Series 3, Number 32 October 2001

The Autopsy, Medicine, and

Mortality Statistics
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 autopsy, medicine, and mortality statistics. National Center for

Health 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—Case Report. 2. Autopsy—United
 

States—Collected Works. 3. Cause of Death—United States—Case Report.
 

4. Cause of Death—United States—Collected Works. W2 A N148vc no. 32
 

2001]
 

RB57 .A89 2001
 

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[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 HUMAN SERVICES

Centers for Disease 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 Science

Lawrence H. Cox, Ph.D., Associate Director for Research

and Methodology

Jennifer H. Madans, Ph.D., Acting Associate Director for

Analysis, Epidemiology, 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 public health.’’

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

Pamela Amato (CAP staff)

Peter Baker, M.D.

Johannes Bjornsson, M.D.

Kevin Bove, M.D.

John Buchino, M.D.

Steven Campman, M.D.

Kim Collins, M.D.

Gregory J. Davis, M.D.

Marcella Fierro, M.D.

Stephen Geller, M.D.

Randy Hanzlick, M.D.

Contributing Authors

Dean Havlik, M.D.
 

Grover Hutchins, M.D.
 

Eun Young Lee, M.D.
 

Larry Nichols, M.D.
 

Joseph Parisi, M.D.
 

John Sinard, M.D., Ph.D.
 

J. Thomas Stocker, M.D.
 

Jessica Troup, M.T. (CAP staff)
 

Keith Volmar, M.D.
 

Nancy Young, M.D.
 

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

Peter Baker, M.D.
 

Allan Bennett, M.D.
 

Johannes Bjornsson, M.D.
 

Michael Cibull, M.D.
 

Kim Collins, M.D.
 

Linda Dallasta, M.D., Ph.D.
 

Amanda Davis, M.D.
 

Gregory J. Davis, M.D.
 

Angela Fields, M.D., Ph.D.
 

Randy Hanzlick, M.D.
 

Dean Havlik, M.D.
 

Charles Hill, M.D.
 

Grover Hutchins, M.D.
 

Rebecca Irvine, M.D.
 

Eric Kiesel, M.D., Ph.D.
 

Eun Young Lee, M.D.
 

Jeff Lee, D.O.
 

Julio Martinez, M.D.
 

Jesse McKenney, M.D.
 

Mario Mosunjac, M.D.
 

Clay Nichols, M.D.
 

Larry Nichols, M.D.
 

Eric Pfeiffer, M.D.
 

Ann Smith, M.D.
 

Wilbur Williams, M.D.
 

iii
Foreword
 

Comments from the National Center for Health Statistics
 

The series of articles in this report document the value of

autopsy in health care and health statistics and provides

educational information about completing cause-of-death

statements. Autopsy information has long been an essential

tool for quality control of medical care and for enhancing the

quality of cause-of-death information reported on the death

certificate. Recognizing that the use of autopsy has declined

considerably in the past 50 years as documented in vital

statistics, the autopsy is nevertheless regarded as an important

tool in medical practice and in improving the cause-of-death

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.

Death certificate information is a major source of

statistical data to identify public health problems, to monitor

progress in public health, to allocate research funds, and to

conduct scientific research. For these reasons, good reporting

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

cause of death, separation of contributing causes in Part 2 of

the medical certification from the sequence of conditions

reported in Part 1, report of a single condition per line,

avoidance of abbreviations, and amendment of the record if

additional information becomes available later. This report

provides additional examples of cause-of-death
 

statements to supplement those available
 

from State and Federal vital statistics programs
 

(e.g., http://www.cdc.gov/nchs/about/major/dvs/handbk.htm).
 

Dr. Hanzlick, the editor of the report, continues his

important contribution to the National Vital Statistics System

and in particular to the quality of national mortality data.

NCHS is pleased to assist the College of American

Pathologists in promoting the distribution of these articles,

which previously appeared in Archives of Internal Medicine.

Harry M. Rosenberg, Ph.D.
 

Special Assistant
 

Division of Vital Statistics
 

National Center for Health Statistics
 

Centers for Disease Control and Prevention
 

Donna L. Hoyert, Ph.D.
 

Statistician (Demographer)
 

Mortality Statistics Branch
 

Division of Vital Statistics
 

National Center for Health Statistics
 

Centers for Disease Control and Prevention
 

iv
Preface The Autopsy Committee of the

College of American Pathologists

undertook the‘‘Autopsy and

Medicine’’ series in 1997 with two

major goals in mind: +	 To illustrate the continued value of

the autopsy to the practice of

medicine; and

+	 To provide educational material and

discussion concerning cause-of-death

statements and completion of the

death certificate.

These goals arose out of recognition

that autopsy rates in the United States,

especially in medical institutions, had

fallen to unacceptable levels for quality

assurance/improvement purposes.

Studies also showa need for improving

our national mortality data derived from

death certificates, which, in turn, should

reflect information obtained at autopsy.

The committee is grateful to Dr.

James Dalen, Editor of Archives of

Internal Medicine, who agreed to

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 asa freestanding publication.

Comments from NCHS are printed on

the following page.

Finally, the committee wishes to

thank Joe Schramm,Ayrika Gunn, and

JessicaTroup of the CAP for their

dedicated service in producing the draft

for publication.

The Autopsy Committee feels that

this publication will be especially useful

for the following individuals: +	 Physicians in medical specialties in

which the deaths of some patients

will occur, making knowledge of the

autopsy and cause-of-death

statementsa desired attribute;

+	 Pathologists and other physicians

who havea need to educate others

on the value of the autopsy; and

+	 Legislators and policy makers whose

duties include analysis of the

autopsy and its role in the practice

of medicine and public health.

Authors who reference the articles

included in this publication should cite

the original reference from Archives of

Internal Medicine when possible.

Complete references are included in ‘‘Wrapping Things Up,’’ the last case

report in this collection.

v
Contents
 

Foreword ................................................................................................ iv
 

Preface .................................................................................................. v
 

The Moribund Autopsy: DNR or CPR? ....................................................................... 1
 

What Killed the Patient: The Disease or the Experimental Treatment? .............................................. 1
 

The Autopsy and New Technology: All That Glitters Is Not a Gold Standard ........................................ 3
 

Elder Abuse and Neglect ................................................................................... 4
 

The Autopsy and the Living ................................................................................ 6
 

Pathologic Findings in a Transplant 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 Autopsies ......................................................................................... 31
 

Complications of Therapy, Nursing Homes, and the Elderly ....................................................... 32
 

Protecting Those at Risk ................................................................................... 34
 

Partial, Limited, or Restricted Autopsies ...................................................................... 35
 

A Tale of the Unexpected: Finding a Zebra .................................................................... 35
 

An Intoxicating Case: The Importance of Toxicology ............................................................ 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

Autopsy: DNR or

CPR?

The decline in the performance of

autopsies in the past three

decades is remarkable: from

41 percent of hospital deaths in 1961 (1)

to 5 percent to 10 percent in the

mid-1990s! (2) House officers in the

1960s were urged to ‘‘get the post’’ on

every patient dying in a teaching

hospital. Observing the postmortem

examination of patients whom they had

taken care of was a critical part of the

training of residents in internal medicine.

Currently, the residency review committee

for internal medicine requires autopsies in

at least 15 percent of deaths on the

medical service in accredited residency

programs. From 1991 to 1994, less than

half of the internal medicine programs

reviewed for accreditation met these

minimal requirements (3).

Numerous reasons for the abrupt

decline in autopsies have been cited. In

1971, the Joint Commission on the

Accreditation of Hospitals eliminated

autopsy requirements for hospital

accreditation. Autopsies have become

very expensive, and these costs are not

reimbursed by third-party payers. The

process for obtaining consent for

autopsies remains cumbersome.

However, the most likely explanation

for the decline is that physicians do not

request autopsies because they believe

that the examinations have lost their value.

The most obvious value of the autopsy is

quality assurance: to compare the

clinician’s premortem clinical diagnosis

with the precise, anatomical cause of

death. Did the patient receive the correct

treatment for the correct disease?

Cabot’s (4) classic paper in 1912

based on 3,000 autopsies quantified the

percent of correct clinical diagnoses for

a variety of diseases. Diabetes and

typhoid were correctly diagnosed before

death in more than 90 percent of the

cases examined after death. However,

common diseases such as cirrhosis,

acute endocarditis, bronchopneumonia,

and acute nephritis were missed in more

than 50 percent of the cases.

Obviously, clinical medicine has

made massive strides since 1912. Some

clinicians may believe that our current

sophisticated high-tech diagnostic tests

render the autopsy superfluous. Many

pathologists do not agree that the

autopsy has been rendered superfluous

by modern technology. Perhaps they are

justifiably alarmed at the imminent

demise of the autopsy.

Landefeld, et al. (1) in 1988 found

that by performing autopsies, major

unexpected findings were detected. A

premortem diagnosis of these findings

would probably have improved survival

in 11 percent of the cases examined at a

university hospital and 12 percent of the

cases at a community hospital.

Shanks, et al. (5) reported the value

of the autopsy in 213 cases of

perioperative death. They found major

discrepancies in clinical diagnoses that

were treatable and could affect survival

in 21 percent of the cases.

In a review of 1,000 autopsies

performed between 1983 and 1988,

Sarode, et al. (6) found ‘‘major

discrepancies’’ between the autopsy

findings and the clinical diagnosis in 317

(32 percent) of the 1,000 autopsies. Two

recent studies found major discrepancies

in the diagnosis of malignant tumors.

Veress and Alafuzoff (7) reported that

15 percent of all major cancers were not

diagnosed before autopsy. Manzini, et

al. (8) reported that 34 percent of tumors

with metastasis were missed before the

autopsy.

Given these reports, it may be more

appropriate to save the autopsy, rather

than pronounce it ‘‘DNR’’!

In an attempt to begin CPR of the

autopsy, the Autopsy Committee of the

College of American Pathologists has

prepared a series of brief case reports

for the Archives of Internal Medicine. In

this series, ‘‘Autopsy and Medicine,’’ a

brief case report will be presented that

illustrates modern uses of the autopsy

for improving patient care, analyzing

potential legal and health risks, meeting

regulations, reducing unnecessary

litigation, and benefiting the public.

NOTE: Volume 157, August 11/25, 1997. James E.

Dalen, M.D., M.P.H. Editor.

References

1.	 Landefeld CS, Chren MM, Myers A,

Geller R, Robbins S, Goldman L.

Diagnostic yield of the autopsy in a

university hospital and a community

hospital. N Engl J Med.

1988;318:1249–54.

2.	 Hasson J, Schneiderman H. Autopsy

training programs to right a wrong.

Arch Pathol Lab Med.

1995;119:289–91.

3.	 Schatz IJ. Internal medicine residency

program violations of the minimum

autopsy rate. JAMA. 1995;273:1092.

4.	 Cabot RC. Diagnostic pitfalls identified

during a study of three thousand

autopsies. JAMA. 1912;59:2295–8.

5.	 Shanks JH, McCluggage G, Anderson

NH, Toner PG. Value of the necropsy

in perioperative deaths. J Clin Pathol.

1990;43:193–5.

6.	 Sarode VR, Datta BN, Banerjee AK,

et al. Autopsy findings and clinical

diagnoses: a review of 1,000 cases.

Hum Pathol. 1993;24:194–8.

7.	 Veress B, Alafuzoff I. A retrospective

analysis of clinical diagnoses and

autopsy findings in 3,042 cases during

two different time periods. Hum Pathol.

1994; 25:140–5.

8.	 Manzini VP, Revignas MG, Brollo A.

Diagnosis of malignant tumor:

comparison between clinical and

autopsy diagnoses. Hum Pathol.

1995;26:280–3.

What Killed the

Patient: The Disease

or the Experimental

Treatment?

A38-year-old woman underwent

excision of a nodular malignant

melanoma of the right scapular

region (level III; Breslow depth,

1.6 mm). Right axillary lymph node

dissection a month later showed

metastases in five of six nodes with

extracapsular spread. Six months later,

the patient had a dental abscess

associated with a dental implant; the

abscess was treated with removal of the

implant and six days of antibiotic

therapy with metronidazole and

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

patient was enrolled in a ganglioside

adjuvant vaccine study (for treatment of

melanoma) and received her first

dose (1,2). After receiving the vaccine,

the patient developed progressive

dyspnea. At first she had dyspnea only

after she walked up a flight of eight

stairs, but it worsened until it occurred

after only minimal effort such as

blow-drying her hair.

On the fifth day, she presented to

the outpatient clinic. Her oxygen

saturation while breathing room air was

96 percent, but when she was walked up

and down the hall on a level surface,

her saturation decreased to 85 percent.

Her pulse was 120 per minute, and her

blood pressure was 95/60 mm Hg. Her

chest was clear. Blood hemoglobin

concentration was 148 g/L with a

hematocrit of 0.43. The white blood cell

count was 9.2 109

/L (neutrophils, 0.70;

lymphocytes, 0.17; monocytes, 0.12;

eosinophils, 0.01), and platelets

numbered 120 109

/L. Findings from

electrocardiography revealed a normal

sinus rhythm with some T-wave

flattening in leads III and a VF. Chest

radiography results were negative and

findings on computed tomographic

scan of the chest showed no evidence

of pulmonary embolus, no pulmonary

nodules, no evidence of infiltrate or

effusion, and no hilar, mediastinal, or

axillary adenopathy. Two deep pectoral

muscle lymph nodes were noted on

the right, and there were multiple low

attenuation lesions throughout the

liver.

The patient was hospitalized

overnight and had no dyspnea in the

hospital. Her dyspnea was attributed to

an allergic reaction to her new pet dog.

She was discharged the next day, but

was rehospitalized the day after that

with progressive dyspnea without

reexposure to the dog, so her dyspnea

was then attributed to adverse effects of

the ganglioside adjuvant vaccine. The

patient also had severe epigastric pain

and right upper quadrant tenderness. She

developed marked elevations of her

serum transaminase levels, and liver

biopsy results showed metastatic

melanoma. A diagnosis of Escherichia

coli urinary tract infection was made on

the eighth hospital day. The patient had

persistent epigastric pain requiring

progressive narcotic analgesia and

worsening dyspnea requiring progressive

supplemental oxygen therapy. A decision

was finally reached to provide comfort

measures only. Terminally she had a

leukocytosis with a left shift and a white

blood cell count of 30.6 109

/L. The

patient died on hospital day 18.

Autopsy Findings

Postmortem examination revealed

metastatic malignant melanoma

involving lymph nodes, liver,

spleen, bone marrow, lungs, pleura,

epicardium, myocardium, gallbladder,

duodenum, pancreas, kidneys, uterus,

adrenals, and left breast. There were

extensive lymph node metastases with

nodes measuring up to 4 cm. The liver

was mildly enlarged, and metastases

replaced approximately 70 percent of the

parenchyma. There were multiple spleen

metastases up to 0.6 cm, multiple lower

thoracic spinal metastases up to 0.5 cm

(with extensive bone marrow necrosis),

visceral pleural metastases up to 0.8 cm,

and epicardial metastases up to 0.3 cm.

Histologic sections from all five lobes

of the lung each showed extensive

interstitial, lymphangitic, and

perivascular tumor. Postmortem blood

culture results were positive for E. coli.

Based on these findings, a

cause-of-death statement was prepared

as follows:

Part 1.

A. Pulmonary lymphangitic

carcinomatosis

Due to or as a consequence of:

B. Metastatic malignant melanoma

(skin of back)

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Escherichia coli sepsis

Comment

The autopsy findings suggest that

stretching of the liver capsule by

metastatic tumor was the reason for the

patient’s epigastric pain and right upper

quadrant tenderness. The autopsy

findings also support the conclusion that

pulmonary lymphangitic and interstitial

tumor was the cause of the patient’s

dyspnea with pulmonary metastatic

tumor being below the limits of

radiologic detection. Although dyspnea

initially coincided temporally with the

administration of the experimental tumor

vaccine and the patient’s exposure to a

new dog, the subsequent sequence of

events and the autopsy findings point

toward tumor-related restriction in

pulmonary expansion and diffusion

capacities as a more likely cause of the

patient’s dyspnea, especially since

dyspnea had worsened without

continued exposure to the dog. Further,

there was no morphologic evidence of

an adverse drug reaction, pulmonary

tumor necrosis or hemorrhage, or other

finding to explain the progressive

dyspnea.

The question arises whether

performing a lung biopsy might have

yielded the diagnosis of lymphangitic

carcinomatosis. This case also suggests

that pulmonary function testing, rather

than radiologic imaging, may be a

helpful way to assess the likelihood of

lymphangitic carcinomatosis. Such

questions, which grew out of the

autopsy in this case, could prompt future

study of the clinical utility of alternative

methods of testing for the diagnosis of

lymphangitic carcinomatosis. Failure to

recognize lymphangitic carcinomatosis

(lymphangiosis carcinomatosa) as a

cause for dyspnea, and its misdiagnosis

as pulmonary embolism, was the subject

of another ‘‘Case of the Month’’ in

which the autopsy findings explained

the lack of response to anticoagulant

therapy (3).

The autopsy was also valuable in

this particular case because it provided a

likely explanation for the patient’s

shortness of breath that was being

attributed to other causes, including the

experimental vaccine therapy she had

received. If an adverse event occurs

following experimental therapy, the

adverse effect may be wrongly

attributed to the experimental therapy

(even without any hypothesis about

possible or likely pathogenetic

mechanisms) unless a better explanation
Series 3, No. 32 [ Page 3

is available. The autopsy in this case

provided a much sounder explanation

for the progressive dyspnea: pulmonary

lymphangitic carcinomatosis. Thus, the

autopsy saved an experimental therapy

from being falsely blamed for an

adverse reaction, and the patient seems

to have died from progression of her

disease rather than a complication of the

treatment she received. We recommend

the performance of an autopsy when

experimental therapy has been used or

when death is suspected to have resulted

from a complication of treatment, even

if an autopsy is not required by

protocol.

NOTE: Volume 160, August 14/28, 2000. Larry

Nichols, M.D., University of Pittsburgh Medical

Center, Pittsburgh, PA; Randy Hanzlick, M.D.,

Emory University School of Medicine, Atlanta,

GA; and the Autopsy Committee of the College of

American Pathologists.

References

1.	 Ollila DW, Kelley MC, Gammon G,

Morton DL. Overview of melanoma

vaccines: active specific

immunotherapy for melanoma patients.

Semin Surg Oncol. 1998;14:328–36.

MEDLINE.

2.	 Minev BR, Chavez FL, Mitchell MS.

New trends in the development of

cancer vaccines. In Vivo.

1998;12:629–38. MEDLINE.

3.	 Pfeiffer EA, Bjornsson J, Hanzlick R,

Autopsy Committee of the College of

American Pathologists. Case of the

month: lymphangiosa carcinomatosa.

Arch Intern Med. 1998;158:14.

MEDLINE.

The Autopsy and New

Technology: All That

Glitters Is Not a Gold

Standard

A66-year-old woman with

metastatic uterine

leiomyosarcoma involving nearly

the entire left lung was admitted to the

hospital for evaluation of dyspnea. On

day 3 of her hospitalization, while

undergoing a computed tomographic

(CT) scan, she reportedly fell from the

CT table, landing between the table and

the scanner. Computed tomographic

scans of her head, neck, and chest were

performed to evaluate her condition and

determine if any injuries were sustained

from the fall. She suffered a

cardiopulmonary arrest while still in the

CT scan room. Resuscitation efforts

were not performed because she had

been placed on do-not-resuscitate status.

Her death was reported to the medical

examiner because of the fall and

possible injury. When the death was

reported to the medical examiner,

information obtained by the medicolegal

death investigator from the hospital

indicated that the CT scan showed upper

cervical spine fracture with spinal cord

compression. The medical examiner

assumed jurisdiction and performed a

complete autopsy.

Autopsy Findings

The autopsy showed a small left

frontal scalp hematoma. There was

near total replacement of the left lung

by hemorrhagic neoplasm, which was

histologically confirmed to be

leiomyosarcoma. There was evidence

of acute hemorrhage within the tumor,

which was viewed by the pathologist

as a probable explanation for the acute

exacerbation of the patient’s dyspnea.

Autopsy also confirmed that a

hysterectomy and salpingooophorectomy had been performed,

consistent with the reported history of

a uterine primary tumor site.

Examination of the neck with both

anterior and posterior neck dissections

revealed no fractures or soft tissue

hemorrhage in the paravertebral

tissues. The upper cervical spinal

canal was easily visualized through

the foramen magnum, and the spinal

cord was unremarkable without

evidence of cord compression or

spinal canal stenosis. Moderate

atherosclerotic cardiovascular

disease was also found. In the

absence of significant trauma, the

cause of her death was attributed to

the following:

Part 1.

A. Uterine leiomyosarcoma with

extensive metastasis to the left lung

Due to or as a consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Atherosclerotic coronary artery

disease

Comment

Because of the discrepancy between

the autopsy findings and the initial

report of spinal column and cord injury,

a review of medical records was

performed and the CT scans were

reviewed with the attending radiologist.

The initial interpretation of the CT scan

by the radiologist was that of a

nondisplaced fracture of the second

cervical vertebral pedicles (bilateral)

without spinal cord compression. The

original report of spinal cord

compression was in error and resulted

from misinterpretation of the ‘‘without’’

symbol O as meaning ‘‘with’’ (c). Thus,

the lack of spinal cord compression at

autopsy was actually consistent with the

original medical record, and the

apparent discrepancy was explained as a

result of the autopsy and retrospective

review of the case.

The lack of vertebral fracture at

autopsy was a second discrepancy that

needed explanation. The hospital had

recently acquired a new CT scanner

with resolution capabilities to the

millimeter level. The CT scans of the

patient presented in this case report

were among the first scans performed

with the new equipment. Defects were

observed with the CT scan in the lamina

of the C2 cervical spine and were

initially interpreted by the radiologist as

fractures. As more experience was

gained with the CT equipment, similar

defects were observed in other patients.

On reevaluation of this patient’s CT

scans, it was determined that the defects

did not represent fractures but instead
Page 4 [ Series 3, No. 32

were perforating vascular foramina.

These foramina could not be visualized

with older equipment because of the

bone-density averaging methods used by

the older equipment.

As new technologies enhance our

abilities to visualize smaller objects and

to detect smaller quantities of various

substances, we must be careful in our

interpretation of the data. In some

instances, as in this case report, we are

not detecting new or abnormal entities,

but now have the ability to measure,

see, or detect ‘‘normal’’ entities that we

previously could not.

This case highlights potential

pitfalls of new technology with

enhanced resolution and the continued

value of the autopsy in serving as a

‘‘gold standard’’ for validating new and

emerging technology. (1,2) Regarding

the present case in particular, because of

the initial diagnosis of cervical spinal

fracture, the hospital was open to

potential criticism, accidental or

wrongful death claims, and litigation.

The confusion about the spinal cord

compression also illustrates the potentially

serious legal risks that may be imposed by

a simple misinterpretation and/or

miscommunication of or about the

medical record. The retrospective medical

record review and discussions with the

radiologist, done in conjunction with the

autopsy and death investigation, clarified

the problem and also provided useful

information to the radiologists. Although

the initial misinterpretation of the CT

scan was rectified by the radiologists,

the autopsy (by an independent agency

in this case) served as the ultimate

medical quality assurance measure, and

was useful to provide further knowledge

about a new technology. The autopsy

was also very valuable to the hospital in

providing information that could be used

to rebut or disprove legal claims that

could arise about the fall and possible

injury.

NOTE: Volume 160, July 10, 2000. Eric Kiesel,

M.D.; Randy Hanzlick, M.D., Emory University

School of Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists, Northfield, IL.

References

1. Sarode VR, Datta BN, Banerjee AK, et

al. Autopsy findings and clinical

diagnoses: a review of 1000 cases.

Hum Pathol. 1993;24:194–98.

MEDLINE.

2.	 Nichols L, Aronica P, Babe C. Are

autopsies obsolete? Am J Clin Pathol.

1998;110:210–18. MEDLINE.

Elder Abuse and

Neglect

An elderly white woman died in

the care of a male friend who

was her caretaker for the past

year. She was found in her bed,

unresponsive, and the police were

notified. Upon arrival, the police found

her in the bed on top of dirty, soiled

linens. Fecal material and areas of urine

staining were present, each in excess of

what would be expected from agonal

defecation and urination. Her physician

refused to sign the death certificate

because he had not seen her in two

years, and previously she had been

doing well. He could not think of a

clear cause of death since her medical

history was significant only for senile

dementia and osteoporosis during the

past four years. The male friend was

considered the next of kin, and he

desperately wanted to complete the

paperwork for burial and insurance

purposes. The physician agreed to sign the

death certificate if a complete autopsy was

performed. The body was taken from the

home to the autopsy room.

