant heart, lung, or other disease.
- Any death suspected to be due to violence; that is suicidal, accidental or homicidal.
- Any death suspected to be due to alcohol or drug intoxication or the result of exposure to other toxic agents.
- Any death of a resident housed in a county or state institution. This refers to any ward or individual placed in such a facility by legal authorization.
- Any death of a person in the custody of law enforcement officers.
- Any death occurring in a nursing home or other private institution without recent medical attendance.
- Any death that occurs unexpectedly during, in association with, or as a result of diagnostic, therapeutic, surgical, or anesthetic procedures.
- Any death suspected to be involved with the decedent's occupation.
- Any death which is possibly -- directly or indirectly -- attributable to environmental exposure, not otherwise specified.
- Any death due to neglect.
- Any stillbirth of 20 or more weeks gestation, unattended by a physician.
- Any death of a pregnant woman, regardless of the gestation period.
- Any death of an infant or child where the medical history has not established some preexisting fatal medical condition.
- Any death which is suspected to be due to infectious or contagious disease wherein the diagnosis and extent of disease at the time are undetermined.
- Any death occurring under suspicious circumstances.
Any death in which there is a doubt as to whether or not it is a Medical Examiner's case should be reported.
If any of the following words/phrases appear on the death certificate, contact the office of the Chief Medical Examiner: accident, addiction, adverse reaction, alcohol, asphyxia, aspiration, at work, bite, burns, cut, ethanol, exposure, fall, fire, fracture, gunshot, homicide, ingestion, injection, injury, intoxication, misadventure, neglect, overdose, paraplegia, poisoning, post-operative (post any treatment/intervention), quadriplegia, sting, suicide, toxicity, uncertain, undetermined, unknown, use, and/or wound.
The following are excerpts from the State of Maryland Postmortem Examiner's Law and Regulations Governing Medical Examiner Cases:
"Medical Examiner's case" means any death which is the result, wholly or in part, of a casualty or accident, homicide, poisoning, suicide, criminal abortion, rape, therapeutic misadventure, drowning, or a death of a suspicious or unusual nature, or of an apparently health individual, or a case which is dead on arrival at the hospital.
Medical Examiner's case does not mean:
- A stillborn or a neonatal death, or emergency room or hospital death in which the cause of death has been established by the hospital physician and is due to disease, and free of evidence of criminal or accidental nature.
- A case in which the patient is dead on arrival at the hospital and the physician who pronounces death has been in previous attendance on the patient; or
- A death which occurs in a hospital within 24 hours of admission, merely because the death occurred within 24 hours
In the case of any anesthetic death occurring in Maryland, the hospital in which death occurred shall notify immediately, by telephone, the Chief Medical Examiner or a Deputy Chief Medical Examiner or Assistant Medical Examiner.”
2. REQUESTING A HOSPITAL AUTOPSY
a. GENERAL INFORMATION
Autopsies are generally performed from 8:00 a.m. to 5:00 p.m. Monday through Friday.
Monday through Friday, autopsies will be performed on the same day that authorization is obtained, provided that all required items are received and that the examination can be started before 2:00 p.m.
No autopsies will be performed on Saturdays and Sundays or on major holidays occurring Monday through Friday, except under the most extenuating circumstances and only with the approval of the on-call pathologist.
All autopsies requested must have a properly completed authorization (Authorization for Autopsy Form). Instructions for completing the Authorization for Autopsy Form are provided below.
A routine autopsy includes examination of the neck, thoracic, abdominal, and pelvic organs, as well as the central nervous system. This extent of examination should be explained to the family member (next-of-kin) authorizing the post-mortem examination. If there are any restrictions or limitations, these should be clearly stated in the autopsy authorization form.
The clinical staff (e.g. clinical physicians, nursing staff) should not promise release of the body at a specified time. Information concerning estimated autopsy completion time and release of body may be obtained by the family or funeral director from the Pathology Office (410-521-5910).
A valid permission, documented on the "Authorization for Autopsy" form (see sample at the end of this section), constitutes the most important administrative prerequisite for this procedure. This form is available at the nursing units, Registration Office, Emergency Department and the Department of Pathology. It is the responsibility of the attending physician to discuss the decision for autopsy with the next-of-kin. The attending physician must also obtain the authorization from the next of kin. The attending physician may designate a Hospitalist or Physician Assistant to discuss the autopsy and obtain consent for autopsy.
The consent must be obtained from the next of kin (closest surviving relative), who is legally responsible for assuming custody of the deceased and providing arrangements for disposition of the remains.