Autopsy Findings

At autopsy, the decedent was noted

to be cachectic, with dried fecal material

between her buttocks. She appeared

dehydrated, with tenting of the skin and

sunken eyes. Decubitus ulcers were

present over the sacral and inferior

buttocks regions. The ulcers extended

through the skin, subcutaneous soft

tissue, and skeletal muscle down to the

bone. The femoral head could be

visualized on the right side. The

surrounding tissue was friable and

necrotic, and necrosis and inflammation

were confirmed by microscopic

examination. A yellow-tan exudate was

present within the ulcers and was

cultured by the pathologists. Blood was

also drawn for culture. Both the blood

culture and wound exudate culture were

positive for Pseudomonas aeruginosa.

Vitreous was drawn for analysis of

electrolytes and the results showed

dehydration with an increase in sodium,

chloride, and urea nitrogen levels. Other

findings included cerebral atrophy with

remote ischemic changes

microscopically.

The cause of death statement was

prepared as follows:

Part 1.

A. Pseudomonas sepsis with

dehydration

Due to or as a consequence of:

B. Decubitus ulcers associated with

senile dementia

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Comment

Each year approximately 10 percent

of adults 65 years and over are abused,

and 4 percent experience moderate to

severe abuse (1–4). Elder abuse has

been recorded since the 19th century,

but it was not brought to the forefront

until 1980, by the U.S. House Select

Committee on Aging. By 2030 the U.S.

population will consist of about 70

million older Americans, which is more

than twice the number in 1990. Thus, an

increase in the number of older victims

of abuse can be expected (5).

In 1987 the American Medical

Association’s Council on Scientific

Affairs defined elder abuse as an act or

omission that results in harm or

threatened harm to the health or welfare

of an elderly person (3). Elder abuse can

be classified into six categories: physical

abuse, sexual abuse, neglect,

psychological abuse, financial and

material exploitation, and violation of

rights (5).
Series 3, No. 32 [ Page 5

Physical abuse is an act carried out

with intention of causing physical pain

or injury, such as hitting, slapping, or

stalking with objects. Sexual molestation

includes contact with genitalia, anus, or

mouth. Neglect is one of the more

common forms of abuse and is

characterized by a failure of the

caregiver to provide the goods or

services that are necessary for optimal

functioning or to avoid harm. Medical

neglect was the form of neglect in the

case reported above because there was

failure to seek medical care appropriate

for the patient’s condition.

Psychological abuse may include

threats, insults, harassment, harsh orders,

and behavior designed to increase social

isolation. Stealing pension checks, not

using funds for support of the elder,

and/or inappropriate use of the elder’s

personal property constitute financial

and material abuse. This latter form of

abuse/neglect could also be alleged in

the current case since the caretaker was

using the decedent’s funds, but not for

her support. Violations of rights occur

when the caregiver deprives the

individual of his or her inalienable

rights, such as freedom of choice, life,

or privacy.

Often, several types of abuse occur

simultaneously. A family member who

may initially take in an elderly patient

may not be aware of the work and

sacrifice involved and may become

subject to the stress of the situation,

which can lead to neglect or abuse (6).

The abused elder most often has a

cognitive impairment, lives in close

proximity to the abuser, lives in social

isolation, and is older than 75 years (7).

Characteristics of the abuser often

include a history of mental illness

and/or substance abuse, excessive

dependence on the elder for financial

support, and a history of violence or

antisocial behavior outside the

family (7). Awareness of these factors

can assist health care workers in

identifying those individuals at risk.

Abuse is like disease: if it is not

considered in the differential diagnosis it

probably will not be diagnosed (7).

Recognition of elder abuse/neglect is

difficult for several reasons, such as the

lack of structured training in screening

for abuse and the discomfort of

discussing the topic with patients. Many

of these elders will even deny help.

Elders may deny abuse because they are

ashamed of being abused or fear

reprisal (7). Medical assessment of the

victim should include a complete

history, complete physical examination,

and documentation of all injuries.

Multiple injuries at various stages of

healing, unexplained injuries, delays

between illness or injury onset and

treatment, ‘‘doctor hopping,’’ and

multiple emergency department visits

are a few of the findings. Pressure

ulcers are often present in the elderly

who are ill, and these should be

thoroughly examined with all the

dressings removed. Evidence of

foul-smelling or necrotic pressure ulcers

that have not been brought to the

attention of the physician should raise

suspicion of neglect (6).

Adult Protective Services is an

agency that exists by law in every State

to investigate cases of possible

abuse (6). States require the reporting of

elder abuse, and the physician can be

held responsible if he/she is aware of

possible abuse but fails to report it. It is

important to understand the avenues of

referral when elder abuse is suspected.

If an elderly victim with a possible

history of abuse dies, a complete

investigation is needed, including

reporting the death to law enforcement,

the coroner, or the medical examiner as

required by statute.

Abuse of the elderly occurs

everywhere in the United States, and

education is the key to detection. Elder

abuse is often difficult to identify and

occurs in all races and all

socioeconomic groups. In addition to

clinical evaluation, the autopsy can play

a major role in the evaluation of

suspected abuse or neglect of the

elderly. The nature and extent of

specific injury can be documented.

Some evaluation of hydration status and

metabolic status may be performed. The

possibility of causes of death other than

abuse/neglect may be evaluated,

sometimes exonerating those falsely

accused of abuse or neglect.

Intoxication, overmedication, or

poisoning may be detected. Some

evidence may be obtained as to the

duration of specific conditions, such as

injuries. The interplay between external

factors and intrinsic disease may be

explored. Information is obtained and

documented that may be used in any

legal proceedings that may follow cases

of alleged abuse and neglect.

Autopsy findings in cases of elder

abuse and/or neglect may be subtle, and

the diagnosis is often difficult for

pathologists to establish because of the

almost invariable presence of some

chronic or debilitating disease that puts

the patient at risk for abuse and/or

neglect in the first place. The autopsy

pathologist cannot always answer

questions or address allegations about

abuse/neglect decisively. However, the

autopsy does provide one last chance to

collect and document findings that may

be useful not only for identifying

abuse/neglect but also for refuting false

claims and protecting the innocent.

Whenever it is suspected that

abuse/neglect may have caused or

contributed to the death of an elderly

person, the medical examiner or coroner

should be notified. In most such cases

with some foundation for suspicion, a

formal medicolegal death investigation,

including autopsy, will be conducted. If

this does not occur but suspicion

remains, consideration should be given

to approaching the legal next-of-kin for

performance of an autopsy.

In the case reported, the death was

certified as shown because it was

believed that the decubiti were beyond

what would be expected with adequate

medical care and were the primary

cause of death, associated with senile

dementia, but also based on some

degree of medical neglect. Whether the

certifier of death reports ‘‘neglect’’ on

the death certificate or classifies deaths

from neglect as ‘‘homicide’’ varies

among jurisdictions. In contrast, most

deaths due to intentionally inflicted

physical abuse would be classified as

homicide when the relationship between

physical abuse (injury) and death is

clear. However, these fine points are not

of major legal import because criminal

prosecution may occur if there is

sufficient evidence of criminal neglect,

regardless of how the manner of death

is certified on the death certificate. The

important factor is that those persons

having knowledge of possible
Page 6 [ Series 3, No. 32

abuse/neglect report the facts to the

appropriate authority so appropriate

investigation and legal actions may

occur.

NOTE: Volume 160, June 12, 2000. Kim A.

Collins, M.D.; Allan T. Bennett, M.D., Medical

University of South Carolina, Charleston; Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

References

1.	 Greenberg EM. Violence and the older

adult: the role of the acute care nurse

practitioners. Crit Care Nurs Q. August

1996;19:76–84.

2.	 American Medical Association white

paper on elderly health: report of the

Council on Scientific Affairs. Arch

Intern Med. 1990;150:2459–72.

MEDLINE.

3.	 Council on Scientific Affairs. Elder

abuse and neglect. JAMA.

1987;257:966–71. MEDLINE.

4.	 Weiler K, Buckwalter KC. Abuse

among rural mentally ill. J Psychosoc

Nurs Ment Health Serv. 1992;30:32–6.

5.	 Program Resources Department,

American Association of Retired

Persons (AARP) and Administration on

Aging (AoA), U.S. Department of

Health and Human Services. A Profile

of Older Americans. Washington, DC:

American Association of Retired

Persons; 1993.

6.	 Schor JD, Selby A, Bertone CA.

Geriatric assessment in the diagnosis

and treatment of elder abuse. NJ

Medicine. 1995;92(2)108–10.

7.	 Lett JE. Abuse of the elderly. J Florida

Med Assoc. 1995;82(10):675–78.

The Autopsy and the

Living

A62-year-old white woman was

found dead in her bed one

morning. She had gone to bed

the night before complaining of a

headache. Her medical history

included hypertension, mild obesity,

and recent headaches; otherwise, her

health had been good. A complete

autopsy was requested by her family

and physician.

Autopsy Findings

The autopsy showed diffuse

subarachnoid hemorrhage caused by a

ruptured berry aneurysm of the middle

cerebral artery. Her heart weight was

increased to 500 g, the left ventricular

wall thickness was increased to 2.0 cm,

and both kidneys showed granular

surfaces consistent with nephrosclerosis.

Microscopic examination of sections of

the heart showed hypertrophic myocytes

and enlarged barrel-shaped nuclei; the

kidneys showed scarred glomerular tufts

typical of nephrosclerosis. All of these

findings are typical in patients with a

history of hypertension.

A 1.5-cm nodule in the left breast

was an incidental finding. Histologic

analysis of sections showed the tumor to

be an invasive ductal carcinoma.

Based on these findings, the

cause-of-death statement was prepared

as follows:

Part 1.

A. Subarachnoid hemorrhage

Due to or as a consequence of:

B. Ruptured berry aneurysm of the

middle cerebral artery

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Systemic hypertension

Comment

The majority of nontraumatic

subarachnoid hemorrhages occur

sporadically, but a large proportion are

associated with hypertension. Heart

disease is the leading cause of death in

the United States, and hypertension is

one of the most prevalent

contributors (1,2). The autopsy provided

good clinicopathologic correlation

between the decedent’s history of recent

headaches and hypertension and the

anatomic findings of berry aneurysm,

subarachnoid hemorrhage, cardiomegaly

with left ventricular hypertrophy, and

nephrosclerosis. The cause-of-death

statement was prepared as shown, with

hypertension listed in Part 2, because

the berry aneurysm probably existed

independently of hypertension but was

probably predisposed to rupture because

of the existence of hypertension. The

breast carcinoma was not reported in the

cause-of-death statement because it did

not cause or contribute to death.

Carcinoma of the breast may be

familial or hereditary. Research has

shown that a family history of breast

cancer is an important risk factor for

development of carcinoma of the

breast (3–5). The term familial breast

cancer is used to describe the

appearance within a family of multiple

cases of breast cancer (4). Many breast

cancers are now known to be associated

with specific genes, notably BRCA1 and

BRCA2, and some are known to be

inherited by autosomal dominant

transmission (4,5). Therefore, the

diagnosis of breast cancer is important

not only to the patient with the disease

but perhaps to family members as well.

In this case, the decedent had three

sisters, two daughters, and one son. The

diagnosis of breast carcinoma in the

decedent should result in specific

communication of the diagnosis to

family members so that appropriate

follow-up measures may be taken.

Above some autopsy room entrance

doors is the Latin phrase hic locus est

ubi mors gaudet succure vitae (this is

the place where death delights to serve

the living). Indeed, the autopsy does

serve the living, especially when

diseases are detected at autopsy that may

be inherited or familial. In addition to the

breast cancer discussed in this case, other

common examples encountered at autopsy

include hypertrophic cardiomyopathy;

serum lipid disorders; inborn errors of

metabolism, such as medium chain

acyl-coenzyme A dehydrogenase

deficiency; and hereditary

hemochromatosis, to name just a few.

Informing the family that such conditions

have been detected at autopsy can literally

be lifesaving since appropriate diagnostic

tests and follow-up may then be initiated.

For example, we have seen a case of

medium chain acyl-coenzyme A

dehydrogenase deficiency (first diagnosed

at autopsy) that caused the unexpected

death of a child. The deceased’s two

siblings were then tested; both were found
to have the condition and were then

treated. As more genetic, familial, or

hereditary conditions are being

elucidated, failure to detect these

conditions at autopsy is a concern

among pathologists because of potential

ramifications for family members. Also

of concern, however, is the fact that

necessary tests may not be readily

available and the costs of these tests

may be very high. Lack of

reimbursement for autopsy-related

procedures compounds the problem in

today’s atmosphere of medical cost

containment. Basically, a pathologist

may wish to perform specific tests but

may not have the necessary laboratory

facility or funds available. This is a

particular problem outside of academic

teaching hospitals and when death

investigations are funded by government

agencies, as commonly occurs with the

medical examiner and coroner systems.

Despite its ‘‘low-tech’’ nature, the

autopsy remains valuable as a quality

assurance measure in medical practice

and as a tool in preventive

medicine (6,7). The autopsy’s role in

medicolegal death investigations

performed by medical examiners and

coroners benefits society in many ways

related to law enforcement, criminal

justice, and public health. The old Latin

phrase has probably never been more

true; death, through the autopsy, does

delight to serve the living.

NOTE: Volume 159, November 8, 1999. Kim A.

Collins, M.D.; Allan T. Bennett, M.D.; Medical

University of South Carolina, Charleston; Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

References

1.	 Kannel WB. Blood pressure as a

cardiovascular risk factor: prevention

and treatment. JAMA.

1996;275:1571–76. MEDLINE.

2.	 Cohn JN. The management of chronic

heart failure. N Engl J Med.

1996;335:490–98. MEDLINE.

3.	 Lynch HT, Lynch J, Conway T, et al.

Hereditary breast cancer and family

cancer syndromes. World J Surg.

1994;18:21–31. MEDLINE.

4.	 Radford DM, Zehnbauer I. Inherited

breast cancer. Surg Clin North Am.

1996;76:205–20. MEDLINE.

5.	 Bertwistle D, Ashworth A. Functions of

the BRCA1 and BRCA2 genes. Curr

Opin Genet Dev. 1998;8:14–20.

MEDLINE.

6.	 Lundberg GD. Low-tech autopsies in

the era of high-tech medicine:

continued value for quality assurance

and patient safety. JAMA.

1998;280:1273–74. MEDLINE

7.	 Burton EC, Troxclair DA, Newman

WP. Autopsy diagnoses of malignant

neoplasms: how often are clinical

diagnoses incorrect? JAMA.

1998;280:1245–48. MEDLINE.

Pathologic Findings in

a Transplant Donor

A43-year old white man was

admitted to the hospital with a

one-year history of severe

headache, extraocular muscle paresis,

upper airway obstruction, and blindness.

Eight years previously, a nonfunctioning

pituitary adenoma was diagnosed and

the patient underwent two

transsphenoidal resections and radiation

therapy for recurrent tumor. Eight

months prior to admission, the patient

underwent an attempted third

transsphenoidal resection for recurrent

headache, followed one month later by

an attempted resection via an open

craniotomy. Postoperatively, the patient

lost all vision; steroid therapy failed to

restore his sight. A magnetic resonance

image scan showed a large pituitary

tumor extending into the paranasal

sinuses. During the patient’s final

admission, endoscopic resection was

again attempted. The procedure was

complicated by intraoperative bilateral

internal carotid artery compression,

which occurred during attempts to lift

and remove the interposing tumor mass.

Subarachnoid hemorrhage and

bihemispheric stroke also developed.

Life support measures were withdrawn

the following day and the patient died,

after which the next of kin donated the

heart for transplantation and the liver for

research.

Series 3, No. 32 [ Page 7

Autopsy Findings

Postmortem examination confirmed

the diagnosis of bilateral internal carotid

artery occlusion caused by mechanical

compression by the partially extricated

tumor mass. Extensive subarachnoid

hemorrhage was also confirmed. Marked

cerebral edema with cerebral uncal and

cerebellar tonsillar herniation were also

present. Microscopic and ultrastructural

examination of the partially calcified

sellar tumor revealed high-grade

fibrosarcoma extending into the nose.

The tumor demonstrated multiple foci of

necrosis and focally brisk mitotic

activity, with an MIB-1 proliferative

index of greater than 50 percent. No

residual pituitary adenoma was

identified. The optic and oculomotor

nerves showed marked atrophy and

fibrotic encasement. Microscopic

examination of the lungs showed a

single, small, noncaseating granuloma

but no metastatic tumor. No metastatic

tumor was identified within the

gastrointestinal tract, spleen, adrenal

glands, kidneys, or bone marrow.

Based on the findings, a cause-ofdeath statement was prepared as follows:

Part 1.

A. Intraoperative bilateral internal

carotid artery compression/occlusion

Due to or as a consequence of:

B. Attempted resection of pituitary

tumor

Due to or as a consequence of:

C. Pituitary sarcoma

Due to or as a consequence of:

D. Radiation therapy of a previous

pituitary adenoma

Part 2. Other significant conditions:

Comment

Sarcoma of the sella turcica is a

rare but recognized type of malignant

neoplasm that occurs in virtually all

reported cases after therapeutic radiation

to a preexisting adenoma or craniopharyngioma (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

and cause optic nerve compression, as

occurred in this patient. The autopsy

procedure enabled the medical staff to

detect this clinically unsuspected tumor

that led to the complications described.

Performance of an autopsy was

valuable in this case for several reasons.

The transplant surgeons who

transplanted the heart were alerted to the

existence of the sarcoma and the

possible risks of incipient cardiac

metastasis and/or granulomatous

infection, illustrating the value of

performing an autopsy on organ donors.

Although the timing of organ

transplantations is such that organs are

transplanted before the availability of

autopsy results, the autopsy does

provide information that is useful for the

follow-up of the transplant recipient.

When tissues other than whole organs

are donated for transplantation (bone,

skin, etc.), they may often be stored and

transplantation delayed until the autopsy

results are available.

The autopsy also revealed a

clinically unsuspected diagnosis, raising

awareness among medical staff of a rare

but known neoplastic complication of

radiation therapy. The autopsy also

provided the physicians and family with

an explanation for the patient’s

blindness and for the failure of steroid

therapy. Finally, the demonstration at

autopsy of a malignant tumor invading

the base of the skull was useful in

elucidating that the patient had a grim

prognosis, a rare and serious malignant

neoplasm, and that the complications

related to surgery would not be

unexpected in the setting of extensive

invasive tumor. These findings were

helpful in consoling the family and

alleviating concerns of malpractice and

wrongful death.

Finally, the pathologist may obtain

useful information from the organ

procurement and transplantation team.

Extensive serologic and laboratory testing

is performed on donor specimens,

including tests that evaluate the possibility

of human immunodeficiency virus and

viral hepatic infections. The results of

such tests are usually reported to the

pathologist, who may not have performed

these tests as part of the autopsy

procedure. The results may be useful in

interpreting autopsy findings and in

assessing risks of performing the autopsy.

NOTE: Volume 159, October 11, 1999. Linda M.

Dallasta, M.D., Ph.D.; Julio Martinez, M.D.; Larry

Nichols, M.D., University of Pittsburgh Medical

Center, Pittsburgh, PA; Randy Hanzlick, M.D.,

Emory University School of Medicine, Atlanta,

GA; and the Autopsy Committee of the College of

American Pathologists.

References

1.	 Powell H, Marshall L, Ignelzi R.

Postirradiation pituitary sarcoma. Acta

Neuropathol (Berl). 1977;39:165–7.

MEDLINE.

History Repeats Itself

(Sometimes)

A28-year-old man was ‘‘punished

with the rope’’ (hanged) for

criminal acts. His body was then

transferred to a local physician for

postmortem study, with emphasis on

examination of the brain, ostensibly to

search for possible reasons for the

deceased’s prior criminal behavior.

Autopsy Findings

Specific postmortem findings are

not available because the report cannot

be located. However, based on the

circumstances, a cause-of-death

statement could be completed as

follows:

Part 1.

A. Hanging

Due to or as a consequence of:

B. Judicial Execution

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Comment

The events described occurred in

1656 and were portrayed in a painting

by Rembrandt titled The Anatomy

Lesson of Dr. Joan Deyman (1).
 

Dr. Deyman was praelector at the
 

Surgeon’s Guild and was also inspector
 

of the Amsterdam medical colleges. The
 

painting showed Dr. Deyman, a group
 

of students, and a cadaver with the
 

calvaria removed and the brain exposed.
 

A more specific cause-of-death

statement cannot be completed with

reasonable certainty because it is

unknown whether the man’s death

actually resulted from asphyxia caused

by neck compression or as a result of

the hangman’s fracture, involving a

fracture of the odontoid process (2). We

also do not know how accurately causes

of death were recorded in Amsterdam at

that time; we do know that registers of

death were maintained in London in the

early 1600s. As judged by later records

in London, however, when the causes of

death were recorded, they did not

always appear in a format that would be

acceptable by today’s standards. For

example, records from the mid-1800s

include such causes of death as ‘‘The

King’s Evil’’ and ‘‘decay of nature’’

along with other, more recognizable

causes of death, such as cholera (3).

Even half a millennium ago

postmortem examination was

appreciated for its educational value;

history repeats itself today in this sense.

Although postmortem examination may

have proceeded largely as an

educational anatomy exercise in Dr.

Deyman’s case, Dr. Deyman was

compensated for the specific services he

rendered. He reportedly was paid 6

silver spoons (valued at 31 guilders and

19 stuyvers) (1). Today, most academic

medical institutions do not pay

case-specific professional fees for

postmortem examination. The Health

Care Financing Administration (HCFA)

provides some financial support for

autopsy services; Part A payments to

medical institutions are made in the

same manner that HCFA supports other

hospital services, such as food and

laundry. No Part B professional payment

is made to the professional staff on a

specific fee-for-service basis, however.

Furthermore, the formula for Part A

payments does not take into account the

number of autopsies performed or their

usefulness within the institution. The

rationale of HCFA has been that autopsy
Series 3, No. 32 [ Page 9

services do not provide useful

information for treating patients and

therefore do not require compensation.

However, autopsy findings can have a

positive impact on subsequent patients.

To cite just a few examples, autopsy can

aid in the detection of nosocomial

infection outbreaks, determine drug

sensitivities of fatal hospital-acquired

infections, or detect pharmaceutical

problems, such as mislabeled or

defective products. Autopsy findings

could be used to assess the accuracy of

diagnostic related groups, which form

the basis of payment for medical care.

To date, HCFA has not done this, as far

as we know.

Autopsies have been done in one

way or another since before the time of

Christ. Evidence of knowledge about

internal anatomy is clear from Egyptian

archeological specimens; however, it is

not really known whether organ removal

was done for any purpose other than

preservation before sometime between

350 and 200 BC in Alexandria, where

anatomy and pathology were reportedly

taught (4). The word autopsy derives

from the Greek autopsia, which means

‘‘seeing with one’s own eyes.’’

Autopsies were performed in Greece as

early as the fifth century BC and were

more formally used by Galen in Greece

in the second century. Historical sources

also acknowledge the use of the autopsy

into the Middle Ages, although

autopsies were performed more often for

religious reasons (to identify suicide, for

example, which was taboo) than for

scientific ones (4,5).

Before the anatomy lesson of Dr.

Deyman was depicted in 1656, autopsies

had been performed in the New World.

Autopsies were performed on Siamese

twins in Hispaniola in 1553; near the

area of the current Maine/Canadian

border in 1605 to determine why French

explorers were dying (of scurvy,

apparently); and in Hartford, Conn., in

1662 to assess whether an 8-year-old

had died of witchcraft (4,6).

It was not until the 18th century

that autopsy was used more like it is

today with an emphasis on the science

of pathology. In 1769, Morgagni

published The Seats and Causes of

Diseases Investigated by Anatomy,

which correlated autopsy findings with

the clinical aspects of diseases, laying

the basis for the field of pathology. In

1858, Virchow introduced the cellular

aspects of pathology and disease in his

work Cellular Pathology. Other

autopsy-based publications appeared in

the intervening years (4).

Several symposia on the history of

the autopsy have been published since

1965 (7–10). The most recent of these

includes a table of more than 80 disease

entities that have been ‘‘discovered or

critically clarified through the autopsy’’

since 1950 (11). More recently, autopsy

has played a critical role in identifying

the Hantavirus pulmonary syndrome,

pathologic conditions associated with

human immunodeficiency virus

infection, and emerging infectious and

environmental conditions (12).

The autopsy has benefitted society

for thousands of years and continues to

do so. It has not outlived its usefulness.

The nature of the questions to be

addressed by postmortem examination

have changed over the years, but the

ability of the autopsy to address many

of them has not. New diseases will

continue to emerge. The need will

probably always exist to evaluate

diagnostic and therapeutic effectiveness

and disease patterns on an ongoing basis

for quality improvement purposes.

There is little doubt that the autopsy

will continue to be among those medical

procedures that define significant

historical landmarks in the science and

art of medicine.

NOTE: Volume 159, September 13, 1999. Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; Grover M. Hutchins,

M.D., The Johns Hopkins Medical Institutions,

Baltimore, MD; and the Autopsy Committee of the

College of American Pathologists.

References

1.	 Southgate MT. The Anatomy Lesson of

Dr. Joan Deyman. JAMA.

1997;278:530.

2.	 Spitz WU. Asphyxia. In: Spitz WU, ed.

Spitz and Fisher’s Medicolegal

Investigation of Death: Guidelines for

the Application of Pathology to Crime

Investigations. 3rd ed. Springfield, IL:

Charles C. Thomas Publisher;

1993:449.

3. British Office of National Statistics.

Death Counts [videotape]. London,

England: Health Education Video Unit

of the Leicester Royal Infirmary NHS

Trust; 1996.

4. Iserson KV. Death to Dust: What

Happens to Dead Bodies? Tucson, AZ:

Galen Press; 1994:115–7.

5.	 Fisher R, Platt M. History of forensic

pathology and related laboratory

sciences. In: Spitz WU, ed. Spitz and

Fisher’s Medicolegal Investigation of

Death: Guidelines for the Application

of Pathology to Crime Investigations.

3rd ed. Springfield, IL: Charles C.

Thomas Publisher; 1993:3–4.

6.	 Flanagin A. The first postmortem

recorded in the country. JAMA.

1993;270:1891.

7.	 Symposium on the autopsy [multiple

articles and authors]. JAMA.

1965;193:805–14.

8.	 The autopsy: a beginning, not an end

[multiple articles and authors]. Am J

Clinical Pathol. 1978;69(suppl):215–65.

9.	 The autopsy: revitalizing the ultimate

medical consultation [multiple articles

and authors]. Arch Pathol Lab Med.

1984;108:437–523. MEDLINE.

10.	 College of American Pathologists

Conference XXIX. Restructuring

autopsy practice for health care reform

[multiple articles and authors]. Arch

Pathol Lab Med. 1996;120:700–85.

11. Hill RB, Anderson RE. The recent

history of the autopsy. Arch Pathol Lab

Med. 1996;120:702–12. MEDLINE.

12.	 Nolte K, Simpson GL, Parrish RG.

Emerging infectious diseases and the

forensic pathologist: the New Mexico

model. Arch Pathol Lab Med.

1996;120:125–8. MEDLINE.

Incidental and

Not-So-Incidental

Findings

A63-year-old Hispanic man was a

moderate alcohol consumer with

a 50 pack per year history of

cigarette smoking. After the onset of

acute nonradiating chest pain, he was

taken to the emergency department,

where his chest pain continued and he

became restless and cyanotic. Cardiac

arrest occurred within 15 minutes, and

resuscitative attempts were unsuccessful.

The emergency department physicians

requested an autopsy to determine the
Page 10 [ Series 3, No. 32

cause-of-death, which they suspected

was a ruptured aortic aneurysm.

A review of the patient’s medical

history in preparation for the autopsy

showed a hospital admission 5 months

earlier for substernal chest pain with

radiation to the neck and shoulders.

The pain resolved, and an

electrocardiogram showed normal

sinus rhythm and a normal axis. Neither

the electrocardiogram nor the cardiac

enzyme levels showed evidence of

myocardial infarction, and the findings

of a dipyridamole stress test were

interpreted as normal, without evidence

of significant coronary artery disease.

Autopsy Findings

Autopsy disclosed diffuse

three-vessel coronary atherosclerosis

with almost complete stenosis of the left

anterior descending coronary artery. No

thrombi were seen; the heart weighed

430 g; and the left ventricle showed

concentric hypertrophy. Microscopically,

there was moderate perivascular and

interstitial myocardial fibrosis, consistent

with chronic ischemia, but no acute

infarction was identified. The lungs

were normal except for a single focus of

pulmonary capillary hemangiomatosis

within the right lower lobe,

characterized by proliferation of small

capillaries in alveolar septal walls and

interstitium, along with proliferating

capillaries within small pulmonary

veins. The capillary lining consisted of

uniform, small, flat to cuboidal

endothelial cells without atypia. No

aortic aneurysms were found, but the

aorta and major arteries showed

atherosclerosis of moderate degree.

Based on these findings, a cause-ofdeath statement was prepared as follows:

Part 1.

A. Atherosclerotic cardiovascular

disease

Due to or as consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Comment

Although the patient’s symptoms

suggested coronary artery disease, the

electrocardiogram, cardiac enzyme

levels, and dipyridamole stress test

results did not provide evidence of

coronary artery or heart disease. Death

in this case serves as a sobering

reminder of the limitations of some

methods in detecting serious and

life-threatening cardiovascular disease.

Normal dipyridamole stress test results

do not necessarily exclude the presence

of significant coronary artery disease.

After infusion of dipyridamole,

adenosine concentration increases and

has a potent vasodilatation effect that,

although having little impact on

coronary arteries that show more than

75 percent stenosis, may increase blood

flow in normal coronary arteries three to

five times baseline levels (1). Even in

the face of significant coronary

atherosclerosis, however, dipyridamole

infusion may cause considerable

increase in blood flow to the

myocardium supplied by nondiseased or

lesser-diseased coronary arteries, and

radionucleotide imaging can identify

such areas of increased perfusion (1). As

may have occurred in this case,

false-negative dipyridamole test results

may occur in patients with global

coronary artery disease, because there

will not be heterogeneity of regional

myocardial blood flow and the results

may appear to be normal (1). The

dipyridamole stress test has a reported

sensitivity of 86 percent and a

specificity of 71 percent in predicting

the presence of coronary artery disease,

but results may vary on the basis of

several factors, including the type of

radionucleotide imaging agent

used (2,3).

Also, in this case, the autopsy

disclosed the rare finding of localized

pulmonary capillary hemangiomatosis,

which is characterized by a proliferation

of small capillaries within peribronchial,

perivascular, septal, and subpleural

regions of the lungs. Most of the 23

cases reported in the literature showed

diffuse involvement throughout both

lungs (4–7). The condition may be

misdiagnosed as pulmonary

veno-occlusive disease during life and

may not be correctly diagnosed until

autopsy (8). It causes symptoms and

signs such as pulmonary hypertension,

hemoptysis, and right-sided heart failure,

and is usually progressive, with most

cases resulting in death (7). Treatment

includes pneumonectomy with

heart-lung transplantation, and one case

showed favorable results with interferon

alfa-2a (8,9). In the case reported herein,

the lesion was unusual because it was

focal, the decedent was apparently

asymptomatic, and the finding was

basically an incidental one.

Nevertheless, this case shows how

autopsies may provide ‘‘incidental’’

information that may be useful in

studying and learning about the natural

history of some conditions or in

studying what might be an early stage

or forme fruste of a particular disease

entity. For example, a ‘‘pleural ball’’

was described in one case in which the

ball was attached to the lung by two

fibrous bands, possibly providing an

explanation for how pleural balls may

first form and then break loose to occur

as free bodies in the pleural cavity (10).

The autopsy was valuable in this

case for several reasons. It clarified the

cause-of-death for death certification

purposes, provided possible explanations

for why diagnostic tests during life did

not detect the fatal condition, disclosed

an unusual incidental finding of some

academic interest, and provided

information with a firm foundation for

explaining more fully to the family the

patient’s clinical course and

cause-of-death. The autopsy provided

both incidental and not-so-incidental,

very relevant information and

exemplifies why the autopsy remains the

‘‘gold standard’’ in determining causes

of death, clarifying clinical issues, and

resolving enigmas.

NOTE: Volume 159, August 9/23, 1999. Dean M.

Havlik, M.D., University of New Mexico School

of Medicine, Albuquerque; Wilbur L. Williams,

M.D., University of New Mexico School of

Medicine and Albuquerque Veterans Affairs

Medical Center; Randy Hanzlick, M.D., Emory

University School of Medicine, Atlanta, GA; and

the Autopsy Committee of the College of

American Pathologists.
References

1.	 Braunwald E, ed. Braunwold’s Heart

Disease: a Textbook of Cardiovascular

Disease. 3rd ed. Philadelphia, PA: WB

Saunders Co; 1997:288–90.

2.	 Chou TM, Amidon TM. Evaluating

coronary artery disease noninvasively:

which tests for whom? West J Med.

1994;161:173–80. MEDLINE.

3.	 MaHmarian JJ, Verani MS. Myocardial

perfusion imaging during

pharmacological stress testing. Cardiol

Clin. 1994;12:223–45. MEDLINE.

4.	 Al-Fawaz IM, Al Mobaireek KF,

Al-Suhaibani M, Ashour M. Pulmonary

capillary hemangiomatosis: a case

report and review of the literature.

Pediatr Pulmonol. 1995;19:243–8.

MEDLINE.

5.	 Masur Y, Remberger K, Hoefer M.

Pulmonary capillary hemangiomatosis

as a rare cause of pulmonary

hypertension. Pathol Res Pract.

1996;192:290–5. MEDLINE.

6.	 Jing X, Yokoi T, Nakamura Y, et al.

Pulmonary capillary hemangiomatosis:

a unique feature of congestive

vasculopathy associated with

hypertrophic cardiomyopathy. Arch

Pathol Lab Med. 1998;122:94–6.

MEDLINE.

7.	 Humbert M, Maitre S, Capron F, Rain

B, Musset D, Simonneau G. Pulmonary

edema complicating pulmonary

capillary hemangiomatosis. Am J

Respir Crit Care Med.

1998;157:1681–5. MEDLINE

8.	 Faber CN, Yousem SA, Dauber JH,

Griffith BP, Hardesty RL, Paradis IL.

Pulmonary capillary hemangiomatosis:

a report of three cases and a review of

the literature. Am Rev Respir Dis.

1989;140:808–13. MEDLINE.

9.	 White CW, Sondheimer HM, Crouch

EC, Wilson H, Fan LL. Treatment of

pulmonary hemangiomatosis with

recombinant interferon alfa-2a. N Engl

J Med. 1989;320:1197–1200.

MEDLINE.

10.	 Hanzlick R, Zaki S, Ross W. Pleural

pearl: an immature pleural ball? Am J

Forensic Med Pathol. 1988;9:159–60.

MEDLINE.

Outcome Analysis and

Quality Assessment

Awhite male infant was born at 37

weeks’ gestation. Soon after

delivery, hypoplastic left heart

syndrome was diagnosed. A Norwood

procedure was performed (a palliative

procedure with anastomosis of the aorta

to the right ventricle for systemic

circulation and an atrial septectomy

formed to avoid pulmonary venous

hypertension). Reexploration was

required for postoperative bleeding,

which was controlled surgically.

Urosepsis and disseminated intravascular

coagulopathy complicated the clinical

course and the infant died. The surgeons

requested permission for autopsy from

the family so that the surgical procedure

could be reassessed, but the family

declined and stated that the infant had

been ‘‘cut on enough.’’ However, when

the option of a limited autopsy was

discussed, the family consented to a

postmortem examination limited to the

heart and lungs.

Autopsy Findings

Autopsy showed that all suture sites

were intact; there were no sutures that

compromised vessels or other critical

structures, and there were no vascular

thromboses. However, there were

unexpected infarctions of both cardiac

ventricles and infarction and lobular

pneumonia within the right lower lung

lobe.

Based on these findings, a

cause-of-death statement was prepared:

Part 1.

A. Hypoplastic left heart syndrome

Due to or as a consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Biventricular myocardial infarction;

right lower lung infarction and

lobular pneumonia

Series 3, No. 32 [ Page 11

Comment

The cause-of-death statement as

shown is appropriate because the limited

autopsy hampered the ability to fully

evaluate possible factors that caused or

contributed to death. No doubt, the

underlying cause-of-death was

hypoplastic left heart syndrome.

However, the specific nature of the

immediate cause-of-death could not be

fully explained because of the limited

autopsy. The conditions cited in Part 2

certainly played a significant role and

were therefore reported as ‘‘other

significant conditions.’’

Despite its limited nature, the

autopsy showed that the infant’s surgical

procedure was done without obvious

complications, such as breakdown of

anastomosis sites, suturing closed a

coronary artery, or thrombosis of

anastomosed vessels. The pediatric

cardiothoracic surgeons, pediatric

cardiologists, residents, and medical

students involved in the care of the

infant attended the autopsy and were

able to see the outcome of their work

and treatment. They examined their

surgical work and explained their

decision-making processes and

techniques to the pathologists and others

at the autopsy; the pathologist was then

able to demonstrate and explain the

pathological changes to the clinicians.

Based on the autopsy findings, treatment

modalities were discussed, as well as

options available for future patients. The

cardiologists educated all those

attending regarding hypoplastic left

heart syndrome and its clinical findings,

correlating clinical features, and

postmortem results. Pathology residents

gained experience in the dissection of a

pediatric heart as well as an

understanding of the issues related to

the examination of such hearts. Thus,

everyone involved learned more about

hypoplastic left heart syndrome,

acquired useful information about the

course and treatment of the infant, and

broadened the scope of their medical

experience to the extent that it may

affect the care of future patients. These

benefits exemplify the value of outcome

analysis and quality assessment, to
Page 12 [ Series 3, No. 32

which the autopsy contributed much in

this case.

The autopsy findings were

discussed at subsequent conferences,

with additional discussion of treatment

modalities and outcomes. The

conferences were attended not only by

the infant’s clinicians, but also by others

who did not attend the autopsy or had

no direct involvement in the treatment

of this patient. These individuals also

benefitted from the information gathered

from this autopsy and the thorough

review of hypoplastic left heart

syndrome. Patients with hypoplastic left

heart syndrome are at risk for acidosis,

shock, and multiorgan dysfunction

secondary to hypoxia. In complicated

cases, infarctions may occur in various

organs, as in the heart and lungs of this

infant (1).

Finally, the analysis of the facts and

findings was useful in discussions with

the patient’s family, providing them with

peace of mind and a sense of closure.

They were assured that everyone

involved in the antemortem and

postmortem care of the infant had been

thoughtful, diligent, and thorough; that

what could have been done was done;

and that the institution’s staff was

comprehensive, professional, and caring

in the services provided.

As illustrated by this case, the

limited autopsy can be an excellent tool

to help physicians perform quality

assessment and analyze outcomes.

Despite major advances in medical

technology, recent studies validate the

continued contributions of the

autopsy (2–4). When possible, it is

desirable to perform a complete autopsy.

Attitudes and approach can play a major

role in how the results of the autopsy

are used (5–7). The preference for

complete autopsy should be discussed

with families and the possibility of a

limited autopsy should be offered to

them if they do not wish to consent to

the performance of a complete autopsy.

NOTE: Vol 159, July 12, 1999. Allan T. Bennett,

M.D.; Kim A. Collins, M.D., Medical University

of South Carolina, Charleston, SC; Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

References

1.	 Aiello VD, Ho SY, Anderson RH,

Thiene G. Morphologic features of the

hypoplastic left heart syndrome: a

reappraisal. Pediatr Pathol.

1990;10:931–43. MEDLINE.

2.	 Nichols L, Aronica P, Babe C. Are

autopsies obsolete? Am J Clin Pathol.

1998;110:210–8. MEDLINE.

3. Burton EC, Troxclair DA, Newman WP

III. Autopsy diagnoses of malignant

neoplasms: how often are clinical

diagnoses correct? JAMA.

1998;280:1245–8. MEDLINE.

4.	 Kumar P, Taxy J, Angst DB, Mangurten

HH. Autopsies in children: are they still

useful? Arch Pediatr Adolesc Med.

1998;152:558–63. MEDLINE.

5.	 Grunberg SM, Sherrod A, Muellenbach

R, Renshaw M, Zaretsky S, Levine

AM. Analysis of physician attitudes

concerning requests for autopsy. Cancer

Invest. 1994;12:463–8. MEDLINE.

6.	 Wilkes MS, Link RN, Jacobs TA,

Fortin AH, Felix JC. Attitudes of house

officers toward the autopsy. J Gen

Intern Med. 1990;5:122–5. MEDLINE.

7.	 Stolman CJ, Castello F, Yorio M,

Mautone S. Attitudes of pediatricians

and pediatric residents toward obtaining

permission for autopsy. Arch Pediatr

Adolesc Med. 1994;148:843–7.

MEDLINE.

The Rest of the Story

A78-year-old woman with

hypertension presented with a

gangrenous foot that had kept

her from ambulating. During the

surgical closure following above-theknee amputation she developed

precipitous hypotension followed by

cardiopulmonary arrest and death.

The pathology resident on call to

perform autopsies received an

authorization to perform an autopsy that

had been completed by the patient’s

physician and the legal next of kin. In

the area of the form for notation of

restrictions (such as ‘‘autopsy to be

limited to chest and abdomen only’’)

were the words ‘‘please do not disfigure

the face.’’ Because the face is almost

never disfigured during an autopsy

(unless dissection is required in a

forensic autopsy for medicolegal

purposes or special needs have arisen

during a hospital-based autopsy and

permission has been granted by the legal

custodian of the body), the wording

caused the resident to wonder whether

the physician understood and conveyed

to the next of kin the nature of routine

autopsy procedures. A review of other

autopsy authorization forms showed that

similar wording was common, such as

‘‘keep the head intact,’’ ‘‘be gentle,

would like open-casket funeral,’’ ‘‘keep

facial features natural,’’ and ‘‘be careful

to do nice surgical incisions.’’

Shortly thereafter, at an introductory

session about the autopsy for new

internal medicine interns and residents,

the participants were asked to raise their

hands if they had ever received

instruction in medical school about how

an autopsy is performed. Very few

participants raised their hands; fewer

participants had actually seen an autopsy

performed; and even fewer participants

had received any instruction on how to

ask a family member for permission to

perform an autopsy or how to explain

how an autopsy is performed.

The pathology resident and his

supervisor had a discussion in which the

idea was put forth that some (or perhaps

many) clinicians may be reluctant to

request permission to perform an

autopsy because they are uncomfortable

with their lack of knowledge about

autopsy-related issues. If they do not

know how the procedure is performed,

they may not be comfortable addressing

questions that may be asked by the

family members. If the clinician is not

aware of the routine sequence of events,

clinicians may be hesitant to answer

questions about the logistics of autopsy

performance (such as, How long does it

take to perform an autopsy? Will the

autopsy preclude viewing the body at

the funeral home? Will it cost the family

any money if an autopsy is performed?).

Clinicians may unknowingly answer

questions incorrectly or provide

misleading information.

The pathology resident’s supervisor

thought that it might be helpful to

describe some of the basic features of

autopsy performance so that clinicians

who are unaware of specific details may

be better prepared to have discussions

with families. This article includes such

information.
Autopsy Findings

The autopsy showed extensive

bilateral pulmonary thromboemboli that

originated in the lower extremities.

There was no evidence of fat

embolization or adverse reaction to

anesthesia.

Based on autopsy findings, a

cause-of-death statement could be

completed as follows:

Part 1.

A. Bilateral pulmonary

thromboembolism

Due to or as a consequence of:

B. Deep vein thrombosis associated

with immobility

Due to or as a consequence of:

C. Peripheral vascular disease

Part 2. Other significant conditions:

Hypertensive cardiovascular disease

Comment

The autopsy findings in this case

were useful for completing the death

certificate, answering questions that

were posed by the patient’s physician

and family, and ruling out untoward

effects that could potentially have been

directly related to the surgical procedure

or anesthesia. However, another major

value of the autopsy was that it brought

an important issue to light that some

clinicians may not be fully prepared to

explain the autopsy procedure or answer

questions about autopsy performance.

Information about autopsy-related

procedures is provided below in the

form of commonly asked questions with

answers. The comments are related

mainly to autopsies that are performed

in hospitals, with the consent of the next

of kin.

How Does One Ask for

Permission to Perform an

Autopsy?

Guidance on how to request

permission for an autopsy was provided

previously (1). Templates and pocket

cards with specific language have been

provided as a model for adaptation to a

particular practice setting.

How Long Does It Take to

Perform an Autopsy?

The time required depends on the

case. In most cases, the part of the

autopsy dissection in which the organs

are removed and examined

macroscopically requires 2 or 3 hours at

most. Usually, the body will be

available for transport to the funeral

home a few hours after the autopsy is

begun. In efficient settings, the

preparation and examination of

microscopic slides, review of the

medical record, performance and review

of laboratory tests performed as a result

of the autopsy, and preparation of the

final autopsy report may require a week

or less; however, a few weeks is often

required. If there is compliance with the

inspection and accreditation

requirements of the College of American

Pathologists, most cases will be

completed within 30 working days

unless the case is complicated.

Preliminary autopsy results should be

available within 2 to 3 working days.

What Is a Complete Autopsy?

A complete autopsy generally

includes removal and examination of the

brain and the organs of the neck, thorax,

abdomen, and pelvis, with microscopic

sections prepared for major viscera and

other tissues, as required (2). Specific

postmortem laboratory tests are

performed as indicated by the clinical

history and autopsy findings.

What Is a Limited Autopsy?

In a limited autopsy, one or more of

the components of a complete autopsy

are not performed. Limited autopsies are

usually performed because the family

has restricted the extent of the autopsy.

Sometimes, however, the pathologist or

clinician may restrict the extent of

autopsy; this might occur, for example,

in a suspected case of Creutzfeldt-Jakob

disease for which professional

guidelines advise that only the brain be

removed (3,4).

Series 3, No. 32 [ Page 13

What Is Done With the

Organs?

The answer varies with the

institution. In the hospital setting,

especially if there is a pathology

training program, the internal organs

may be retained by the pathology

department. They may be saved

indefinitely for teaching purposes or

they may ultimately be disposed of,

usually by incineration. In some

institutions, the bulk of the organs are

returned to the body cavity (in a plastic

bag) after the necessary samples have

been taken. The latter procedure is

especially common in medicolegal

(forensic) autopsies. In most hospital

settings, however, the organs are

retained. If the organs are retained, the

autopsy authorization form should

clearly indicate that the hospital has the

right to retain, use, and dispose of the

organs in compliance with applicable

laws.

What Parts of the Body Are

Incised?

Typically, only two incisions are

made on the body surfaces. To remove

the brain, an incision is made that

extends from behind one ear across the

top of the head posterior to the vertex

and downward behind the other ear.

This incision is such that when it is

repaired at the funeral home, even in a

bald person, it is not visible when the

body is in the supine position with the

head on a pillow in the casket. The top

of the skull (calvaria) is removed by

sawing circumferentially after the scalp

has been reflected anteriorly and

posteriorly and at an obtuse angle in the

posterior skull to keep the skullcap from

rotating when it is replaced after

removal of the brain. After removal of

the brain and inspection of the inside of

the skull, the skullcap is replaced and

the scalp margins are reapproximated.

The other incision is a Y-shaped incision

that extends from each anterior shoulder

region toward the midline over the

lower sternum, then downward in the

midline toward the pubis. The soft tissue

can then be reflected upward to the

underside of the mandible, which allows

inspection and removal of the soft tissue
Page 14 [ Series 3, No. 32

of the neck, and laterally, which allows

removal of the anterior chest wall in one

piece (sternum and adjacent ribs to the

costochondral junction), making the

organs of the thorax, abdomen, and

pelvis accessible for removal. After the

autopsy, the chest plate is replaced and

the soft tissue flaps are reapproximated.

Usually, the major autopsy incisions are

loosely sewn together; at the funeral

home, the incisions are tightly repaired

with suture and other agents, such as

special glue and sealers. Other incisions

may be made (for example, in the legs

to look for venous thrombi), but such

incisions are not routine and may, in

some institutions, require special

permission depending on the wording in

the autopsy authorization form.

Are Any Other Incisions Made?

In general, effort is made not to

incise areas of the body that are visible

at a viewing of the body at the funeral

home (such as the hands and face).

Whether such incisions are made

depends on how the autopsy

authorization (and its informed consent)

is worded. Without clearly worded

consent for such incisions when needed,

most pathologists would not make

incisions in unusual areas unless specific

permission has been obtained from the

family.

Are the Eyes Removed?

Again, whether the eyes are

removed is based on the needs and the

wording in the autopsy authorization

and informed consent. Many

pathologists require specific

permission from the family for

removal of the eyes. In most hospital

autopsies, the eyes are not routinely

removed for diagnostic purposes. The

corneas or globes may be removed by

an eye bank if the eye bank has

obtained permission from the family

or if other laws permit their removal.