In the case of an adult death, the responsible individual is either the spouse, oldest child of legal age, parent, sibling, or a person acting as a representative of the decedent under a signed authorization of the decedent, in that order of priority. At times, there may be no surviving blood relatives or appointed legal guardian. In the absence of any of the above persons, any other individual willing to assume responsibility to act as the authorizing agent for purposes of arranging the final disposition of the decedent’s body may authorize an autopsy, after attesting in writing that a good faith effort has been made to no avail to contact the aforementioned next-of-kin.
In the case of a deceased child, this individual is usually a parent.
Care must be taken not to bypass the next of kin in order to obtain authorization from a more distant relative (for example, an adult son or daughter of the deceased may not give authorization because he or she does not wish to emotionally upset a surviving spouse). Next of kin may be bypassed, provided they choose not to exercise their legal right to provide for disposition of the remains or they are not capable of doing so for reasons of their own physical or mental health (this should be documented in the presence of a witness).
If the deceased is a registered donor with the Anatomy Board of Maryland, the next of kin shall not be asked for autopsy authorization. An autopsy would preclude the donation.
All bolded sections must be completed on the form, including the date and time when the authorization is obtained.
If it is not possible for the next of kin to come to the hospital and sign the Authorization for Autopsy form, a facsimile (fax) authorization form from the next of kin may be acceptable. This should be discussed with the pathologist.
c. DEATH CERTIFICATES
These must be properly filled out by the attending physician and/or designee by completing those areas necessary as outlined by the Department of Health and Mental Hygiene. On those cases where a postmortem examination is requested, only the portion for the Cause of Death and Contributing Factors should be left for the pathologist to complete.
If a case falls under the jurisdiction of the Office of the Chief Medical Examiner, no death certificate shall be completed by Northwest Hospital Center physicians. The death certificate will be issued by the Medical Examiner's Office.
The Death Certificate should remain with the body of the deceased at all times until the body is transferred by security to the Funeral Home.
d. CLINICAL INFORMATION
Adequate clinical information must be provided by the responsible physician obtaining autopsy authorization. Discussion between the Pathologist and Attending Physician regarding clinical findings and specific indications for postmortem examination is recommended.
e. PERFORMANCE OF AUTOPSIES IN PATIENTS WITH INFECTIOUS DISEASES POSING SIGNIFICANT EXPOSURE RISK TO HOSPITAL PERSONNEL
1) AIDS / HIV AUTOPSIES
The Department of Pathology has a flexible policy with respect to performing autopsies on HIV-positive patients. The decision whether or not such an autopsy will be performed will be based on the potential additional medical information to be derived from this procedure versus the significant exposure risk to hospital personnel.
The attending physician should discuss the potential educational benefits of the procedure prior to requesting permission to perform an autopsy from the next of kin. This will allow the pathologist to make a decision regarding acceptance of the case and the extent of the postmortem examination (if accepted).
2) Other High-Risk Infectious Diseases
Postmortem examination of patients with known or suspected infectious diseases that would cause significant exposure risk to hospital personnel should be discussed with the pathologist by the attending physician prior to obtaining authorization for autopsy. An example of such an infectious disease is a transmissable spongiform encephalopathy (e.g. Creutzfeldt-Jakob disease). The decision whether or not such an autopsy will be performed will be based on the potential additional medical information to be derived from this procedure versus the significant exposure risk to hospital personnel. The pathologist will make a decision regarding acceptance of the case and the extent of the postmortem examination (if accepted).
f. EMERGENCY DEPARTMENT DEATHS
The Department of Pathology will accept authorizations for autopsy of patients expiring in, or before arrival to, the Emergency Department only under certain circumstances. The attending physician should discuss the case with the responsible staff pathologist prior to requesting autopsy authorization from the next-of-kin.
In general, autopsies on patients expiring in, or before arrival to, the Emergency Department may be performed under the following circumstances:
1) A patient deceased upon arrival (“DOA”) from home or a nursing facility for whom there is a current, or a reasonably recent Northwest Hospital Center medical record, provided that a Northwest Hospital Center attending physician has recently seen or treated the deceased and is personally involved in requesting the autopsy, and provided that the case does not fall under the jurisdiction of the Office of the Chief Medical Examiner.