The eyes may be removed as

needed in forensic autopsies performed

under the authority of the medical

examiner or coroner (for example, to

assess the possibility of shaken baby

syndrome).

Is the Spinal Cord Routinely

Removed?

The spinal cord is not routinely

removed, although it is removed

routinely in some institutions. The spinal

cord may be removed in three ways. In

one method, pathologists use a special

spinal cord extractor consisting of a

long rod with a sharp forked blade on

one end, which can be inserted through

the foramen magnum to cut the spinal

roots. The spinal cord can then be

withdrawn through the foramen

magnum. The advantage is that

additional incisions are not required;

however, the extractor should not be

used if subtle changes in the spinal cord

or roots are being evaluated. Another

method is to remove the vertebral

bodies with an anterior approach (after

the organs have been removed) by

sawing through the pedicle of the

vertebral arch, which allows the anterior

spine to be lifted away from the spinal

canal from which the spinal cord may

then be removed. The posterior

approach involves a midline posterior

incision, with reflection of the soft

tissues away from the spinous processes

and posterior vertebral arches, which are

then sawed through, allowing the

posterior portion of the spine to be lifted

away to remove the spinal cord. Either

of the latter two procedures leaves

enough spine and soft tissue in place so

that the body does not distort or

foreshorten.

How Are the Organs Removed?

The brain is removed intact. The

thoracic and abdominal organs may be

removed en masse (in one large block

that may include everything from the

tongue to the anus), in sections (in

which organ systems are removed in

blocks, such as the heart and lungs

together), or individually. The method

chosen depends on the needs of the case

and the pathologist’s preference.

What If There Is a Rush to

Have Funeral Services?

In most instances, the body may be

externally examined, the organs

removed (eviscerated), and the body

prepared for the funeral home within

one to two hours of starting time. This

allows for release of the body promptly,

while the organs may be retained for

later dissection and examination. Such

procedures may be used, for example, if

a death occurs late in the day and the

family does not want to delay transport

of the body to the funeral home until

the following day.

Are Autopsies Performed 24

Hours a Day, 7 Days a Week?

Most pathology departments

perform autopsies during normal

business hours during the week. Thus, if

a death that occurs late in the afternoon,

the autopsy may not be performed until

the following day unless a special

request is made to expedite procedures

as described in the preceding paragraph.

Many pathology departments have staff

on call to perform autopsies on

weekends, but some do not. It is

important to be familiar with the

staffing procedures at the institution

where you work.

Where Is the Autopsy

Performed?

Most hospitals have a morgue and

an autopsy room, and the autopsy is

performed in the hospital. However,

some hospitals do not have autopsy

rooms. In such cases, the body may be

transferred to another location for the

autopsy, such as another hospital or a

funeral home. Physicians should be

familiar with the practice in their

institution so that questions by the

family may be adequately addressed. It

is helpful when autopsies are performed

in the hospital where death occurred so

that the physician’s ability to observe or

review the findings is facilitated.

How Long Are the Organs,

Tissues, and Other Items

Retained?

Unless the organs are specifically

kept for teaching purposes, the dissected

organs are usually disposed of when the

autopsy report has been finalized or

within a short time thereafter.
Series 3, No. 32 [ Page 15

Microscopic slides and the paraffin

blocks from which they are prepared are

usually kept for a number of years and

may be kept indefinitely. Stock tissue or

small pieces of organs and tissues that

are preserved in formalin may be kept

for months or years before they are

disposed. Finalized autopsy reports are

usually kept indefinitely.

What If the Family Members

Want Some or All of the

Specimens?

Technically, the remains of the

deceased belong to the family (legal

next of kin). Thus, the family has a

legal right to the various specimens,

although such requests are rare. Usually,

the wording in the autopsy authorization

either implicitly or explicitly transfers

ownership of the specimens to the

institution or the pathology department.

If specimens are transferred out of the

institution, it is important that such

transfer and storage of body parts or

specimens be done in accordance with

State laws that pertain to the ownership

and storage of anatomical specimens.

Are Implanted Devices

Removed During an Autopsy?

Pacemakers and other implanted

devices (such as orthopedic appliances)

are usually removed, when feasible and

when their presence is known or a

specific request to remove them has

been made. Responsibility for

documentation of the disposition of such

devices usually rests with the physician

(or institution) who implanted the

device. Thus, devices that are removed

may be forwarded to the appropriate

institution or with the body for return to

the family, who may then transfer the

device to the appropriate agency or

institution.

How Are Specimens Used for

Research?

In most hospitals, the autopsy

authorization form specifically states

that organs and tissues removed during

the autopsy may be used by the hospital

for teaching, research, or other purposes.

In general, research on specimens

removed during the autopsy does not

require approval by an institutional

review board, although there are

exceptions. However, the major

determining factor is the specific

language contained in the autopsy

authorization and informed consent. In

the medicolegal (forensic) setting, in

which the family’s permission is not

usually required to perform an autopsy,

the use of organs and tissues is often

restricted to determining the cause and

manner of death, and the procurement of

tissues specifically for research purposes

often requires special permission.

When Is Embalming

Performed?

If the body is embalmed, the

procedure is usually done at the funeral

home after the autopsy has been

performed and the body has been

transported out of the hospital. However,

embalming may be done prior to the

autopsy either inadvertently because the

body was taken to the funeral home

before the autopsy was performed or

intentionally because there is a known

infectious disease that may pose some

risk to the autopsy prosectors. Some

hospitals have embalming equipment

and may routinely embalm bodies prior

to autopsy.

Is There a Cost to the Family?

Most hospitals do not charge a fee

for an autopsy when an autopsy is

performed on a patient who died in the

hospital. However, some hospitals

charge a fee if the autopsy is requested

by the family but the hospital does not

have a particular interest in performing

an autopsy. Other hospitals charge a fee

to perform an autopsy if the deceased

was a patient at the hospital but died

outside the hospital. Because billing

practices for autopsies vary among

institutions, it is important for

physicians at a given institution to know

what those practices are. On occasion,

some funeral homes will charge

additional fees for body preparation

when an autopsy has been performed.

However, this is not common, and some

funeral directors believe it is not

appropriate to levy such additional fees.

The family may be instructed to check

with their funeral director if they are

concerned about possible autopsy-related

fees imposed by the funeral home.

Conclusions

We hope that the information

provided herein will be helpful to

clinicians who request permission to

perform autopsies, explain autopsy

procedures, and answer questions related

to autopsy performance. When needed,

questions may be directed to a

pathologist in the institution where the

autopsy will be performed or to the

funeral director, if questions are related

to body preparation and other aspects of

funeral services (5,6).

NOTE: Volume 159, June 14, 1999. Randy

Hanzlick, M.D.; Mario I. Mosunjac, M.D., Emory

University School of Medicine, Atlanta, GA; and

the Autopsy Committee of the College of

American Pathologists.

References

1.	 Hutchins GM, Hanzlick R, and the

Autopsy Committee of the College of

American Pathologists. Case of the

month. Arch Intern Med.

1998;158:219–20. MEDLINE.

2.	 Hutchins GM, ed, and the Autopsy

Committee of the College of American

Pathologists. Autopsy Performance and

Reporting. Northfield, IL: College of

American Pathologists; 1990.

3.	 Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Case of the month:

familial olivopontocerebellar atrophy.

Arch Intern Med. 1997;157:2557.

MEDLINE.

4.	 Crain B. Safety tips for anatomic

studies of possible Creutzfeldt-Jakob

disease. CAP Today. 1996;10:56.

MEDLINE.

5.	 Mayer RG. Embalming: History,

Theory, and Practice. East Norwalk,

CT: Appleton & Lange; 1990.

6.	 Hanzlick R. Embalming body

preparation, burial, and disinterment: an

overview for forensic pathologists. Am

J Forensic Med Pathol.

1994;15:122–31. MEDLINE.
Page 16 [ Series 3, No. 32

Education of the

Pathologist

A47-year-old man was admitted to

the hospital with complaints of

leg swelling and shortness of

breath. His medical history included

chronic alcohol abuse and diabetes.

Serologic testing indicated hepatitis C

infection. Evaluation also showed

probable cirrhosis and spontaneous

bacterial peritonitis due to cultureproven infection with Escherichia coli.

Antibiotic therapy was administered.

While in the hospital, the patient fell

from his bed and sustained a head injury

on the sixth hospital day. He was

conscious and responsive when

discovered on the floor near his bed, but

within an hour he required intubation

after a sudden deterioration in mental

status. Neuroimaging showed a subdural

hematoma with midline shift. There was

transient clinical improvement, but

fever, increasing leukocytosis, and a

gradual decline in his condition ensued

and he died on hospital day 14.

The patient’s physician obtained

permission for postmortem examination.

The pathology resident who was on duty

became aware that deaths involving

injury are reportable to the medical

examiner, and he reported the death

accordingly because he realized that the

patient’s physician had not notified the

medical examiner. Because permission

for autopsy at the hospital had been

obtained, the medical examiner assumed

jurisdiction of the case for the purpose

of death certification, but permitted the

autopsy to be performed at the hospital.

The death certificate was not completed

by the medical examiner until the

hospital autopsy findings were available

several days after the autopsy.

Autopsy Findings

At autopsy, liver findings were

consistent with hepatitis C infection and

additional autopsy findings included

cirrhosis and resolving peritonitis (the

E. coli infection apparently responded to

antibiotic treatment). There had been

clinical evidence of systemic sepsis

while in the intensive care unit

following the head injury, and multiple

blood cultures at autopsy yielded

Acinetobacter anitratus without

evidence of postmortem contaminants,

supportive of the antemortem diagnosis

of sepsis. There was residual subdural

hematoma over one cerebral hemisphere.

Because of the patient’s accelerated and

continual downhill course after the fall,

the medical examiner concluded that the

head injury was a significant factor in

causing death. Thus, a cause-of-death

statement could be prepared as follows:

Part 1.

A. Acinetobacter anitratus sepsis

Due to or as a consequence of:

B. Complications of subdural

hematoma

Due to or as a consequence of:

C. Blunt force head injury sustained in

fall from bed

Part 2. Other significant conditions:

Alcohoholic cirrhosis, hepatitis C

infection

Comment

The conditions in Part 2 were

reported because the cirrhosis and

hepatitis C infection were ongoing and

coagulation disturbance related to liver

disease was thought to have predisposed

the patient to subdural hematoma

following head injury. Listing these

conditions in Part 2 is appropriate

because the conditions did not, in and of

themselves, result in the fall, which may

well have been an independent event

that could have occurred if cirrhosis and

peritonitis had not existed.

The attribution of death to a fall in

the hospital may raise the concern that

the cause-of-death statement puts the

hospital at potential risk for some legal

action, but the cause-of-death as stated

is the truth to the best of the certifier’s

knowledge and the truth should not be

skirted for fear of litigation.

The pathology resident learned

much from the performance of this

autopsy. He learned about correlating

autopsy findings with the clinical history

and practical approaches to formulating

opinions about the relative contribution

of injury and disease in causing death.

He also learned more about the

importance of reporting appropriate

deaths to the medical examiner, and also

gained additional experience with the

practical aspects of performing the

autopsy and preparing the autopsy

report. Adequate experience at autopsy

performance and reporting are critical

for the pathology resident to become

competent and proficient at autopsy

performance prior to finishing

pathology residency training and

entering independent practice. In

recognition of this need, the American

Board of Pathology requires a resident

to perform a minimum of 50 autopsies

as part of the qualifications to take the

board examination in anatomic

pathology (1).

Shortly after this case, the autopsy

training director was contacted by the

pathology training program

administrator, who asked if some

adjustments could be made to allow

pathology residents in their last year

of training to spend additional time on

the autopsy service. The reason was

that residents needed additional

autopsy experience to qualify for the

board examination, and time was

running short. This problem occurred,

at least in part, because the

institutional autopsy rate had declined

as it has in many other institutions (2).

Autopsy rates have declined in some

training institutions to the point that

the number of autopsies is barely

adequate to provide pathology

residents with the required number of

autopsies. In fact, the required number

of autopsies for board qualification

was 75 a few years ago, but the

number was reduced to 50 because of

insufficient autopsy rates in many

training institutions. It is now

permissible for two pathology

residents to share in the performance

of an autopsy for the purpose of board

qualification, another adjustment

necessitated by low autopsy rates.

Also, the Joint Commission for

Accreditation of Health Care

Organizations and the Residency

Review Committee for internal

medicine residency programs each had

minimum autopsy requirements at one
time. No longer is that the case,

however, and the tail seems to have

‘‘wagged the dog.’’ Rather than

enforcing the requirements, the

requirements were dropped,

presumably because too few

institutions were in compliance. Thus,

autopsy rates are now almost

exclusively dependent on the interest

of clinicians, the institution, or the

patient’s family, and regulations no

longer foster autopsy performance.

Clinicians need to recognize that

performance of an adequate number of

autopsies is not only needed as part of

an intellectually honest institutional

quality assurance and improvement

program, but where pathology training

programs exist, also because there must

be a sufficient number of autopsies to

afford pathologists adequate training and

experience. Even if the pathologist ends

up in a practice where autopsies are

rarely performed, it is still important

that the autopsies that are performed are

performed and reported well. Adequate

exposure to the autopsy during

pathology residency training is required

to ensure such an outcome, and

adequate autopsy rates are an integral

part of the equation.

Internal medicine and surgical

residents would have a suboptimal

training experience if the number of

patients they could evaluate and treat

was severely restricted. The same

applies to pathology residents and the

quality of their training relative to the

number of autopsies they can perform.

Physicians and the public need to

recognize that education of the

pathologist is one of the many benefits

that the autopsy affords to society and

the practice of medicine (3). A

well-trained autopsy pathologist can be

of great value to the clinician and

medical practice by providing complete,

thorough, and accurate documentation

and interpretation of autopsy findings,

which are used in conjunction with the

clinical history.

NOTE: Volume 159, May 10, 1999. Randy

Hanzlick, M.D.; Jesse K. McKenney, M.D., Emory

University School of Medicine, Atlanta, GA; and

the Autopsy Committee of the College of

American Pathologists.

References

1.	 The ABP Examiner. December

1993;15:2.

2.	 Hanzlick R, Baker P, and the Autopsy

Committee of the College of American

Pathologists. Institutional autopsy rates

[Autopsy and Medicine]. Arch Intern

Med. 1998;158:1171–2. MEDLINE.

3.	 Hill RB, Anderson RE. Contributions

of the autopsy to modern medical

science and practice. In: The Autopsy:

Medical Practice and Public Health

Policy. Newton, MA: ButterworthHeinemann; 1988:43–6.

Unavoidable

Outcomes versus

Misadventures

A48-year-old man presented at the

hospital and described a 22.5-kg

weight loss and progressive

difficulty swallowing over the past 6

months. The following day, an

esophageal biopsy showed squamous

cell carcinoma. Radiographic studies

indicated liver metastases. The tumor

was judged to be inoperable and

palliative treatment included placement

of an esophageal endoprosthesis (a

metallic metal mesh tube) and

chemotherapy with fluorouracil and

cisplatin. One week later the patient had

an episode of major hematemesis and

cardiopulmonary arrest that could not be

reversed with resuscitation. It was

apparent that the underlying

cause-of-death was most likely

esophageal squamous cell carcinoma,

but the patient’s physician requested an

autopsy to determine the immediate

cause-of-death and the cause of the

terminal gastrointestinal hemorrhage,

with special interest in evaluating

whether death resulted from a

mechanical complication of the stent or

its placement.

Autopsy Findings

Autopsy showed an ulcerating

tumor mass in the mid-esophagus with

hepatic metastases and local infiltration

Series 3, No. 32 [ Page 17

into the surrounding soft tissues and

substernal soft tissue. An

aortoesophageal fistula existed between

the posterior aortic arch and the anterior

mid-upper esophagus. Two additional

posterior esophageal perforations were

present: one near each end of the stent.

The stent was intact and there was no

evidence that the stent itself had caused

a traumatic perforation of the esophagus.

The thoracic cavity did not contain

blood but the esophagus and stomach

contained copious blood and blood

clots. Microscopic sections of each

perforation site showed extensive tumor

necrosis with multiple areas of tumor

ulceration and an acute inflammatory

infiltrate. Malignant tumor cells were

identified at all levels of the esophagus

that were sampled. The aortic fistula site

showed acute inflammation extending

from the intima through the wall and

into the periadventitial soft tissues and

tumor infiltrate.

Based on these findings, a

cause-of-death statement could be

prepared as follows:

Part 1.

A. Esophageal hemorrhage

Due to or as a consequence of:

B. Aortoesophageal fistula

Due to or as a consequence of:

C. Squamous cell carcinoma of the

esophagus

Part 2. Other significant conditions:

Comment

The autopsy in this case was

valuable for several reasons. First, the

specific reason for the fatal hemorrhage

was identified and the immediate

(esophageal hemorrhage) and

intermediate (aortoesophageal fistula)

causes of death were accurately

determined and reported. Second, it was

determined that the esophageal

perforations were due to tumor necrosis

rather than mechanical perforation

related to the stent or its placement.

Without an autopsy, the hemorrhage

may have been erroneously attributed to
Page 18 [ Series 3, No. 32

a misadventure or product defect

involving the stent or its placement.

Instead, it was established that the

perforation and hemorrhage was an

unavoidable outcome of appropriate

therapy. The information obtained from

autopsy not only disclosed what actually

happened to the patient, but at the same

time, it showed that potential claims of

misadventure and culpability would not

be well-founded. Third, the autopsy

demonstrated that the chemotherapeutic

agents were probably effective in

causing tumor necrosis, but that tumor

necrosis can cause untoward effect such

as the fatal hemorrhage that occurred in

this case.

Although rare, aortoesophageal and

esophagorespiratory fistulas have been

reported in patients after palliative

treatment with metallic stents and

chemotherapy and/or radiotherapy (1).

One retrospective study of 60 patients,

however, did not show an association

between previous chemotherapy and

perforation (2). Another study reported

that the addition of irradiation and

chemotherapy in conjunction with stent

placement resulted in longer

survival (3). Regardless, tumor

lysis/necrosis secondary to

chemotherapy has been reported to

occur as quickly as 38 hours after

administration (with great variability),

but consistent with the 1-week interval

observed in our cases (4,5). It could be

argued that mechanical pressure of the

stent may have accelerated tumor

necrosis by compression of

esophageal/tumor vasculature. If so, the

outcome could still be regarded as an

unavoidable outcome of an appropriate

treatment, and thus, could be considered

a complication of therapy that would not

fall in the domain of the ‘‘therapeutic

misadventure.’’

NOTE: Volume 159, April 12, 1999. Amanda

Davis, M.D.; Angela Fields, M.D., Ph.D.; Charles

Hill, M.D.; Randy Hanzlick, M.D., Emory

University School of Medicine, Atlanta, GA; and

the Autopsy Committee of the College of

American Pathologists.

References

1. Siersema PD, Tan TG, Sutorius FF, et

al. Massive hemorrhage caused by a

perforating Gianturco-Z stent resulting

in an aortoesophageal fistula.

Endoscopy. 1997;29:418–20.

2.	 Raijman I, Siddique I, Lynch P. Does

chemoradiation therapy increase the

incidence of complications with

self-expanding coated stents in the

management of malignant esophageal

stricures? Am J Gastroenterology. 1997;

92:2192–6.

3.	 Ludwig D, Dehne A, Burmester E,

et al. Treatment of unresectable

carcinoma of the esophagus or

the gastroesophageal junction by

mesh stents with or without

radiochemotheray. Int J Oncology.

1998;13:583–8.

4.	 Burton JC. Tumor lysis syndrome in

nonhematopoietic neoplasms. Cancer.

1989;64:738–40.

5.	 Shamseddine AI, Khalil AM, Wehbeh

WH. Acute tumor lysis syndrome with

squamous cell carcinoma of the vulva.

Gynecol Oncol. 1993;51:258–60.

MEDLINE.

Death and Devices

A49-year-old man had a history of

idiopathic cardiomyopathy and

had been receiving

antiarrhythmic medications for the past

several years. He was admitted to the

hospital for evaluation of atrial

fibrillation with a rapid, uncontrolled

ventricular response. Partial ablation of

the atrioventricular node was performed,

and a pacemaker was implanted. He was

discharged from the hospital on the next

day with a stable heart rate of 50 to 60

beats/min. He was found unresponsive

at home 10 days after discharge, and

resuscitative efforts were unsuccessful.

The family, in cooperation with the

decedent’s cardiologist, requested that

an autopsy be performed to determine if

there had been a complication related to

the pacemaker placement or ablation

procedure and if the pacemaker had

malfunctioned.

Autopsy Findings

The results of the autopsy revealed

marked biventricular hypertrophy (heart

weight, 720 g) and moderate-to-severe

dilation of all four cardiac chambers.

The coronary arteries had atherosclerosis

with 80 percent luminal narrowing in the

right artery, 60 percent luminal

narrowing in the left anterior descending

artery, and 25 percent luminal narrowing

in the left circumflex coronary artery.

The ablation site had endocardial

ulceration and underlying hemorrhage.

Histological sections showed myocyte

hypertrophy and mild fibrosis of the

ventricles. The atrioventricular node

region had coagulation necrosis and

granulation tissue consistent with the

recent ablation. The sinoatrial node

appeared normal. As requested by the

family, the pacemaker was released to

an attorney according to established

institutional procedures. The results of

the pacemaker testing were

communicated to the cardiologist and

showed no defects in pacemaker

function.

Based on these findings, the

cause-of-death statement could be

prepared as follows:

Part 1.

A. Dilated cardiomyopathy

Due to or as a consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Coronary artery atherosclerosis

Comment

The family was considering

medicolegal action against the

cardiologist, the electrophysiologist who

performed the atrioventricular node

ablation and pacemaker placement, and

the manufacturer of the pacemaker. The

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

consistent with dilated cardiomyopathy,

along with high-grade stenosis of one

coronary artery. No complications were

identified from the ablation or

pacemaker placement. The autopsy also

allowed the pacemaker to be removed

and submitted for testing. It seems likely

that the autopsy results and pacemaker

testing demonstrated to the family that

medical care for the decedent had been

appropriate, and indications are that no

medicolegal actions are being pursued.

The autopsy may be the only source

of information about implanted medical

devices and the body’s reactions to

them. Such information may be crucial

in understanding the course in individual

patients. An autopsy-based series may

provide a better understanding of

medical device function and

complications for many types of devices

and implanted materials, such as

synthetic grafts. Other medical devices

frequently assessed during autopsy

include catheter, endotracheal,

nasogastric, and feeding tube placement

and the location and status of devices,

such as intravenous filters inserted to

prevent pulmonary embolism.

Pacemaker units and wires can be

evaluated and recovered during the

autopsy for further testing (1). A

transistor radio placed near a pacemaker

may allow detection of an audible click

when the pacemaker discharges,

allowing assessment of pacemaker rate

at the postmortem examination.

Postmortem radiographs may enable

detection of gross breaks in pacemaker

wires, and when wires have been

implanted for long periods, careful

autopsy dissection may be required to

remove the wires from adherent fibrous

tissue without damaging the wires.

Automatic implantable cardioverters

or defibrillators pose a hazard to the

autopsy pathologist (2). Some of these

devices must be inactivated prior to

autopsy to prevent discharge of electric

current and potential electric shock. In

some cases, the wires can be removed

from the power unit or cut close to the

power unit before beginning the autopsy.

The autopsy pathologist appreciates

advance notification that a body

contains implanted or exogenous

material of potential risk, including

radioactive materials, so that appropriate

precautions may be taken. Another

potential risk is the presence of

‘‘implanted’’ material of a different

nature, such as fragments of bombs and

explosives, which are sometimes

encountered during an autopsy and may

cause a serious catastrophe (explosion

and/or injury) if not recognized and

handled correctly (3).

Implanted medical devices, once

removed, may be tested by a local

electrophysiology laboratory or by the

manufacturer. The manufacturer can

probably provide the most thorough

testing, but there is an inherent concern

about possible conflicts of interest.

Ideally, a disinterested independent

testing agency should be used. It may be

necessary, however, to release the device

to an attorney who can arrange for

testing on behalf of the interested party,

especially if medicolegal action seems

imminent. In such cases, it would be

prudent to involve the attorney for the

institution to assure that testing is

thorough and unbiased. Institutions and

pathology departments should have

policies and procedures that address the

release of medical devices to attorneys

or other third parties while protecting

the interests of the institution and

department.

NOTE: Volume 159, January 11, 1999. Peter B.

Baker, M.D., Ohio State University College of

Medicine, Columbus; Randy Hanzlick, M.D.,

Emory University School of Medicine, Atlanta,

GA; and the Autopsy Committee of the College of

American Pathologists.

References

1.	 Wilson CJ. The pathology of cardiac

pacing. In: Silver MD, ed.

Cardiovascular Pathology. New York,

NY: Churchill Livingstone Inc;

1991:1429–64.

2.	 Prahlow JA, Guileyardo JM, Barnard

JJ. The implantable cardioverterdefibrillator: a potential hazard for

autopsy pathologists. Arch Pathol Lab

Med. 1997;121:1076–80. MEDLINE.

3.	 Clark MA. Autopsy guidelines for

explosion fatalities. In: Froede R, ed.

Handbook of Forensic Pathology.

Northfield, IL: College of American

Pathologists; 1990:205–15.

Not-So-Obvious Uses

of the Autopsy

A33-year-old black man was

admitted with second- and

third-degree burns over

50 percent of the total body surface

area. The burns were not considered

life-threatening and were treated with

fluid replacement, debridement, and

silver sulfadiazine. Neither fasciotomies

nor skin grafts were required. The

patient’s condition improved initially but

then deteriorated slowly during a

3-week course. Chest x-ray films

showed increasing bilateral infiltrates

with some focal nodularity, and the

mediastinum was also perceived to be

widened. On the 23rd hospital day, the

patient died. There was no clinical

evidence of local burn wound infection

or systemic sepsis.

Autopsy Findings

The autopsy showed second- and

third-degree burns that were healing.

Minimal bacterial colonization was

identified microscopically. The lungs

were heavy and weighed 750 g (left)

and 800 g (right) and were firm to

palpation, both findings suggestive of

pneumonia. Focal spherical lesions as

large as 15 mm in diameter with

hyperemic rims were identified

throughout the lung parenchyma.

Examination of the mediastinal lymph

nodes showed marked enlargement as

high as 10 cm in some locations. The

spleen and liver were enlarged,

weighing 800 g and 3200 g,

respectively. The results of microscopic

examination of the lungs showed the

spherical lesions to be early fungus

balls. A Gomori methenamine-silver

stain was performed and showed acutely

branching, septate filaments typical of

Aspergillus species. During the

histological staining process, a tissue

specimen known to contain fungal

hyphae and a tissue specimen lacking

fungal elements, both obtained from

previous autopsies, were also stained to

serve as controls for the procedure. In

addition, multiple sections of lymph

nodes, spleen, and liver showed
Page 20 [ Series 3, No. 32

numerous Reed-Sternberg cells with a

typical background milieu of Hodgkin

disease.

Based on the autopsy findings, the

cause-of-death statement was reported as

follows:

Part 1.

A. Aspergillus pneumonia

Due to or as a consequence of:

B. Hodgkin disease

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Thermal burns

Comment

The pathologist prepared the

cause-of-death statement as shown

because she believed that the Aspergillus

pneumonia would probably not have

occurred had the patient not had the

underlying Hodgkin disease, but she

also believed that the stress of the

healing thermal burns probably

contributed to the development of

pneumonia. The thermal burns were

healing with no evidence of significant

local or systemic infection. Because an

injury (burns) was involved, the death

was reported to and certified by the

medical examiner, and the injury-related

information on the death certificate was

also completed specifying how and

when the burns occurred (1).

The autopsy is an excellent mode of

quality control within the hospital

because it may be used to assess the

accuracy of disease diagnosis and the

effectiveness of treatment (2). There are,

however, other uses of the autopsy for

medical education, research, technology,

and other applications that may not be

so obvious (2).

The standard autopsy authorization

form used by hospitals usually allows

the hospital to retain and dispose of

autopsy tissue at its discretion and

includes specific provisions that samples

derived from an autopsy may be used

for the purpose of teaching, diagnosis,

and research. As occurred in conjunction

with this case, tissues or other

specimens from previous autopsies may

be used in the pathological workup of

other cases, including not only autopsy

cases, but also clinical specimens.

Autopsy specimens may serve as

positive or negative controls for special

histological, immunohistochemical, and

immunocytochemical stains. The

autopsy also offers an opportunity to

retain tissues for educational slide sets

for students of histology and pathology.

Tissue from tumors obtained during an

autopsy may be used for special

chromosome and gene studies, to obtain

genetic material for synthesis of biologic

substances, and postmortem serum

samples can be saved for exploration of

serological markers of neoplasia (3–6).

Control specimens are needed in

cytogenetic analysis for procedures, such

as fluorescence in situ hybridization (6),

and these specimens may be obtained

during autopsy. Prospective collection of

selected tissues and the measurement of

environmental toxins may also be

performed in some settings. When

appropriate permission is obtained,

tissues, such as bone and cardiac valves,

can be obtained during autopsy for

transplantation. The autopsy provides an

opportunity for health care profession

trainees to learn procedures, such as

fine-needle aspiration, cytology

preparations, bone marrow aspiration,

and biopsy, and to further refine

knowledge of anatomy and dissection

methods required for surgical and other

invasive procedures. Anatomical variants

and anomalies may be studied, and

clinical imaging techniques may be

correlated with anatomical findings. The

autopsy may also be useful for

surveillance of emerging infectious

diseases (7).

In addition to providing information

about the cause-of-death and nature and

extent of disease, the autopsy has many

not-so-obvious uses that can provide

numerous benefits to the medical

profession and the practice of medicine.

NOTE: Volume 158, December 7/21, 1998. Kim

A. Collins, M.D.; Clay A. Nichols, M.D., Medical

University of South Carolina, Charleston; Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

References

1.	 Hanzlick R, ed. Options for writing

cause-of-death statements by including

injury events, trauma, and fatal

derangements. In: Cause-of-Death

Statements and Certification of Natural

and Unnatural Deaths. Northfield, IL:

College of American Pathologists;

1997:33–48.

2.	 Wilkes MS, Link RN, Jacobs TA,

Fortin AH, Felix JC. Attitudes of house

officers toward the autopsy. J Gen

Intern Med. 1990;5:122–5. MEDLINE.

3. Feldman H, Sanchez A, Morzonov S, et

al. Utilization of autopsy RNA for the

synthesis of the nucleocapsid antigen of

a newly recognized virus associated

with hantavirus pulmonary syndrome.

Virus Res. 1993;30:351–67.

MEDLINE.

4.	 Amedee-Manesme O, Furr HC, Olson

JA. The correlation between liver

vitamin A concentrations in

micro-(needle biopsy) and

macrosamples of human liver

specimens obtained at autopsy. Am J

Clin Nutr. 1984;39:315–9. MEDLINE.

5.	 Suvarna SK, Start RD. Cytodiagnosis

and the autopsy. J Clin Pathol.

1995;48:443–6. MEDLINE.

6.	 Trask BJ. Fluorescence in situ

hybridization: applications in

cytogenetics and gene mapping. Trends

Genet. 1991;7:149–54. MEDLINE.

7.	 Nolte K, Simpson GL, Parrish RG.

Emerging infectious diseases and the

forensic pathologist: the New Mexico

model. Arch Pathol Lab Med.

1996;120:125–8. MEDLINE.

Death and Distraction

A13-year-old black youth was

living in a foster home.

According to the foster mother,

he fell in the tub and sustained an injury

to the right hip. The boy was described

as being sarcastic, belligerent, and a

poor historian during the examination at

the hospital. He also accused the

physician of trying to play with him.

The results of radiography of the right

hip were negative for fracture. His

temperature was 37.6o

C; pulse rate, 82

beats/min; respiration rate, 20/min; and

blood pressure, 110/62 mm Hg. The

examination was not prolonged, and the

boy was sent home with the diagnosis
of a right-hip contusion. Ibuprofen was

prescribed for pain. Two days later at a

follow-up visit, the boy denied any

problems other than some tenderness in

the right hip. The foster mother reported

a productive cough in the child. Again,

he was difficult to examine and had a

nonchalant attitude. Examination

revealed the following: temperature,

38.7o

C; pulse rate, 108 beats/min; and

respiration rate, 24/ min. A complete

blood cell count showed a white blood

cell count of 0.01 109

/L (11.7/mL).

Lungs were described as clear by

auscultation. He was described as in no

acute distress and sent home with a

diagnosis of right-hip strain. Two and a

half days later, he was found dead in

bed. An autopsy was requested by the

coroner, who had been notified of the

death pursuant to State death

investigation statutes.

Autopsy Findings

At autopsy, the right and left lungs

weighed 600 and 520 g, respectively.

Numerous white-tan nodules ranging

from 0.1 to 1.0 cm in greatest

dimension covered the pleural surfaces

of both lungs. Several of the nodules

were surrounded by a hyperemic rim.

Patches of green-gray, fibrinous material

were over the diaphragmatic surfaces of

both lungs. On sectioning, similar

white-tan nodules were present

throughout both lungs, with focal

necrosis. The surrounding pulmonary

parenchyma was dark red and firm. The

process involved the majority of the

lungs. Several similar-appearing nodules

involved both renal cortices. The results

of the remainder of the autopsy,

including the examination of the right

hip, were unremarkable. Microscopic

sections of the lungs showed acute

pneumonia with hemorrhage, segmented

neutrophils, fibrin, necrosis, and

bacterial colonies. Similar findings were

seen in the sections of the kidneys.

Lung cultures were taken and revealed

heavy growth of Staphylococcus aureus.

Based on these findings, the

cause-of-death statement was prepared

as follows:

Part 1.

A. Bilateral Staphylococcus aureus

pneumonia

Due to or as a consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Comment

During the past century, the

epidemiologic, clinical, and pathologic

findings of staphylococcal pneumonia

have been extensively researched and

documented (1–4). This potentially fatal

disease is associated with fever, an

elevated white blood cell count, pleural

involvement, necrosis, and often a blood

culture positive for S aureus (1–4). In

this case, the staphylococcal pneumonia

was florid in both lungs, with severe

pleural involvement, marked necrosis,

and hematologic spread to both kidneys.

The boy had a fever, an increased

respiration rate, an elevated white blood

cell count, and was certainly in

discomfort. The critical diagnosis was not

made probably because the examination

was focused on the hip injury and the

patient was difficult to examine.

Across the country, many children

are in foster homes and temporary living

situations. Interviewing these children

can be extremely difficult due to learned

behavior and coping mechanisms (5,6).

Defensive barriers allow such children

to claim absence of illness and

symptoms (5). When presented with

such cases, the examiner must be

perceptive beyond the usual

interviewing of an adolescent (5).

The autopsy in this case was a

learning experience for several reasons.

First, it allowed excellent clinicopathological correlation between the child’s

presentation and examination and the

autopsy findings of pneumonia. Second,

the autopsy findings emphasized the

challenge of interviewing troubled

adolescents, a growing segment of our

population (6–8), as well as that fatal

outcomes may result when a patient is

Series 3, No. 32 [ Page 21

uncooperative. Third, it reminds us that

it is not uncommon for the deceased to

have been examined by a physician a

few days before death. Usually, the

causes of death in such cases involve an

infectious process that was more

aggressive than was recognized

clinically or cardiovascular causes, such

as coronary artery disease. The former

situation emphasizes the need for

thorough evaluation of patients with

symptoms and signs that are possibly

attributable to infectious causes, and the

latter situation points out that

cardiovascular examination may only

reflect the status of the patient at the

time of examination. Such unexpected

deaths following a recent visit to a

physician frequently result in

consternation and litigious thoughts

among family members and survivors,

but it is important to recognize that a

given death may not have been related

to a medical oversight or error in

clinical judgment.

NOTE: Volume 158, November 9, 1998. Kim A.

Collins, M.D.; C. Jeff Lee, D.O., Medical University

of South Carolina, Charleston; Randy Hanzlick,

M.D., Emory University School of Medicine,

Atlanta, GA; and the Autopsy Committee of the

College of American Pathologists.

References

1.	 Eichwald HF, Shinefield HR. The

problem with staphylococcal infection

in newborn infants. J Pediatr.

1960;56:665–74.

2.	 Huxtable KA, Tucker AS, Wedgwood

RJ. Staphylococcal pneumonia in

childhood. AJDC. 1964;108:262–9.

3. Fang GD, Fine M, Orloff J, et al. New

and emerging etiologies for

community-acquired pneumonia with

implications for therapy. Medicine

(Baltimore). 1990;69:307–16. MEDLINE.

4. Torres A, Serra-Batlles J, Ferrer A, et

al. Severe community-acquired

pneumonia. Am Rev Respir Dis.

1991;144:312–8. MEDLINE.

5.	 Schenck BR. Understanding Teenagers:

Emotional and Social Changes. Halifax:

Virginia Cooperative Extension

Service;1983:1–4. Publication 350–014.

6.	 Phares V, Lum JJ. Family

demographics of clinically referred

children: what we know and what we

need to know. J Abnorm Child Psychol.

1996;24:787–801. MEDLINE.
Page 22 [ Series 3, No. 32

7.	 Hibbs ED. Child and adolescent

disorders: issues for psychosocial

treatment research. J Abnorm Child

Psychol. 1995;23:1–10. MEDLINE.

8.	 Kovacs M, Lohr WD. Research on

psychotherapy with children and

adolescents: an overview of evolving

trends and current issues. J Abnorm

Child Psychol. 1995;23:11–30.

MEDLINE.

Allaying

Apprehension

A39-year-old white man noticed a

rash on his legs 10 days before

death, but he did not seek

medical attention. He also experienced

increasing fatigue. Two days before

death, he went to a primary care

physician with complaints of a sore

throat. At this time, he was diagnosed as

having tonsillitis and pharyngitis and

was sent home with a prescription for

antibiotics. The medical records did not

indicate the presence of a skin rash. On

the day of death, he came into the

emergency room with a fever and

weakness. He quickly became

unresponsive to stimuli. The emergency

department physicians noted lower

extremity petechiae and localizing

neurological signs on the right side.

Approximately 2 hours after presentation,

he was pronounced dead. The patient had

no notable medical history. The family

and emergency department physicians

requested an autopsy to determine the

cause-of-death. The physicians were

justifiably concerned about meningococcal

meningitis and the possibility of infectious

exposure of the staff and community.

Autopsy Findings

The results of an autopsy performed

under isolated conditions revealed a

4.5-cm hemorrhage within the left basal

ganglia that extended into the

surrounding white matter. There were

external petechial hemorrhages on the

head, chest, forearms, and legs.

Internally, petechial hemorrhages were

identified within the lungs and trachea.

Splenomegaly (480 g) was noted. The

tonsils and the cervical and para-aortic

lymph nodes were enlarged and

microscopically showed reactive

lymphoid hyperplasia. A peripheral

smear of antemortem blood showed a

slightly increased white blood cell count

(1.5 109

/L) and decreased platelet

count (5.0 109

/L). A manual differential

blood cell count exhibited 0.03 blasts,

0.87 promyelocytes, 0.03 myelocytes,

and 0.07 lymphocytes. The

promyelocytes were characterized by

large nuclei and cytoplasm that

contained small eosinophilic granules

and multiple fine Auer rods. The results

of bone marrow examination showed

0.10 blasts and 0.50 promyelocytes.

These findings are diagnostic of acute

myelogenous leukemia,

French-American-British class M3

(acute promyelocytic leukemia).

Bacterial and viral cultures of blood,

lungs, and cerebrospinal fluid were

without growth. The results of a latex

agglutination test on cerebrospinal fluid

for Neisseria species were negative.

Based on these findings, the cause-ofdeath statement was prepared as follows:

Part 1.

A. Intracerebral hemorrhage in basal

ganglia

Due to or as a consequence of:

B. Thrombocytopenia

Due to or as a consequence of:

C. Acute myelogenous leukemia

Part 2. Other significant conditions:

Comment

Hematopoietic malignancies are a

recognized but relatively rare cause of

sudden natural death. Patients with acute

promyelocytic leukemia typically have

coagulopathy at presentation with

decreased platelet counts and laboratory

tests suggestive of disseminated

intravascular coagulation. There is a

dramatic increase in the numbers of

promyelocytes and blasts within the

bone marrow that spill over into the

peripheral blood. The classic cytogenetic

finding seen in at least 80 percent of

cases is a balanced translocation

between chromosomes 15 and 17. There

is a high rate of remission when treated

with conventional chemotherapy, but

this therapy often exacerbates the

coagulopathy (1).

Autopsy was important in this case

for several reasons. It alleviated the

emergency department physicians’

concerns about the possibility of

infectious disease and the potential for

infection transmission to close contacts.

Autopsies are extremely helpful in

identifying or excluding infectious

diseases and potential outbreaks. The

information in this case was shared with

the emergency department personnel and

family after the major disease process

was identified, which was on the same

day of death. It is important for an

autopsy pathologist to convey specifics

about a case in a timely manner so the

information can be used effectively.

Procedures, such as frozen sections,

touch preparations of tissues for

histological examination, and blood or

marrow smears, have rapid turnaround

times, are often applicable to the

autopsy, and may enable rapid answers

to questions regarding the death.

This autopsy also revealed an

unsuspected diagnosis. In retrospect, the

patient had classic symptoms of acute

promyelocytic leukemia, but these

symptoms are nonspecific and could also

be seen in many other disease processes.

Probably the most important aspect of this

autopsy, and of most autopsies in general,

is that the family received an explanation

for the sudden demise of their relatively

young relative. This important aspect of

the autopsy in extending the continuum of

care to survivors is sometimes overlooked

in a busy medical practice or medical

institution.

NOTE: Volume 158, October 12, 1998. Dean M.

Havlik, M.D.; Rebecca Irvine, M.D., University of

New Mexico School of Medicine, Albuquerque;

Randy Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy Committee

of the College of American Pathologists.

Reference

1.	 Foucar K. Bone Marrow Pathology.

Chicago, IL: American Society of

Clinical Pathologists Press; 1995.
Making Amends

A60-year-old man was diagnosed

as having recurrent idiopathic

pancreatitis for 3 years. Other

medical history included type 1 diabetes

mellitus, nephrolithiasis that required

lithotripsy, and cholecystitis that

required cholecystectomy. He had

abdominal symptoms that led to

diagnoses of pancreatic abscesses and

peritonitis. Medical management and

surgical drainage led to the culture of

multiple organisms from the

inflammatory process, then systemic

sepsis and coagulopathy developed and

resulted in death. The family initially

declined to have an autopsy performed,

and the cause-of-death statement on the

death certificate was prepared by the

attending physician as follows:

Part 1.

A. Intra-abdominal abscess

Due to or as a consequence of:

B. Peripancreatic abscess

Due to or as a consequence of:

C. Chronic pancreatitis

Part 2. Other significant conditions:

The following day the responsible

family member contacted the clinician

and requested that an autopsy be

performed. The family member was

referred to the autopsy service and

arrangements were made to receive a

facsimile transmission of a signed and

witnessed autopsy permission form

stating the restrictions of autopsy which,

in this case, specified that no

examination of the head or brain was to

be performed.

Autopsy Findings

Autopsy revealed widespread

intra-abdominal abscesses. The head of

the pancreas contained a 3-cm mucinous

cystic neoplasm, which was microscopically proved to be an infiltrating

mucinous cystadenocarcinoma.

Metastatic adenocarcinoma was found in

the lungs, subcarinal and pulmonary

hilar lymph nodes, perirenal soft tissue,

and peripancreatic and periportal lymph

nodes. The pancreas also showed

hemorrhagic cystic spaces consistent

with abscesses and pseudocysts with

hemorrhage. The location and

morphologic characteristics of the tumor

indicated that it had obstructed the

pancreatic duct, which probably

accounted for the pancreatitis and

pseudocyst formation.

Comment

After receiving the results of the

autopsy, the family member contacted

the clinician and requested that the

death certificate be changed. The

clinician agreed to make a change but

did not know the correct process, so he

asked the attending pathologist. The

pathologist pleaded ignorance on the

matter but offered to find out the

appropriate way to change a death

certificate. She consulted available

publications that included generic

information on what is referred to as the

death certificate amendment process

(1,2). She took the advice in the

publications and contacted the State’s

office of vital statistics and learned that

in her jurisdiction, death certificate

amendments within 3 years of the

patient’s death simply require that the

original certifier of death submit a letter

to the vital statistics office requesting

and specifying the desired changes.

Accordingly, a letter was composed

making the request and indicating that

the cause-of-death statement be

amended to read as follows:

Part 1.

A. Sepsis

Due to or as a consequence of:

B. Peritonitis

Due to or as a consequence of:

C. Pancreatic abscess

Due to or as a consequence of:

D. Metastatic cystadomocarcinoma of

the pancreas

Part 2. Other significant conditions:

Series 3, No. 32 [ Page 23

The clinician sent a copy of the

letter to the family and the office of

vital statistics, which made the requested

amendment. Both the family and the

vital statistics system benefitted because

the cause-of-death was accurately

recorded after the amendment.

In this case, the family’s initial

refusal to authorize an autopsy led to

the clinician’s prompt completion of the

death certificate based on information

that was available at the time, which is

the correct procedure to follow. Then,

the unexpected reversal of the family’s

wishes and unexpected autopsy findings

led to the need for death certificate

amendment. In such instances,

knowledge of death certificate correction

procedures is required.

When it is known that an autopsy is

going to be performed and the

cause-of-death is not known prior to

autopsy, it is prudent to delay filing of

the death certificate until the provisional

autopsy findings are available, which is

usually a matter of only a day or two. If

the provisional autopsy findings are

insufficient to complete the death

certificate, a certificate may then be

filed as pending further study. Then,

when the final autopsy report is

completed, a supplemental report must

then be filed with the office of vital

statistics so the death certificate can be

finalized (1).

If a death certificate with a stated

cause-of-death has been filed but is later

discovered to be in error (such as the

case reported herein), the correction

process is referred to as death certificate

amendment.

The regulations for filing

supplemental reports and making

amendments are determined by each

state. The vital statistics office can

provide the specific details and

procedures for the state it serves. It may

be useful for the institution or office to

develop a standard letter or in-house

procedure to file supplemental reports or

make amendments.

Although there was initial

speculation that the family’s request for

a death certificate change may have

been based on their pursuing of a

possible lawsuit for failure to diagnose

the malignant neoplasm, three years

have passed and nothing further has
Page 24 [ Series 3, No. 32

been heard from the family or their

attorneys. Apparently, the concerns were

unwarranted; as is often the case, the

family simply wanted to know what

happened and have the record accurately

reflect the circumstances and details of

death.

Finally, this case shows that the

autopsy may answer many questions

even when a complete autopsy has not

been performed (permission to examine

the head or brain was not granted).

Limited or partial autopsies were the

topic of discussion in an earlier Case of

the Month (3).

NOTE: Volume 158, September 14, 1998. Ann E.

Smith, M.D.; Grover M. Hutchins, M.D., The

Johns Hopkins Medical Institutions, Baltimore,

MD; Randy Hanzlick, M.D., Emory University

School of Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

References

1.	 National Center for Health Statistics.

Physician’s Handbook on Medical

Certification of Death. Hyattsville, MD:

National Center for Health Statistics;

1996. U.S. Dept of Health and Human

Services publication PH97–1108.

2.	 Hanzlick R, ed, and the Autopsy

Committee of the College of American

Pathologists. The Medical

Cause-of-Death Manual: Instructions

for Writing Cause-of-Death Statements

for Deaths Due to Natural Causes.

Northfield, IL: College of American

Pathologists; 1994.

3.	 Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Case of the month. Arch

Intern Med. 1997;157:2557.

MEDLINE.

Addressing the

‘‘Red Herring’’

A53-year-old white woman was

admitted to the hospital with a

3-day history of cough and

dyspnea. Two years previously, a ductal

carcinoma of the breast (already with

widespread metastases) had been

diagnosed. On this admission,

significant arterial hypoxia was noted.

The results of echocardiography showed

right ventricular dilatation. An electron

beam computed tomographic scan was

interpreted as negative for pulmonary

embolism.

Despite the interpretation, the

patient was diagnosed as having

pulmonary thromboembolism and was

given anticoagulant therapy. She died of

progressive respiratory failure 2 weeks

after admission to the hospital.

Autopsy Findings

Right cardiac ventricular dilatation,

chronic passive visceral congestion, and

microscopic metastases in the vertebral

column, liver, and pancreas were

observed during the autopsy. Careful

dissection of the lungs failed to show

either pulmonary thromboembolism or

metastases. The results of microscopic

examination disclosed numerous small

pulmonary arterial and arteriolar lumens

that were occluded by neoplastic

microemboli. In some vessels, fibrin or

platelet thrombi were present with tumor

cells, and some pleural pulmonary

lymphatics contained tumor

(‘‘lymphangiosis carcinomatosa’’).