2) Death, occurring in the E.D., of a patient who may or may not be known to Northwest Hospital Center and its physicians, provided that the patient had survived long enough for an adequate evaluation of the clinical presentation and establishment of a reasonable working diagnosis, and provided that the case does not fall under the jurisdiction of the Office of the Chief Medical Examiner.
g. TRANSFER OF BODY TO THE MORGUE AND DISTRIBUTION OF PATIENT MEDICAL RECORD/ AUTHORIZATION FOR AUTOPSY FORM
The Northwest Hospital policy on Autopsies provides instructions for transfer of a deceased body to the morgue. This policy also includes specific details regarding distribution of the medical record and autopsy authorization form, that are dependent upon whether an autopsy has been requested. Following completion by clinical staff, the Death Certificate should remain with the deceased body at all times. With regard to the medical record and autopsy authorization form, the following protocol should be followed:
- If no autopsy is to be performed (declined by next-of-kin):
- The nurse will send the medical record to HIM.
- The nurse will indicate on the Disposition of Body form that no autopsy is needed.
- If an autopsy is requested by the next-of-kin:
- The nurse will attach the completed Authorization for Autopsy form to the Medical Record.
- The nurse will ensure that the Medical Record and the Authorization for Autopsy are transported to the Morgue with the body.
- Security will immediately take the Medical Record and Authorization for Autopsy to the Pathology Transcription Room, main hospital building, Room 1WS79.
- It is the responsibility of security to confirm that the autopsy has been completed and that TRC had completed tissue harvesting prior to the release of the body.
- If the need for autopsy is undetermined:
- The nurse will send the Medical Record to HIM.
- The nurse will document appropriate information regarding the lack of decision on
autopsy on the Nursing Deceased Person Checklist form.
- The nurse will document that autopsy is undetermined on the Disposition of Body form.
- The nurse will notify and document that the Nurse Manager/ANC has been notified that the need for autopsy is undetermined.
- The ANC/Nurse Manager will be responsible for notifying Security when a decision concerning the autopsy is made.
- The ANC/Nurse Manager will be responsible to contact the attending physician or designee so that they can obtain authorization and notify Pathology.
- The ANC/Nurse Manager will ensure that the completed Authorization for Autopsy and patient's medical record are sent to the Pathology Department when the decision to perform an autopsy has been made.
The morgue facility is accessible during weekday hours: 8:00 a.m. to 5:00 p.m. On evenings, nights, weekends and holidays, a security officer will open the morgue.
The hospital identifying wristband should not be removed from the deceased body under any circumstances.
Following proper preparation and transport of the body to the morgue on the covered cart, the body is to be transferred to one of the morgue storage carts and placed in the cooler. If all storage carts are occupied, the body is to be left on the covered transport cart inside the autopsy room.
h. INFORMING THE DEPARTMENT OF PATHOLOGY
Whenever an autopsy is requested, the Pathology Department must be notified directly during normal working hours at extension x55910 so that the department can assume responsibility for the performance of the post-mortem examination.
The attending physician (or designee) who obtains the authorization for autopsy is responsible for notifying the Pathology Department or the pathologist on-call.
From 8:00 a.m. to 5:00 p.m., Monday through Friday, contact the Pathology Office (extension 55910). If no notification is made, undue delay may occur in beginning the autopsy.
If necessary, the on-call pathologist can be contacted during evenings, on Saturdays and Sundays, and on major holidays by calling the hospital switchboard operator. However, contacting the on-call pathologist should be reserved for unusual situations, as autopsies are generally only performed during working hours. Contacting the pathologist to discuss an autopsy is one important step in the request process, but by itself, does not complete the request process.
A request for autopsy will not be considered complete and postmortem examination will not be initiated until:
- the clinician has communicated clinical findings to the pathologist
- the Pathology Department has received the following items:
- the appropriately completed and signed "Authorization for Autopsy,"
- the patient's chart/medical record and death certificate (if completed).
These items must be delivered to the Department of Pathology transcriptionists’ office (main hospital building, room 1WS79).
C. RELEASE OF BODIES
The Department of Pathology notifies the Security Department upon completion of the autopsy. The Security Department will notify the funeral home. Funeral home personnel report to the loading dock. The Security Department will be responsible for making a copy of the “death certificate” and, with the funeral home personnel, signs “disposition of body form”. The copy of the Death Certificate will be sent by Security to HIM.
D. AUTOPSY REPORTS
Copies of the Provisional Anatomic Diagnoses (PAD) will be forwarded by the Pathology Department to the attending physician(s) and to Medical Records within two working days of the autopsy. The Final Anatomic Diagnoses (and complete autopsy report) will be sent to the attending physician and Medical Records upon completion of the autopsy. No copies of the report will be mailed directly or faxed to the next of kin or other family members. The next of kin must obtain the results of the postmortem examination from the clinical attending physician or from the Medical Records Department.