Based on these findings, a

cause-of-death statement was prepared

as follows:

Part 1.

A. Cor pulmonale

Due to or as a consequence of:

B. Pulmonary arterial carcinomatous

microemboli

Due to or as a consequence of:

C. Metastatic ductal adenocarcinoma

of breast

Part 2. Other significant conditions:

Lymphangiosis carcinomatosa of

lungs and pleura

Comment

The pathologists concluded that

occlusion of the peripheral pulmonary

vasculature led to cor pulmonale and

that respiratory failure was in part

caused by lymphangiosis carcinomatosa.

The results of the autopsy uncovered a

rare (and in this case clinically

unsuspected), but well described entity

of tumor microemboli to the lungs,

which caused pulmonary hypertension,

cor pulmonale, and death (1,2). The

metastatic route to the lungs was

probably via the vertebral metastatic

deposits.

Performance of this autopsy was

valuable because the results showed the

reason for the patient’s failure to

respond to anticoagulant thrombolytic

therapy for suspected pulmonary

thromboembolism. The case was

analyzed for similarities and differences

to previous institutional experience with

the disease entity, and these data were

forwarded to the referring clinicians as

part of the autopsy interpretation. The

postmortem examination provided

information of immediate value in

several respects. First, the patient’s

relatives were able to understand the

extent of tumor and resultant limitations

of possible therapeutic measures.

Second, the physicians obtained an

explanation for the lack of response to

therapy. Third, the imaging analysis

better appreciated the limitations of

imaging technique resolution in the face

of neoplastic pulmonary microembolism.

Fourth, an accurate and complete causeof-death statement could be prepared.

NOTE: Volume 158, January 12, 1998. Eric A.

Pfeifer, M.D., Johannes Bjornsson, M.D., Mayo

Clinic and Foundation, Rochester, MN; Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

References

1.	 Schriner R, Ryu J, Edwards W.

Microscopic pulmonary tumor

microembolism causing subacute cor

pulmonale. Mayo Clin Proc.

1991;66:143–8.

2.	 Shields D, Edwards W. Pulmonary

hypertension attributable to neoplastic

emboli. Cardiovasc Pathol.

1992;1:279–87.
Requesting an

Autopsy

A28-year-old man with

long-standing asthma was

admitted to the hospital in

status asthmaticus. Necessary treatment

modalities included high-dose

methylprednisolone, sedation, and

succinylcholine-induced paralysis for

intubation. Pulmonary infiltrates were

noted on a chest radiograph, and the

patient could not be weaned from

ventilation use. Decreasing

consciousness was observed, and the

results of a computed tomographic scan

of the head showed ring-enhancing

lesions in the right frontal and left

parietal cerebral lobes. After rapid

neurologic decline, the patient died. The

attending physician asked the medical

house officer, who had recently started

her internship, to obtain permission to

perform an autopsy. However, the house

officer had never been taught in medical

school how to request permission to

perform an autopsy, had never seen an

autopsy performed, and was unfamiliar

with the procedures involved, making

her unsure of how to field questions

from family members. The institution

had prepared and distributed to the

house officers a small laminated card

with instructions for obtaining

permission from the legal next of kin to

perform a postmortem examination. The

house officer reviewed the information

on the card and spoke with the

responsible family member, the patient’s

mother. In addition, an informational

brochure on the autopsy was made

available to the mother, similar to one

that has been published (1). The

patient’s mother consented to the

performance of a complete autopsy.

Autopsy Findings

The results of the autopsy showed

disseminated aspergillosis with fungal

brain abscesses, which had formed in

the setting of high-dose

methylprednisolone treatment of asthma.

The pathology house officer wanted to

include a cause-of-death statement in the

autopsy report so the clinician could use

it to accurately complete the death

certificate. However, the house officer,

also beginning his postgraduate work,

had not received formal training in

medical school on how to write a

cause-of-death statement. He was

provided with an instruction manual (2)

and, after reading relevant portions,

discussed the cause-of-death with the

attending pathologist and completed the

cause-of-death statement as follows:

Part 1.

A. Disseminated aspergillosis

Due to or as a consequence of:

B. Steroid therapy

Due to or as a consequence of:

C. Asthma

Part 2. Other significant conditions:

Comment

After the laminated card was

introduced at the institution, the autopsy

rate rose approximately 30 percent

above the previous rate. Obtaining

permission to perform an autopsy

depends, of course, on asking for

permission, and knowledge of how to

ask for permission in a professional and

compassionate way may facilitate the

process. Complete and accurate

completion of the cause-of-death

statement and death certificate has been

compromised because of a lack of

formal teaching of physicians. In

response to that problem, the College of

American Pathologists has produced

several publications with instructions

and examples of how to write

cause-of-death statements (2–4).

The autopsy was valuable in this

case because it established the

immediate cause-of-death (disseminated

aspergillosis) and documented that a

recognized potential complication of a

necessary and accepted medical therapy

(methylprednisolone treatment) had

occurred in this patient. Reporting the

adverse effects of a medical treatment in

the cause-of-death statement does not

necessarily connote inappropriate

therapy or misadventure but simply

explains the sequence of events that

Series 3, No. 32 [ Page 25

caused the patient’s death. For quality

assurance, medical education, and the

advancement of medical knowledge,

complications of therapy as factors

causing or contributing to death may be

as important to document and evaluate

as the underlying disease conditions.

Publications are available for

purchase from the College of American

Pathologists Publications Department,

800-323-4040. The authors have no

financial affiliation with the College of

American Pathologists.

NOTE: Volume 158, February 9, 1998. Grover M.

Hutchins, M.D., The Johns Hopkins Medical

Institutions, Baltimore, M.D.; Randy Hanzlick,

M.D., Emory University School of Medicine,

Atlanta, GA; and the Autopsy Committee of the

College of American Pathologists.

References

1.	 Autopsy Committee of the College of

American Pathologists. Autopsy: Aiding

the Living by Understanding Death.

Northfield, IL: College of American

Pathologists; 1996.

2.	 Hanzlick R, ed, and the Autopsy

Committee of the College of American

Pathologists. The Medical

Cause-of-Death Manual: Instructions

for Writing Cause-of-Death Statements

for Deaths Due to Natural Causes.

Northfield, IL: College of American

Pathologists; 1994.

3.	 Hanzlick R, ed, and the Autopsy

Committee of the College of American

Pathologists. Cause-of-Death

Statements and Certification of Natural

and Unnatural Deaths. Northfield, IL:

College of American Pathologists;

1997.

4.	 Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Practice protocol for

writing cause-of-death statements for

natural causes. Arch Intern Med.

1996;156:2526.
Page 26 [ Series 3, No. 32

PROTOCOL FOR AUTOPSY REQUEST

When a patient dies, determine if the Medical Examiner/Coroner (phone #) must be

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

charged issue. The following information should be communicated to the family:

The person taking responsibility for the body (usually the next of kin) may give

permission for autopsy.

The family is not charged for the autopsy.

The autopsy may confirm the clinical diagnosis or uncover additional contributory

causes for the patient’s death.

The autopsy contributes toward physician education, research, and improved patient care.

An autopsy will not delay the funeral or interfere with viewing of the body.

A packet of forms is available on the wards. Assistance with previous or pending

autopsies (e.g., facilitating the process or arranging a gross review) can be directed to the

Pathologist-on-call. For further information and reports: Autopsy room (phone #),

Pathologist-on-call (phone #), Admitting Office (phone #), Autopsy Pathology Division

Office (phone #).

SAMPLE VERBAL AUTOPSY REQUEST

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

responsibility to inform you that you have the right to have an autopsy performed in order to

be more certain about the cause of death and to learn more about this type of disease.

(If this is unacceptable, a partial autopsy should be recommended, i.e., ‘‘I recommend that

we at least examine the ________.’’) Although it is an expensive procedure, the hospital does

not charge the patient’s account or the family for autopsy examinations.

We are grateful when the family gives consent for an autopsy because the hospital

physicians will be able to learn more about the disease that caused your ____’s death, and

we will be able to evaluate or improve our treatment. An autopsy will not delay the funeral

or interfere with viewing of the body.

As the responsible person, do you want an autopsy (or partial autopsy) to be performed?

If yes, you will need to sign this form (autopsy consent form) and I will explain it to you

before you sign.

OR

If yes, you may give consent by telegram, facsimile, or by phone. Arrangements for this

type of consent may be made with the Admitting Office (phone #) or through the hospital

operator (phone #).

Sample laminated card that may be distributed to house officers or those physicians

who request permission for autopsy performance. The card may be sized to fit in a

pocket and has general information on one side (upper frame) and sample text for

requesting permission on the other side of the card (lower frame). Specific wording

must be designed with institutional needs, policies, and local laws in mind.

‘‘Negative’’ Results of

Autopsy and Elusive

Cause-of-Death

A91-year-old man was a nursing

home resident mainly due to

mild dementia. He died suddenly

after taking his evening meal. The

nursing home staff reported that he had

been in his usual state of health when

he suddenly collapsed; death was

pronounced within minutes of the

collapse. His medical history included

nodular goiter diagnosed 27 years prior

to death, a 6-year history of atrial

fibrillation, and a 4-year history of an

unspecified type of mild dementia. Mild

mitral regurgitation was also noted 2

years before death. Notably absent from

the clinical history was any evidence of

systemic hypertension, ischemic heart

disease, cerebrovascular disease, or

diabetes mellitus.

Autopsy Findings

Atherosclerotic luminal

stenosis (70 percent) was identified in

the distal circumflex branch of the left

coronary artery. Other coronary arteries

had 40 percent to 50 percent maximum

stenosis. Mild floppiness of the mitral

valve was present. The heart weighed

340 g (expected mean, 290 g). No gross

or microscopic evidence of acute or

chronic myocardial ischemia was

identified. Other findings included

nodular goiter, moderate centrilobular

pulmonary emphysema, a diaphragmatic

hernia, moderate aortic atherosclerosis,

and moderate arterial nephrosclerosis.

The brain weighed 1195 g (expected

mean, 1270 g) and appeared slightly

atrophic. Microscopic examination of

the brain revealed mild, nonspecific

neurodegenerative changes, including

scattered neuritic plaques in the

neocortex. Evidence of amyloid

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

Part 1.

A. Sudden witnessed death

Due to or as a consequence of:

B. Presumed cardiac dysrhythmia

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Atherosclerosis, floppy mitral valve,

atrial fibrillation

Comment

The results of the autopsy were

remarkable for the absence of organ

changes specific enough to cite with

reasonable probability a specific single

condition or sequence of conditions that

accounted for death. Coronary stenosis

was of marginal significance, evidence

of acute or chronic myocardial ischemia

was absent, and other vital organs

lacked sufficient changes to explain

death without tenuous assumptions.

Biochemical or toxicologic

derangements may certainly cause death

without corresponding morphologic

changes, but there was no clinical or

postmortem evidence of such

disturbances.

The absence of autopsy findings

sufficient to explain death may pose a

dilemma for the physician completing

the death certificate: this dilemma is not

uncommon when causes of death in the

elderly are at issue (1–3). Because death

certificate data may ultimately be used

for epidemiological purposes, it is

important that death not be attributed to

specific causes that are arbitrarily

selected, speculative, or nonexistent. In

the case presented herein, it is likely

that had autopsy not been performed,

death might have been erroneously

attributed to myocardial infarction or

some other form of ischemic heart

disease. Unfortunately, due to the low

national autopsy rate, especially among

the elderly nursing home population,

erroneous reporting of the

cause-of-death is undoubtedly frequent.

The cause-of-death statement shown

herein states the facts: death appeared to

result from a cardiac dysrhythmia, and

there were other conditions that likely

contributed to death and may have been

the basis of the dysrhythmia, but a

specific cause of the dysrhythmia could

not be determined with reasonable

probability.

Atherosclerosis, floppy mitral valve,

and atrial fibrillation may each be

associated with a fatal cardiac rhythm

disturbance, but fatal rhythm

disturbances may also occur without

these conditions. The word ‘‘presumed’’

was included because the results of an

autopsy cannot confirm the occurrence

of a cardiac rhythm disturbance, which

is a functional rather than anatomical

derangement.

Each of the causes listed in Part 2

will be included and coded in multiple

cause mortality data that are used for

statistical purposes. A user of the

original cause-of-death statement or

death certificate will realize from the

wording and structure of the

cause-of-death statement that a clear cut

cause-of-death was not identified, even

after performing an autopsy. Both

practical and statistical needs were met

by writing the cause-of-death statement

as shown. There is bias in some forms

of mortality data derived from death

certificates as a result of nosologic

coding procedures, but certifiers of

death can avoid confounding the bias by

reporting the cause-of-death as

accurately, specifically, and completely

as possible and, when needed, in

less-specific terms to avoid

overreporting conditions for which there

is little or no basis (5,6).

Definitive proof of a cause-of-death

is not needed to report it on the death

certificate. Adequate evidence may

consist of a cause being more likely

than not. In this case, sufficient

evidence was lacking to cite a specific

condition or sequence of conditions in

Part 1 as being more likely than not, so

the cause-of-death statement was

prepared using nonspecific terminology

in Part 1. In most cases, however, a

specific condition or sequence of

conditions may be stated in Part 1 with

reasonable probability of accuracy based

on the clinical history, available medical

records, and autopsy findings when

needed.

The results of an autopsy do not

always reveal the cause-of-death.

However, the performance of an autopsy

allows better assessment of likely causes

and enables exclusion of many possible

causes. The results of an autopsy also

enable assessment of comorbidity, the

identification of conditions that existed

but were not the cause of the patient’s

death. For research, epidemiological

studies, and elucidation of the courses of

disease and treatments, it may be just as

valuable to know the diagnoses existing

at death (DEAD) as it is to know the

cause-of-death.

NOTE: Volume 158, July 13, 1998. Johannes

Bjornsson, M.D., Mayo Clinic and Foundation,

Rochester, Minn; Randy Hanzlick, M.D., Emory

University School of Medicine, Atlanta, GA; and

the Autopsy Committee of the College of

American Pathologists.

References

1.	 Kohn RR. Cause of death in very old

people. JAMA. 1982;247:2793–97.

2.	 Gloth FM III, Burton JR. Autopsies and

death certificates in the chronic care

setting. J Am Geriatr Soc.

1990;38:151–5.

3.	 Klatt EC, Meyer PR. Geriatric autopsy

pathology in centenarians. Arch Pathol

Lab Med. 1987;111:367–9.

4.	 The Autopsy and Forensic Pathology

Committees of the College of American

Pathologists. Cause-of-death statements

and the elderly. In: Hanzlick R. ed.

Cause-of-Death Statements and

Certification of Natural and Unnatural

Deaths: Protocol and Options.

Northfield, IL: College of American

Pathologists; 1997:15–24.

5.	 National Center for Health Statistics.

Instruction Manual Part 2a: Instructions

for Classifying the Underlying

Cause-of-Death. Hyattsville, MD:

National Center for Health Statistics;

1993:1–106.

6.	 Hanzlick R. The relevance of queries

and coding procedures to the writing of

cause-of-death statements. Am J

Forensic Med Pathol. 1996;17:319–23.
Page 28 [ Series 3, No. 32

Speculation and

Competing Causes of

Death

A man in his late forties had been

in good general health. He had

smoked two packs of cigarettes

per day but had recently stopped. He

had become an avid exerciser, running

about 24 to 32 km and swimming 1.6 to

3.2 km each week. Paroxysmal atrial

fibrillation developed and was initially

controlled by the use of digitalis.

However, during a 2-year period, the

episodes of atrial fibrillation became

more frequent and required

cardioversion and trials of several other

antidysrhythmic drugs. Atrial flutter was

noted during an office visit with his

cardiologist. The next day, he staggered

and fell on a jogging path. Emergency

services were called, but an attempt to

resuscitate the patient was unsuccessful.

Autopsy Findings

An autopsy was performed under

the authority of the local medicolegal

death investigation system because death

was sudden, unexpected, and

unexplained. The heart weighed 450 g

(average normal weight about 345 g for

weight and height). There was calcific

atherosclerosis of the left anterior

descending coronary artery with luminal

narrowings estimated at 70 percent.

There was no significant alteration in

the left main, left circumflex, or right

coronary arteries. The brain was not

examined. The remaining organs and

tissues showed nothing that was

reported as significant.

Based on the gross and microscopic

autopsy findings and negative results of

a toxicologic screen, the cause-of-death

was reported as follows:

Part 1.

A. Calcific coronary artery sclerosis

Due to or as a consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Cardiomegaly

Comment

The widow consulted an attorney; a

lawsuit was instigated against several

health care providers who had treated

the decedent, alleging that they had

failed to diagnose and treat coronary

artery disease, which was reported as

the cause-of-death. The attorneys for the

defendants engaged a pathologist to

review the case, and the consulting

pathologist noted that myocarditis was

present focally in the histologic sections,

including an area with myocyte necrosis

in the atrioventricular node. There was

no histologic evidence of acute

myocardial ischemia typical of coronary

insufficiency or of the type sometimes

seen in unstable angina. There was no

evidence of sudden changes in the

coronary arteries, such as plaque

fissuring, hemorrhage, or thrombosis.

Based on these findings, the

consulting pathologist indicated that an

alternative cause-of-death could be

reported as follows:

Part 1.

A. Myocarditis, undetermined type

Due to or as a consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Atrial fibrillation/flutter

The consulting pathologist advised

the attorneys that coronary artery

disease, especially in the face of

demonstrable myocarditis, may not have

been the actual cause-of-death in this

case. Although coronary artery disease

was reasonably included in the

differential diagnosis based on the

autopsy findings and circumstances of

death, the patient’s previous athletic

activity and exercise tolerance, lack of

anatomical and clinical evidence of

myocardial ischemia, marginally

significant coronary artery stenosis, and

histologic evidence of myocarditis

indicated that myocarditis may have

been a more likely cause-of-death (3,4).

The results of the autopsy in this

case, used as a basis to report the

cause-of-death on the death certificate,

seemed to support the widow’s initial

lawsuit. However, the autopsy results

provided histologic samples that could

be reviewed and that ultimately

provided an alternative explanation for

the cause-of-death. If an autopsy had not

been performed, death might have been

attributed to coronary artery disease, and

the same legal action may have resulted.

However, in that scenario the

information obtained from the autopsy

would not have been available to

address relevant issues and adjudicate

the case. Also, if an autopsy had not

been performed, the additional expense

of exhumation might have been

necessary to perform an autopsy, in

which case the findings may have been

more difficult to interpret because of

postmortem artifacts.

This case points out the need for

certifiers of death to realize the possible

ramifications of the wording in the

cause-of-death statement as well as the

need to evaluate possible competing

causes of death. One does not need to

be absolutely certain about a

cause-of-death to report it on the death

certificate. In fact, in many cases it is

sufficient if a cause-of-death is ‘‘more

likely than not (5)’’ and one should not

skirt the responsibility of reporting a

reasonable and likely specific

cause-of-death, when possible. However,

a reported cause-of-death should consist

of more than speculation, especially

when other competent and equally

likely (i.e., competing) causes of death

may exist.

Medicolegal death investigations

performed under the jurisdiction of a

medical examiner or coroner, as was

done in this case, are often geared

toward differentiating natural

deaths (due to disease) from unnatural

deaths (due to injury or poisoning). For

a variety of reasons, including

workforce, funding, available resources,

and operational strategies and priorities,

medicolegal death investigation systems

may not pursue a full and

comprehensive pathologic workup once

death has been determined to be natural

in manner. Whether tissue samples are

retained for histologic examination and,

if retained, processed only to paraffin

blocks (and not routinely reviewed) or to
glass slides (which may or may not be

routinely reviewed), varies from place to

place. Also, some medicolegal death

investigation systems may be limited by

law or other regulation in the extent to

which a death may be investigated when

there is no evidence of injury,

poisoning, or foul play (6). Thus, it is

not surprising that cases like the one

reported herein sometimes occur.

It is also important to realize that

experienced medical examiners and

coroners are used to investigating deaths

with anatomical findings that do not fit

precisely with well-established concepts

and pathophysiologic patterns. Such

cases may result in the need to report a

cause-of-death in rather generic terms

because demonstrable evidence of a

specific fatal derangement, immediate

cause-of-death, or mechanism of death is

lacking. For example, simply attributing

death to coronary artery atherosclerosis (or

to a somewhat vague condition, such as

cardiomegaly, anesthesia-related death, or

homicidal violence) without further

explanation is appropriate and necessary

in some situations.

When a lawsuit involves

information derived from the

cause-of-death on a death certificate or

autopsy report, a first step should be to

ascertain the basis and likely accuracy

of the reported cause-of-death so that

valuable time and resources are not

wasted and possible misinformation is

not perpetuated.

NOTE: Volume 158, August 24, 1998. Grover M.

Hutchins, M.D., The Johns Hopkins Medical

Institutions, Baltimore, MD; Randy Hanzlick,

M.D., Emory University School of Medicine,

Atlanta, GA; and the Autopsy Committee of the

College of American Pathologists.

References

1.	 Kitzman DW, Scholz DO, Hagen PT,

Ilstrup DM, Edwards WD. Age-related

changes in normal human hearts during

the first 10 decades of life, Part

II (maturity): a quantitative anatomic

study of 765 specimens from subjects

20 to 99 years old. Mayo Clin Proc.

1998; 63:137–46.

2.	 Dominitz I, Boruchow IB, Hutchins

GM. Focal myocardial ischemic

necroses associated with unstable

angina pectoris. J Am Coll Cardiol.

1996;28:910–4.

3. Aretz HT, Gillingham ME, Edwards

WD, et al. Myocarditis: a

histopathological definition and

classification. Am J Cardiovasc Pathol.

1986;1:3–14.

4.	 Lieberman EB, Hutchins GM,

Herskowitz A, Rose NR, Baughman

KL. A clinicopathologic description of

myocarditis. J Am Coll Cardiol.

1991;18:1617–26.

5.	 Hanzlick R, ed. Cause-of-Death

Statements and Certification of Natural

and Unnatural Deaths: Protocol and

Options. Northfield, IL: College of

American Pathologists; 1997.

6.	 Combs DL, Parrish RG, Ing RT. Death

Investigation in the United States and

Canada. 1995. Atlanta, GA: Centers for

Disease Control and Prevention; 1996.

Institutional Autopsy

Rates

A35-year-old man with end-stage

acquired immune deficiency

syndrome was admitted to the

hospital for severe abdominal pain,

abdominal tenderness, and fever. A

computed tomographic scan showed

colonic distension, thickening of the

colonic wall, and a possible rectal

mass. Death occurred within 24 hours

of admission to the hospital, and

permission to perform an autopsy was

requested to evaluate the

gastrointestinal tract. Recently, he had

been given clindamycin for

empirically suspected central nervous

system toxoplasmosis.

Autopsy Findings

The results of the autopsy showed

pneumonia due to cytomegalovirus

infection and massive dilatation of the

entire colon, which had a diameter

approximately three times the normal

size. The colonic wall was thickened

and edematous, the mucosa of the distal

colon was necrotic, and the remaining

mucosa showed numerous ulcerative

lesions and a thick fibropurulent

pseudomembrane. Microscopically, the

colon showed morphologic changes

Series 3, No. 32 [ Page 29

typical of pseudomembranous colitis,

normally distributed ganglia (i.e., no

evidence of congenital megacolon), and

no features suggestive of ulcerative

colitis, regional enteritis, ischemic bowel

disease, or other infectious bowel

disease. The brain showed organizing

abscesses consistent with recently

treated toxoplasmosis.

Based on the autopsy findings, a

cause-of-death statement could be

prepared as follows:

Part 1.

A. Toxic megacolon

Due to or as a consequence of:

B. Pseudomembranous colitis

Due to or as a consequence of:

C. Clindamycin therapy for cerebral

toxoplasmosis

Due to or as a consequence of:

D. Acquired immune deficiency

syndrome

Part 2. Other significant conditions:

Pneumonia due to cytomegalovirus

Comment

Although clindamycin-associated

pseudomembranous colitis due to

Clostridium difficile is a well-known

entity (1), it is not commonly associated

with toxic megacolon. The findings in

this case prompted the pathologist to

consider a retrospective review of

autopsy cases at the institution to a

search for similar cases among the

patients with acquired immune

deficiency syndrome who had been

treated with clindamycin. Unfortunately,

the number of autopsies performed in

such cases was too small to enable such

an analysis. This problem prompted the

pathologist to review the overall autopsy

rates in the institution.

A review of annual institutional

mortality and autopsy data showed that

the annual deaths of inpatients remained

relatively constant between 1986 and

1995 but the number of autopsies

performed had progressively declined

from 250 in 1986 to 105 in 1995,

resulting in an autopsy rate that declined
Page 30 [ Series 3, No. 32

from 17 percent to 7 percent of

in-hospital deaths. A review of the

literature (2) showed that similar trends

have occurred nationally and that

nationwide autopsy rates gradually

declined from 41 percent in 1964 to

about 15 percent in 1983. A 1994 survey

of 244 hospitals conducted by the

College of American Pathologists (3)

showed that half of hospitals had

autopsy rates at or below 8.5 percent

and 75.0 percent had autopsy rates

below 13.5 percent. Interestingly,

accreditation programs (4) in internal

medicine recommend an autopsy rate of

at least 15 percent.

Why have autopsy rates fallen so

dramatically? This question and other

issues have been discussed extensively

for 35 years at various symposia in the

United States (5–8). In brief, the

following are the most commonly

mentioned reasons:

Lack of reimbursement—In general,

hospitals do not charge families for

autopsy services, insurers do not usually

pay for autopsy costs, and the Health

Care Financing Administration’s

Medicare reimbursements do not

provide payments (Part B) for specific

autopsy services. Part A reimbursements,

according to the Health Care Financing

Administration, include nonline item

money to support autopsy services, but

the payment is not based on autopsy

rate, autopsy use, outcomes assessment,

or actual autopsy costs. In essence, the

lack of reimbursement makes the

autopsy a ‘‘loss leader,’’ which hospital

financial managers and pathology

departments must manage.

Lack of incentive—The autopsy is a

labor-intensive and expensive procedure.

In most hospital settings, pathologists

are not paid on a fee-per-case basis.

Managed care has resulted in fewer

pathologists who have to work longer

and harder, and the autopsy poses

workforce burdens with little incentive.

Decreased emphasis in medical

school—Medical schools have moved

toward clinical problem-solving

curricula and away from basic sciences.

Time allocated to pathology curricula

has dwindled. Many medical students

now graduate with no training in

autopsy procedure, no instruction on

how to request permission for an

autopsy, and no opportunity to view an

autopsy in progress or the inside of a

cadaver. Perhaps as a result of decreased

emphasis, it has been shown that

clinicians frequently do not ask for

permission to have an autopsy

performed.

Technological advances—The

dramatic and rapid advancements in

diagnostic modalities such as computed

tomography and magnetic resonance

imaging have improved the ability to

view images of internal bodily aspects,

resulting in the perception among

clinicians that the autopsy may be

replaced by imaging and other methods.

Changing nature of disease

patterns—Changing disease patterns

affect the autopsy in two ways. First,

some pathologists have become

concerned about the increased risk of

occupational exposure to potentially

fatal and/or drug-resistant, blood-borne,

respiratory, and other pathogens, causing

them to take a closer look at the

risk-benefit ratio of autopsy

performance. Second, the increase in

deaths involving human immunodeficiency virus infection and survival

among patients with terminal diseases of

many types have changed the mortality

patterns in some institutions. More

patients have lengthy illnesses and

prolong hospitalization during which

many of their disease processes may be

elucidated.

Negative feedback—Many

pathologists are not interested in the

autopsy and have attitudes of

indifference, avoidance, and in some

cases, antagonism resulting in

half-hearted autopsy performance. These

attitudes and practices may negatively

affect the attitudes and practices of

clinicians in the institution who are the

suppliers of autopsy authorizations and

users of autopsy information.

Despite the use of sophisticated

imaging technologies and other new

diagnostic tools, recent studies (9–11)

demonstrate that 32 to 42 percent of

autopsies reveal at least one major

unexpected or clinically unconfirmed

finding that contributed to the patient’s

death. In addition, approximately

93 percent of clinical questions made

known to the pathologist prior to

autopsy are answered in the results of

the autopsy (11–12). These studies

indicate that the autopsy continues to be

a valuable resource for education and

quality assurance. The positive

contributions of the autopsy have also

been recognized by the American

Medical Association (2). One of

us (R.H.) has educated physician house

staff about these data, and the

institution’s autopsy rate rose nearly

30 percent in one year.

Several reasons cited herein for

declining autopsy rates could be

addressed by regionalization of hospital

autopsies to medical centers with

interest in performing autopsies,

experience in performing autopsies

involving infectious and complex

conditions, and adequate facilities for

recommended and regulated infection

control practices (8).

NOTE: Volume 158, June 8, 1998. Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; Peter Baker, M.D., Ohio

State University School of Medicine, Columbus;

and the Autopsy Committee of the College of

American Pathologists.

References

1.	 Cotran RS, Kumar V, Robbins SL.

Robbins Pathologic Basis of Disease.

4th ed. Philadelphia, PA: WB Saunders

Co: 1989;360–1.

2.	 AMA Council on Scientific Affairs.

Autopsy; a comprehensive review of

current issues. JAMA. 1987;258;364–9.

3.	 Baker PB, Zarbo RJ, Howanitz PJ.

Quality assurance of autopsy permit

form information, timeliness of

performance, and issuance of

preliminary report: a College of

American Pathologists Q-Probes

study of 5434 autopsies from 462

institutions. Arch Pathol Lab Med.

1996;120:346–52.

4.	 Program requirements for residency

education in internal medicine.

Accreditation Council for Graduate

Medical Education Web site. Available

at http://www.acgme.org/acgme/

progreq/lm.htm. Accessed March 27,

1998.

5.	 Agnrist A. What remedies for the

failing autopsy? In: Symposium on the

autopsy. JAMA. 1965;193:805–14.

6.	 Williams MJ, Peary TM. The autopsy, a

beginning, not an end. Am J Clin

Pathol. 1978;69 (suppl 2):215–6.

7. College of American Pathologists
Foundation Conference on the Autopsy.

Revitalizing the ultimate medical

consultation. Arch Pathol Lab Med.

1984;108:437–512.

8. College of American Pathologists

Conference XXIX. Restructuring

autopsy practice for health care reform.

Arch Pathol Lab Med.

1996;120:700–85.

9. Sarode VR, Datta BN, Banergee AK, et

al. Autopsy findings and clinical

diagnoses: a review of 1000 cases.

Hum Pathol. 1993;24:194–8.

10.	 Veress B, Alafuzoff I. A retrospective

analysis of clinical diagnoses and

autopsy findings in 3,042 cases during

two different time periods. Hum Pathol.

1994;25:140–5.

11. Baker PB, Saladino AJ. Autopsy

Contributions to Quality Assurance:

Data Analysis and Critique. Northfield,

IL: College of American Pathologists;

1993. Q-Probes series No. 93–06.

12.	 Fowler EF, Nicol AG, Reid IN.

Evaulation of a teaching hospital

necrospy service. J Clin Pathol.

1977;30:575–8.

Private Autopsies

Awhite man in his thirties fell

from a ladder at work and broke

his back (lumbar vertebral

fracture). He was taken to a local

hospital where he was given supportive

treatment while being evaluated for

surgical repair of the fracture. About 4

days after admission, he suddenly

became dyspneic, underwent

cardiopulmonary arrest, and died.

During resuscitation, subxiphoid

aspiration using a pericardial needle was

performed, revealing blood. The

clinicians felt that death resulted from

hemopericardium probably due to a

ruptured coronary artery aneurysm and

certified the cause-of-death as such. The

medical examiner was notified of the

death but did not investigate,

presumably because a natural

cause-of-death was reported by the

clinicians. An autopsy was not

performed at the hospital. The body was

buried a few days following death.

The patient’s family assumed that

death was related to the back injury,

which occurred on the job, and they

attempted to process a claim for

compensation. However, they were told

that they did not have a claim because

there was no evidence that the death

resulted from the work-related injury

since the death was certified as being

due to a specific natural cause. The

family was perplexed and contacted an

attorney, who recommended that an

autopsy be performed to evaluate

whether the stated cause-of-death was

correct and whether the fall and

vertebral fracture somehow caused or

contributed to death.

The attorney contacted a pathologist

and discussed the case. After executing

a legal authorization for autopsy, signed

by the legal next of kin, the body was

exhumed and a pathologist performed an

autopsy for an agreed upon fee, using a

local morgue and paying a user’s fee to

cover supplies and overhead expenses in

the morgue.

Autopsy Findings

The results of the autopsy did not

confirm the presence of a coronary

artery aneurysm, hemopericardium, or

reason for a hemopericardium to exist.

Because of the body cavity trocar and

aspiration procedure performed during

the embalming process (1), which

introduces puncture-like artifacts and

can remove abnormal fluid

collections (1), a specific explanation for

blood having been obtained during the

subxiphoid aspiration could not be

determined; aspiration of intracardiac

blood was one explanation. The results

of the autopsy showed lumbar vertebral

fracture and the presence of multiple,

bilateral, pulmonary emboli.

Based on these findings, a

cause-of-death statement could be

prepared as follows:

Part 1.

A. Pulmonary embolism

Due to or as a consequence of:

B. Lumbar spine fracture sustained in

a fall from a ladder

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Series 3, No. 32 [ Page 31

Comment

It is unclear why the medical

examiner did not accept jurisdiction and

perform an autopsy in this case because

the possibility of death due to injury

existed based on the close temporal

relationship between injury and death. It

is also unclear why an autopsy was not

performed at the hospital where the

death occurred. Oversight,

miscommunication, or misunderstanding

by one or more parties may have played

a role. Fortunately, an autopsy was

eventually performed, which allowed the

family to proceed with their personal

and financial matters. Unfortunately,

however, the family had to expend effort

and money to arrange and pay for a

private autopsy when an autopsy might

have been performed earlier in a

different setting. In cases such as this

one in which the correct cause-of-death

was determined after the original death

certificate was incorrectly completed

and filed, effort should be made to

amend (i.e., update or correct) the

original death certificate, which usually

requires contacting the original certifier.

When an injury is involved, the medical

examiners or coroners could be

contacted (in the jurisdiction where the

injury or death occurred, depending on

the laws of that State), and they can

then assume jurisdiction of the case and

amend the death certificate.

In other cases, the family (or the

patient’s physician) may need or want to

have an autopsy performed, but the

death clearly does not come under the

jurisdiction of the medical examiner or

coroner and, for one or more of several

reasons, an autopsy cannot be performed

at the hospital. Such reasons include the

following: the patient did not die in the

hospital; the family was not informed in

a timely fashion that an autopsy could

be performed in the hospital; the facility

in which death occurred does not have

formal provisions for autopsy services;

or the family wants an autopsy to be

performed but does not want the

hospital to do it because of perceived

conflicts of interest or concern about

possible coverups. Some hospitals will

only perform autopsies when patients
Page 32 [ Series 3, No. 32

die in the hospital, although some will

perform one even if the patient dies

outside the hospital if the patient has an

active medical record or has recently

been admitted and discharged.

Procedures and arrangements vary

among hospitals with respect to such

circumstances.

For all the reasons cited, the

physician of a patient who dies may be

called upon or desire to arrange for a

private autopsy performed on a

fee-for-service basis. The following are

several approaches to finding such a

service:

+	 If the family has an attorney, the

attorney may be aware of a

pathologist who will perform

autopsies on a private basis on

behalf of the family.

+	 The pathology department at a local

hospital may be contacted. In many

instances, the pathologist may be

able to provide such services or

recommend a pathologist who

provides such services.

+	 The office of the medical examiner

or coroner may be contacted. Many

pathologists who work in the offices

of the medical examiner or coroner

provide private autopsy services

independently from their duties as

medical examiner, coroner, or

coroner’s pathologist or will be able

to recommend a pathologist who

provides such services.

+	 The College of American

Pathologists (800-323-3040) may be

able to provide names of several

pathologists who practice in the area

where the service is needed.

+	 There are an increasing number of

commercial and private autopsy

service companies that have a

nationwide network of people who

will provide autopsy services on a

private basis (2). Information about

some companies can be obtained

through the Internet or perhaps from

a local pathologist, medical

examiner, or coroner’s pathologist

who may be familiar with

advertisements for such services.

Regardless of the ultimate

arrangement, the autopsy service

provider will probably require a legally

executed authorization for autopsy,

completed and signed by the legal next

of kin and/or their authorized attorney.

A sample, generic authorization form

has been published (3). It may be

necessary to transport the body across

long distances or State lines, which may

require embalming before transport.

Most hospitals do not bill the family

when an autopsy is performed, but few

private autopsies are performed free of

charge, and the fee may be considerable.

Financial arrangements should be clear

to all parties prior to the performance of

a private autopsy.

Organized, commercial autopsy

service enterprises are relatively new

and growing in number. How they

perform and interface with medical

professional guidelines and standards,

facility inspections, and accreditation

and certification procedures remains to

be seen.

NOTE: Volume 158, May 11, 1998. Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; Grover M. Hutchins,

M.D., The Johns Hopkins Medical Institutions,

Baltimore, MD; and the Autopsy Committee of the

College of American Pathologists.

References

1.	 Hanzlick R. Embalming. Body

preparation, burial, and disinterment; an

overview for forensic pathologists. Am

J Forensic Med Pathol.

1994;15:122–31.

2.	 Glabmar, M. Breathing new life into

autopsies. American Medical News.

March 9, 1998; Business section: 13–5.

3.	 Geller SA. Autopsy permission and

consent. In: Hutchins GM, ed, Autopsy

Performance and Reporting. Northfield,

IL: College of American Pathologists;

1990:27.

Complications of

Therapy, Nursing

Homes, and the

Elderly

Following several cerebrovascular

strokes, an elderly man was

placed in a nursing home for

long-term care because of his

immobility and paresis. Regular sessions

in a heated whirlpool were part of his

therapeutic regimen. One day, shortly

after being placed in the whirlpool, he

moaned and thrashed. He was promptly

removed from the whirlpool and noted

to have erythematous skin extending

from the nipples to the feet. The on-call

physician was notified and observed

blistered and erythematous skin.

Treatment consisted of burn wound

management, and death occurred several

days later from burn wound sepsis.

Autopsy Findings

The results of the autopsy showed

patterned thermal injury (burns)

involving most of the skin surface of the

trunk and extremities below the level of

the nipples and included erythema

sloughed epithelium in a distribution

typical of an immersion scald burn.

Autopsy results also showed old

cerebral infarcts, nonspecific changes

related to aging; and no apparent

immediate cause-of-death other than the

burns. An investigation of the scene and

an examination of the whirlpool

disclosed that the hot water coming into

the whirlpool could exceed scalding

temperature (the thermostat on the hot

water heater was set too high) and that

the temperature sensor on the whirlpool

measured the temperature of the water

in the incoming water pipe, not the

water in the whirlpool basin. Thus, the

water faucet could be operated in such a

way that the temperature indicator

would indicate a safe temperature (when

cool water was running in the line)

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.
Based on the results of autopsy and

investigation, a cause-of-death statement

could be prepared as follows:

Part 1.

A. Burn wound sepsis

Due to or as a consequence of:

B. Scald burns of torso and extremities

Due to or as a consequence of:

C. Whirlpool treatment with

overheated water

Part 2. Other significant conditions:

Remote cerebral infarctions,

cerebral artery atherosclerosis

Comment

Because death was related to an

injury, the medical examiner was

notified of the death and assumed

jurisdiction for the investigation and

autopsy. The manner of death was

classified as accidental because the

death was caused by an unintentional

injury (i.e., burns, an external condition).

An appropriate cause-of-death statement

is shown, which reports the injury

information in Part 1. The

cerebrovascular conditions are

appropriately reported in Part 2 because

they explain why the man was in the

whirlpool; however, these conditions

were not directly linked in a causal

relationship with the thermal burns,

which essentially were an independent

event (1). Had the burns not occurred,

the man most likely would not have

died when he did.

Performance of the autopsy was

valuable because it allowed

documentation of the event of injury

and evaluation for the presence of other

plausible, competing causes of death

that were ruled out. The autopsy

provided information that could be used

to confidently address issues of injury

and death causation without relying on

incomplete information or speculation.

The associated investigation of the

scene and circumstances provided

information that was potentially valuable

in preventing subsequent patient

injuries. The whirlpool and water

heating system could be modified to

make them safe, including a reduction in

the thermostat setting on the water

heater to below 48.8o

C. Information

from the autopsy and investigation was

used by the State licensing board (which

conducted an investigation) and also

forwarded to the whirlpool manufacturer

and could be used for training

employees on whirlpool and water

temperature safety. Data in the literature

about the relationship of time,

temperature, and thermal scald burns

were validated in that the ultimately

fatal burns occurred within seconds of

immersion in the scalding water. (Water

temperature of 54.4o

C can scald within

a few seconds (2).) Because the

information discovered through the

performance of the autopsy and

investigation was thorough, potential

legal claims could be promptly and

accurately addressed.

There is little doubt that the autopsy

is underused as a method for evaluating

mortality patterns, the health of the

aging population, and the subset of such

patients in nursing homes or long-term

care facilities. Approximately 20 percent

of deaths occur in nursing homes;

however, in New York State, for

example, the autopsy rate for nursing

home patients during a 5-year period

was only 0.8 percent (3). During a

7-year period in a teaching nursing

home, the autopsy rate was only

3.5 percent, but it did increase to

10.8 percent after an extensive

educational effort (4). The Centers for

Disease Control and Prevention’s

National Center for Health Statistics

data tapes indicate that in the United

States autopsies were performed on

fewer than 1 percent of patients who

died in nursing homes between 1990

and 1994. Deaths in nursing homes

sometimes raise concerns about

unsuspected injury, patient management,

and possible abuse or neglect. The

performance of an autopsy can address

these issues. Unfortunately, many

nursing homes lack full-time physician

staff, autopsy rooms, pathology services,

or formal affiliations with hospital-based

autopsy services, posing some obstacles

to autopsy performance. The fact that

the patient was old and seemed to die of

senescence or other ill-defined natural

causes (5) may also serve as a deterrent

Series 3, No. 32 [ Page 33

to requesting permission for autopsy, as

does the lack of an established method

of payment or reimbursement for

autopsy services related to nursing home

patients.

In the case presented herein, an

autopsy was performed because the

medical examiner was notified and

death involved an injury. In many cases,

however, death may clearly have

resulted from natural disease processes,

and even if reported to the medical

examiner or coroner, the death may not

be investigated. Whenever injury (such

as falls, fractures, burns, etc.), abuse, or

foul play are suspected, or the death

seems sudden, unexpected, and not

explained with reasonable certainty,

medical examiners or coroners should

be notified and they will usually accept

the case for investigation. In cases that

do not involve medical examiners or

coroners, those caring for the elderly are

responsible for arranging for an autopsy

with the legal next of kin.

Gerontologists and nursing home

physicians need to recognize that

performing an autopsy may be valuable

in selected cases, and it may be useful

to pursue planned arrangements for the

provision of pathology and autopsy

services when they are indicated.

This case also points out that

patients may die of medical procedures

and therapies. Such cases need to be

fully evaluated and pose special needs

when completing the death certificate,

including the reporting of the

complication in the cause-of-death

statement (1).

NOTE: Volume 158, April 13, 1998. Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists. We thank Norman W. Staehling,

M.S., and Steven S. Yoon, Sc.D., M.P.H., of the

Centers for Disease Control and Prevention,

Atlanta, GA, for their assistance in accessing and

tabulating the nursing home autopsy data.

References

1.	 Hanzlick R. ed., and the Autopsy and

Forensic Pathology Committees of the

College of American Pathologists in

conjunction with the National

Association of Medical Examiners.

Cause-of-Death Statements and
Page 34 [ Series 3, No. 32

Certification of Natural and Unnatural

Deaths: Protocol and Options.

Northfield. IL: College of American

Pathologists; 1997.

2. Moritz AR, Henriques FC. Studies of

thermal injury: the relative importance

of time and temperature in causation of

thermal burns. Am J Pathol.

1947:23:695–720.

3.	 Katz PR. Seidel G. Nursing home

autopsies: survey of physician attitudes

and practice patterns. Arch Pathol Lab

Med. 1990:114:145–7.

4.	 Gloth FM 111, Burton JR. Autopsies

and death certificates in the chronic

care setting. J Am Geriatr Soc.

1990:36:151–5.

5.	 Kohn RR. Cause of death in very old

people. JAMA. 1982;247:2793–97.

Protecting Those at

Risk

A59-year-old woman presented

with a 13.5kg weight loss,

malaise, and chronic cough of

2 months’ duration. The results of a

chest x-ray examination suggested a

cavitary lesion of the left upper lobe,

and based on empirical evidence, she

was given antituberculous medications.

Sputum cultures had not yet been

obtained when, 2 days after admission,

she was found dead on the floor in the

bathroom of her hospital room with

copious amounts of blood emanating

from the nose and mouth. A family

member with human immunodeficiency

virus infection had been living in her

home, but the deceased patient had no

serologic or clinical evidence of human

immunodeficiency virus infection. Six

months earlier, she had been admitted

for respiratory symptoms and was

diagnosed as having bacterial

pneumonia in the left upper lobe, which

was treated with antibiotics during a

short hospital stay.

Autopsy Findings

The results of an autopsy showed

excessive involvement of the left upper

lobe of the lung with tuberculosis,

including an apical lesion (Simon foci)

that infiltrated into the chest wall and

eroded into pulmonary arteries and

bronchi causing massive hemorrhage

into the pulmonary airways.

Based on the autopsy findings, a

cause-of-death statement could be

written as follows:

Part 1.

A. Pulmonary hemorrhage

Due to or as a consequence of:

B. Broncial-pulmonary artery fistula

Due to or as a consequence of:

C. Pulmonary tuberculosis

Part 2. Other significant conditions:

Comment

In the institution where this death

occurred, a considerable number of

patients with human immunodeficiency

virus, mycobacterial, and opportunistic

infections are treated. Of concern is a

trend toward tuberculosis infection

among patients who are not known to

be immunocompromised. An autopsy

may be necessary to establish such

diagnoses when a patient dies before a

definitive diagnosis can be made

clinically.

The emergence and re-emergence of

fatal infectious diseases and unexplained

deaths due to possibly infectious causes

should cause a resurgence in the use of

the autopsy as a diagnostic

procedure (1–3). Although the usefulness

of postmortem cultures is sometimes

limited because of postmortem growth

of bacterial contaminants or antibiotic

treatment during life (which may result

in cultures negative for infectious

agents), new methods, such as

DNA-based tests and

immunohistochemical studies, will

facilitate and improve the identification

of infection causing agents in

postmortem specimens. However,

cultures will still be required to identify

many infectious agents and test for drug

sensitivities, when indicated, to fully

evaluate the nature of an important

infectious agent. Although universal

precautions dictate that all cases be

regarded and managed as potentially

infectious, it is helpful for the clinician

to provide information in advance to the

pathologist who will perform the

autopsy on likely or known infectious

conditions and the specific nature of the

conditions.

Following the demonstration of

Mycobacterium tuberculosis infection in

the results of the autopsy in this case,

the hospital infection control department

was notified of the findings so that

appropriate followup could occur with

the county health department, as

required, potentially exposed physicians,

hospital staff, and family members. The

autopsy enabled a definitive diagnosis

that was suspected but not confirmed

clinically because death occurred before

sputum analysis was performed,

emphasizing the potential value of

promptly identifying patients who

harbor M tuberculosis infection. The

autopsy findings were forwarded to the

department of medicine for mortality

and management review processes in

light of the patient’s earlier admission

with pneumonia of the left upper lobe.

NOTE: Volume 158, March 9, 1998. Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; Larry Nichols, M.D.,

University of Pittsburgh Medical Center,

Pittsburgh, PA; and the Autopsy Committee of the

College of American Pathologists.

References

1.	 Schwartz DA, Herman CJ. The

importance of the autopsy in emerging

and reemerging infectious diseases.

Clin Infect Dis. 1996;23:248–54.

2.	 Perkins BA, Flood JM, Danila R, et al.

for The Unexplained Deaths Working

Group. Unexplained deaths due to

possibly infectious causes in the United

States: defining the problem and

designing surveillance and laboratory

approaches. Emerg Infect Dis.

1996;2:47–53.

3.	 Nolte KB, Simpson GL, Parrish RG.

Emerging infectious agents and the

forensic pathologists: the New Mexico

model. Arch Pathol Lab Med.

1996;120:125–8.
Partial, Limited, or

Restricted Autopsies

A17-year-old girl had a 7-year

history of neurologic decline that

appeared to be related to a

familial degenerative neurologic

disorder. She developed chronic

malnutrition, decubitus ulcers,

marasmus, and repeated episodes of

aspiration pneumonia. Her status was

placed on do not resuscitate, and she

died with a clinical picture of acute

respiration distress syndrome.

Autopsy Findings

The extent of the autopsy was

restricted by the family to removal and

examination of the brain and spinal

cord. The permit also restricted making

incisions into the back or torso. The

findings of an extensive neuropathologic

workup of the brain were most

compatible with a familial

olivopontocerebellar atrophy.

Based on these findings, a

cause-of-death statement could be

prepared as follows:

Part 1.

A. Familial olivopontocerebellar

atrophy

Due to or as a consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Comment

Although the spinal cord may be

removed during an autopsy through the

foramen magnum using a special tool,

the removal may be difficult without

causing considerable artifactual damage.

Removal of the spinal cord from a

posterior or anterior approach was not

possible because a request by the next

of kin to avoid incision into the back

was specifically stated on the autopsy

permit and permission for opening the

chest and abdomen, which could have

enabled anterior removal of the spinal

cord was also not obtained. Thus,

examination of the spinal cord was

complicated in this case.

Limited (restricted or partial)

autopsies are appropriate in some cases,

such as cases that necessitate identifying

the nature of a lesion lacking definitive

diagnosis before death when other

aspects of the clinical course and death

are well explained or cases when the

next of kin will give permission for a

limited autopsy but not a complete one.

Effort should be made in cases of a

limited autopsy to ensure that all parties

realize that information derived from a

limited autopsy will also be limited.

‘‘Partial autopsies, partial answers’’ is

the phrase sometimes quoted to make

the point (1). When arranging for an

autopsy, it may be appropriate for the

clinician or family member who is

requesting the autopsy to discuss with

the pathologist whether the autopsy can

address specific issues that have arisen

and, if a limited autopsy is being

considered, to what extent the ability to

address relevant issues in the case might

be limited (2). Regardless of its limited

nature, the autopsy in this case did

provide information that could be used

to further define the pathologic basis of

the familial nervous system atrophy that

affected this patient and others in her

family. However, because the lack of a

complete autopsy precluded

identification of a specific immediate

cause-of-death (such as pneumonia,

pulmonary embolism, diffuse alveolar

damage, metabolic derangement, or

other plausible cause), the

cause-of-death statement was prepared

using the single line, Part 1 format

shown herein (i.e., only the underlying

cause-of-death is stated). The evaluation

of visceral and other nervous system

changes was also precluded.

NOTE: Volume 157, December 8/22, 1997.

Randy Hanzlick, M.D., Emory University School

of Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

Series 3, No. 32 [ Page 35

References

1.	 Davis G. Organ limited autopsies:

obtaining permission for postmortem

examination of the urinary tract. Arch

Pathol Lab Med. 1995;119:1092. Letter.

2.	 Hutchins GM, ed., and the Autopsy

Committee of the College of American

Pathologists. Autopsy Performance and

Reporting. Northfield, IL: College of

American Pathologists; 1990.

A Tale of the

Unexpected: Finding a

Zebra

A56-year-old woman was

admitted for nausea and

projectile vomiting of several

days’ duration. A review of her medical

history failed to provide significant

information, and the physical

examination showed only marked

obesity. During the course of the

patient’s workup, a computed

tomographic scan of her head indicated

ring-enhancing lesions in the frontal and

parietal lobes of the brain, each 2.5 cm

in greatest dimension and reported as

being consistent with metastases. The

patient was transferred to the

neurosurgical service, where she

suddenly died. An autopsy was

requested by the physician with the goal

of determining the primary site of the

patient’s presumed carcinoma.

Autopsy Findings

Postmortem fine-needle aspiration

biopsy of the cerebral lesions showed

only neutrophils and necrotic debris.

Cerebral herniation was evident.

Subsequent histological study indicated

that the lesions were abscesses, not

metastases. An assiduous postmortem

search for a source of infection revealed

suppurative gingivitis and no other

source of infection.

Based on these findings, the

cause-of-death statement was prepared

as follows:
Page 36 [ Series 3, No. 32

Part 1.

A. Cerebral herniation

Due to or as a consequence of:

B. Intracerebral abscesses

Due to or as a consequence of:

C. Bacteremia

Due to or as a consequence of:

D. Suppurative gingivitis

Part 2. Other significant conditions:

Comment

Although the clinical and imaging

studies in this case clearly were

consistent with a carcinoma, the autopsy

proved that an infectious, rather than

neoplastic, process was responsible for

the patient’s death.

Performance of this autopsy was

valuable for several reasons. First,

although sophisticated imaging

technology is available and continually

improving in quality, an autopsy often

indicates clinically unsuspected or

unobserved findings or clarifies the

nature of lesions known to exist

clinically. Second, the class of disease

causing death was different from that

clinically suspected, and the death

certificate could be accurately

completed. Third, information useful to

the medicine and neurosurgery

departments and hospital quality

improvement offices was generated.

The autopsy findings were

immediately reported to the medicine

and neurosurgery departments at an

afternoon postmortem conference and

more formally presented at respective

morbidity/mortality conferences the

following month. At those conferences,

the fact was reiterated that 10 to

41 percent of autopsies reveal previously

unsuspected diagnoses (1).

NOTE: Volume 157, November 10, 1997. Gregory

J. Davis, M.D., University of Kentucky College of

Medicine, Frankfort; Randy Hanzlick, M.D.,

Emory University School of Medicine, Atlanta,

GA; and the Autopsy Committee of the College of

American Pathologists.

References

1.	 Hill RB, Anderson RE. Contributions

of the autopsy to modern medical

science and practice. In: The Autopsy:

Medical Practice and Public Health

Policy. Newton, Mass:

Butterworth-Heinemann; 1988:43–66.

An Intoxicating Case:

The Importance of

Toxicology

A60-year-old man had a history of

hypertensive heart disease with

congestive heart failure, chronic

alcohol abuse, prior pontine lacunar

infarcts, and remote head trauma from

an auto accident that occurred 30 years

before. He complained of decreased

urine output and suprapubic tenderness

and was admitted with a diagnosis of

prostatism and possible pyelonephritis.

About 24 hours following admission, he

experienced a cardiac rhythm

disturbance and a seizure and then died.

Concern was expressed by the survivors

that there had been some mistake on the

part of the hospital staff or physicians

since his death was perceived to be

sudden. The medical examiner was

notified but declined to investigate

because of the patient’s significant

medical history. The permission to

perform an autopsy was obtained from

the legal next of kin.

Autopsy Findings

Autopsy findings included prostatic

hyperplasia with chronic prostatitis,

hepatic steatosis with early cirrhosis, a

570 g heart with concentric left

ventricular hypertrophy and dilatation,

and old pontine lacunar infarcts with no

demonstrable acute central nervous

system findings. Pyelonephritis was not

present. The postmortem blood alcohol

level was 24 mmol/L (112 mg/dL), and

the postmortem vitreous humor alcohol

concentration was 1 mmol/L

(30 mg/dL).

Comment

The postmortem alcohol studies

indicated that the patient consumed

alcohol at the hospital (1). Alcohol had

not been prescribed, and it was

presumably provided by a visitor.

Findings from an examination of the

liver at autopsy were consistent with

long-term alcohol use. There was no

history of posttraumatic or other seizure

disorder. Acute intoxication from

alcohol consumption can lead to cardiac

rhythm disturbance (and seizures), and

the timing of death in regard to alcohol

consumption suggested that alcohol

consumption may have played some role

in this death. Furthermore, long-term

alcohol use is associated with

hypertension and unexplained

dysrhythmias. A seizure due to alcohol

withdrawal was viewed as extremely

unlikely because of the blood alcohol

concentration, which was probably

rising based on the blood vitreous

humor alcohol ratio (1).

Although the autopsy did not

clearly identify a cause-of-death, many

conditions were ruled out, and the

findings confirmed the clinical

diagnoses except for pyelonephritis,

which was included in the clinical

differential diagnoses.

The discovery that the patient had

consumed alcohol shortly before the

fatal events provided information that

could be used to address some legal

claims that might arise. The tests for

alcohol could not have been performed

legally in the jurisdiction of the hospital

without permission to conduct a

postmortem examination since invasive

procedures were required to obtain the

specimens. As illustrated by this case,

toxicologic tests may play an important

role in evaluating hospital deaths. When

deaths occur suddenly or unexpectedly

in the hospital, it is prudent (or perhaps

legally required) to report the death to

the local medical examiner or coroner.

Although the medical examiner declined

to investigate this case, the hospital

fulfilled its legal obligation to report the

death.

Based on all the available

information, the most likely explanation

for death was that the patient’s
underlying hypertensive heart disease

caused a cardiac rhythm disturbance

with agonal seizure disorder, probably

influenced to some degree by alcohol

consumption. Thus, a cause-of-death

statement could be prepared as follows:

Part 1.

A. Hypertensive heart disease

Due to or as a consequence of:

B.

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Acute alcohol intoxication,

long-term alcohol (ethanol) use,

agonal seizure

NOTE: Volume 157, September 7, 1997. Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

References

1.	 Caughlin JD. Correlation at postmortem

blood and vitreous humor alcohol

concentrations. Can Soc Forensic Scr J.

1983;16:61–8.

2.	 Schuekit MA. Alcohol and alcoholism.

In: Wilson JD, Braumunld E,

Isselbacher KJ, et al., eds. Harrison’s

Principles of Internal Medicine. 12th

ed. New York, NY. McGraw Hill Book

Co; 1991:2148.

Multiple Benefits

from an Autopsy

A47-year-old white man,

diagnosed as having human

immunodeficiency virus (HIV)

in 1989, was admitted in 1996 for

nausea and vomiting of 4 days’

duration. He had several previous

episodes of pneumonia and cutaneous

Kaposi lesions. During hospitalization,

he became confused. A lumbar puncture

was performed: following the procedure,

the headache and confusion worsened

with development of hypotension.

The patient died 8 hours following

the lumbar puncture. The patient’s

medical history included an

appendectomy 30 years previously and a

hiatal hernia repair in 1994. An autopsy

was requested by the physician, with the

major goal of assessing the possibility

of opportunistic meningitis or brain

herniation following lumbar puncture.

Autopsy Findings

The major autopsy findings

included multiple abdominal adhesions

resulting in small bowel obstruction,

perforation, and peritonitis; bacterial

bronchopneumonia; and no evidence of

meningitis, brain herniation, or HIV

encephalopathy.

Based on these findings, a

cause-of-death statement was prepared

as follows:

Part 1.

A. Perforation of jejunum with

peritonitis

Due to or as a consequence of:

B. Obstruction of jejunum

Due to or as a consequence of:

C. Postoperative intra-abdominal

adhesions

Due to or as a consequence of:

D. Delayed complications of

appendicitis

Part 2. Other significant conditions:

Human immunodeficiency virus

infection, bacterial pneumonia

Comment

The pathologist thought that the

location of adhesions corresponded to

the appendectomy procedure rather than

the hiatal hernia repair. Pneumonia and

HIV infection were listed as other

significant conditions because

pneumonia was thought to have

contributed to death and HIV infection

may have increased susceptibility to

peritonitis and/or pneumonia, but these

conditions did not result in the

underlying cause-of-death reported in

Part 1 (1).

Series 3, No. 32 [ Page 37

Performance of this autopsy was

valuable because it enabled accurate

completion of the death certificate;

alleviated clinical concern about

possible brain herniation; explained the

patient’s nausea and vomiting; and

provided information that should be

useful in the medical department and

hospital quality improvement programs.

A copy of the autopsy report was

forwarded to the medical department

and hospital quality improvement offices

because in the institution where this

death occurred deaths resulting from

unexpected findings or complications of

medical procedures are subject to

quality assessment review, even if

management seems appropriate. Such a

program helps meet the requirement of

the Joint Commission on Accreditation

of Healthcare Organizations (2) that

institutions have a policy stating how

autopsy findings are used to improve

care in the institution.

NOTE: Volume 157, August 11/25, 1997. Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists.

References

1.	 Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists, eds. The Medical

Cause-of-Death Manual: Instructions

for Writing Cause-of-Death Statements

for Deaths Due to Natural Causes.

Northfield, IL: College of American

Pathologists: 1994.

2.	 Joint Commission on Accreditation of

Healthcare Organizations. Accreditation

Manual for Hospitals: 1995. Oak

Brook, IL. Joint Commission on

Accreditation of Healthcare

Organizations: 1994.
Page 38 [ Series 3, No. 32

Clarifying an

Untoward Outcome

A20-year-old man who was a

college baseball player in

excellent health complained of

back pain and malaise. His symptoms

became progressively worse despite

being prescribed several medications.

Nausea, bloody diarrhea, submandibular

lymphadenopathy, hemoptysis, blurred

vision, and dizziness developed. On

presentation to an emergency

department, the results of laboratory

studies showed marked leukocytosis and

disseminated intravascular coagulation.

The patient was transferred to a

university hospital, where the possibility

of an unusual viral illness was

considered. He appeared stable on

admission to the hospital but suddenly

became unresponsive and apneic 4 hours

later. A cardiac monitor indicated

electromechanical dissociation, and the

advanced cardiac life support protocol

was unsuccessful. An autopsy was

requested by the physician primarily to

identify the etiologic agent of the

presumed fatal viral illness.

Autopsy Findings

Major autopsy findings included

severe hypersensitivity myocarditis,

acute respiratory disease syndrome,

interstitial nephritis, and centrilobular

hepatic necrosis. All the organs

examined showed marked eosinophilia

and features of disseminated

intravascular coagulation. Bacterial and

viral cultures and the results of serologic

tests and a drug abuse shown were

negative. A review of the drug use

history indicated that the patient had

been taking several medications

including cephalexin,

trimethoprimsulfamethoxazole,

phenylbutazone, and an unknown

antihistamine, for approximately

2 months.

Based on these findings, the

cause-of-death statement was prepared

as follows:

Part 1.

A. Hypersensitivity myocarditis

Due to or as a consequence of:

B. Drug-related hypersensitivity—

specific drug unknown

Due to or as a consequence of:

C.

Part 2. Other significant conditions:

Disseminated intravascular

coagulation

Comment

The autopsy findings not only

confirmed the clinical diagnosis of

disseminated intravascular coagulation,

but also indicated the clinically

unsuspected origin of disseminated

intravascular coagulation, a severe drug

hypersensitivity reaction. Several of the

drugs the patient took have been

implicated in such hypersensitivity drug

reaction so it is impossible to determine

which drug or combination of drugs was

responsible. The cardiac findings were

typical of hypersensitivity myocarditis, a

condition associated with a variety of

drugs. Hypersensitivity myocarditis is

rarely recognized clinically and is often

first discovered in the results of a

postmortem examination. Most patients

with this condition do not appear

critically ill but may die suddenly,

presumably because of an

arrhythmia (1,2). The autopsy in this

case was useful for important reasons.

First, it provided an explanation of the

cause-of-death to the family, eliminating

to some extent the attendant frustration

and bewilderment in such a death.

Second, it dispelled the fear of an

exotic, fatal contagious disease within

the community in this well-publicized

case. Third, information was disclosed

that is appropriate for reporting to the

Food and Drug Administration’s

MedWatch Reporting System for

adverse drug reactions and problems

with medical devices and for review by

the patient’s physicians. The case also

illustrates how commonly prescribed

drugs can be associated with fatal

adverse reactions that need be

considered and explained when

prescribing medications.

NOTE: Volume 157, October 13, 1997. Eun

Young Lee, M.D., Michael L. Cibull, M.D.,

University of Kentucky College of Medicine,

Lexington; Randy Hanzlick, M.D., Emory

University School of Medicine, Atlanta, GA; and

the Autopsy Committee of the College of

American Pathologists.

References

1.	 Kounis NG, Zavras GM, Soufras GO,

Kitrou MP. Hypersensitivity

myocarditis. Ann Allergy.

1989;62:71–5.

2.	 Burke AP, Saenger J, Mullick F,

Virmani R. Hypersensitivity

myocarditis. Arc Pathol Lab.

1991;115:764–9.

Wrapping Things Up

Introduction

This is the 30th and final

installment in the Autopsy and Medicine

Case of the Month series, which has

been published in Archives since the

first Case Report of August 1997. The

Autopsy Committee of the College of

American Pathologists is grateful to

Archives Editor James Dalen for

providing the opportunity to

re-emphasize the value of the autopsy to

the practice of medicine and society.

In his editorial titled ‘‘The

Moribund Autopsy: DNR or

CPR?’’ (August 1997), Editor Dalen

introduced the series and correctly

pointed out the moribund condition of

autopsy utilization in the United States

in virtually all spheres but the

medicolegal (forensic) one (1). He

advocated CPR for the autopsy rather

than letting the last several decades of

declining autopsy rates and utilization

relegate the autopsy to DNR status. We

agree with his recommendation and we

hope that the series has convinced

others to think and act similarly.

Over the past 3 years, numerous

values and contributions of the autopsy

have been emphasized in the series

using a Case Report presentation. The

cases presented are only a small sample
Series 3, No. 32 [ Page 39

of those encountered in everyday

practice in which the autopsy provides a

benefit to the practice of medical

science and society. We cannot touch on

every point made, but in this article, we

present a capsule summary of the major

issues addressed in the series.

Case Report Summary

The various case reports in the

Autopsy and Medicine Series

emphasized the following information

about the autopsy and/or the value and

contributions made by the autopsy:

1.	 improvement in the accuracy and

completeness of the cause-of-death

as reported on the death

certificate; alleviation of concern

about possible untoward outcomes

that could have adversely impacted

upon the institution or physician in

terms of potential liability;

elucidation of findings that more

precisely explain the patient’s

symptoms and signs; and the value

of autopsy findings for required

and voluntary hospital quality

improvement programs (2);

2.	 detection of undesirable,

unacceptable, or contraindicated

patient behavior (such as drinking

nonprescribed alcoholic beverages

in the hospital) which may have

contributed to death, and, if

undetected, might allow erroneous

conclusions or unfounded

allegations (3);

3.	 detection of drug hypersensitivity

reaction causing fatal myocarditis

that provided information for

reporting to the FDA and allayed

clinical and public concern about a

possible fatal exotic infectious

process in the community (4);

4.	 clarification that cerebral ringenhancing lesions observed on CT

were abscesses rather than

metastases as suspected and that

the cause-of-death was suppurative

gingivitis that had not been

recognized clinically (5);

5.	 recognition that ‘‘limited autopsy’’

may sometimes be needed and

appropriate but that the

information obtained is also

limited (6);

6.	 explanation that lymphangiosis

carcinomatosa of lungs and pleural

existed rather than pulmonary

thromboemboli, thus explaining to

clinicians and survivors the

patient’s lack of clinical response

to anticoagulant thrombolytic

therapy (7);

7.	 provision of suggested wording for

use by physicians who request

permission for autopsy from the

legal next-of-kin (8);

8.	 detection of previously

undiagnosed tuberculosis in a

hospitalized patient who died

suddenly from a

bronchial-pulmonary fistula, with

discussion of the use of the

autopsy for diagnosing emerging

infectious diseases and infectious

disease of concern to

institutions (9);

9.	 provision of information about the

cause and circumstances of death

when death possibly results from

medical devices that malfunction

or which are not used

appropriately (10);

10.	 discussion of the ‘‘private

autopsy’’ in which a pathologist,

for an agreed-upon fee, may

perform an autopsy for a third

party (such as the family) outside

of the usual institutional setting for

hospital deaths or medicolegal

(forensic) cases (11);

11. listing of possible reasons for the

decline in institutional autopsy

rates over the past several decades

in the United States (12);

12.	 recognition that the autopsy may

be ‘‘negative’’ (i.e., not

demonstrate specific findings) and

not necessarily answer questions

that have arisen, or identify a

specific cause-of-death (13);

13.	 recognition that the autopsy

provides reports, tissues, and other

specimens that may be

re-examined at a later time if legal

or other controversial issues arise;

that such information helps avert

the need for speculation; and that

some findings and their

significance can be interpreted in

more than a singular way (14);

14.	 discussion of the use of autopsy

findings to amend (correct) a death

certificate that was incomplete or

originally in error (15);

15. recognition that autopsy findings

can be used to allay concern

among medical professionals and

the public when a death presents

as one that could have public

health ramifications (such as

meningococcemia), but is proven

to be of other causes that are of

little or no concern (16);

16.	 illustration of how the autopsy

allows excellent clinico-pathologic

correlation when the clinical

course is atypical or involves

unusual causes (17);

17.	 discussion of autopsy utilization

for not-so-obvious procedures such

as providing control tissue for

special histologic stains, or to

obtain genetic material from

neoplasms, for example (18);

18.	 discussion of the use of the

autopsy to investigate deaths that

involve implanted medical devices

such as pacemakers (19);

19.	 recognition that the autopsy may

be used to distinguish whether

death resulted from an unavoidable

outcome (20);

20.	 recognition that the autopsy is not

only a valuable teaching tool for

clinicians, but is also needed as an

educational and training tool for

pathologists who are training in a

pathology residency program (21);

21.	 presentation of answers to

numerous commonly asked

questions about the autopsy, which

may be helpful to clinicians who

are often asked such questions by

family members (22)

22.	 discussion of the use of the

autopsy for outcome analysis and

quality assessment of therapeutic

interventions (23);

23.	 recognition of the value of the

autopsy in detecting findings

incidental to the cause-of-death,

and findings that may better

explain to the family the patient’s

clinical course or lack of detection

of serious disease by routine

diagnostic tests (24);

24.	 discussion and historical review of

the use of the autopsy, including

considerations that deal with

inadequate financial support from
Page 40 [ Series 3, No. 32

health care payment agencies (25);

25.	 recognition of the value of the

autopsy in evaluating transplant

donors and in evaluating

complications of radiation

treatment for neoplasms (26);

26.	 discussion of how the autopsy may

disclose previously undiagnosed

conditions that may have impact

on survivors, such as breast cancer

that may have a familial

occurrence (27);

27.	 discussion of the value of the

autopsy in evaluating suspected or

alleged elder abuse and neglect,

which serves to protect patients,

institutions, and health care

workers (28);

28.	 discussion of the use of the

autopsy in bringing about clinical

recognition of limitations,

idiosyncrasies, or possible

interpretive errors when new

technologies are implemented (29);

and

29.	 discussion of autopsy utilization to

help determine the relative roles of

the underlying disease and/or its

treatment in causing or

contributing to death (30).

Comments

The autopsy has been used in North

America for nearly 400 years. Although

disease patterns have changed and new

technologies have emerged during that

time, human anatomy, cellular, and

subcellular structure and function have

not changed much to our knowledge.

Although our understanding of these

things continues to deepen, there is still

much to learn from the scientific

standpoint. On the practical side, there

are often relatively simple questions that

arise when death occurs which the

autopsy may easily and reliably answer.

Thus, from both the scientific and

practical viewpoints, the autopsy

remains a useful tool to ‘‘see things for

one’s self.’’

Many medical technologies

(diagnostic and therapeutic devices and

methods) have come and gone

completely, yet the autopsy persists. Its

withstanding of the test of time—albeit

on occasional shaky ground—is

testimony to its place as an essential

component of the practice of medicine.

Take, for instance, the recent growth in

the clinical use of laparoscopic

procedures, which are not always

without untoward complication.

Information has been obtained from

autopsy that has prompted rethinking

about the safe uses of laparoscopic

surgery. Thus, an old procedure (the

autopsy) remains valuable to evaluate

newer ones.

Recent reports of large numbers of

in-hospital deaths due to complications

of diagnostic and therapeutic procedures

provide good reason to perform more

autopsies if for no reason other than to

enable the collection and documentation

of objective postmortem findings to

refute or support claims that arise. Who

knows, we could find out that many

such deaths are being incorrectly

attributed to medical procedures and

treatments. Of course, we could find out

otherwise. Regardless, there would be

some objective information available

beyond that which would exist if an

autopsy were not performed.

Even if technologies were to

emerge (let’s call it an ‘‘autopsy

machine’’) which could replace part or

all of the autopsy procedure, such as

scans or other imaging procedures,

robotic procedures, or less invasive

methods such as fiber-optic scope

procedures, classical autopsies will still

need to be performed as the standard to

which these emerging methods are

compared, and in cases where the newer

technologies may have limitations.

Certain lesions or objects will still need

to be physically removed for analysis.

And, in the foreseeable future, an

autopsy performed by a pathologist will

probably remain more reliable and

cost/time effective than automated or

hands-off procedures.

It’s easy to advocate the use of the

autopsy. But what specific things can be

done to revitalize its use? We have a

few suggestions.

To be sure, not all pathologists wish

to perform autopsies, and that fact is

undoubtedly part of the reason for the

historical decline in autopsy utilization.

In fact, an autopsy attitude adjustment is

probably indicated within parts of the

pathologist community. For institutions

in which there is a need to perform

autopsies, steps need to be taken to

ensure that pathology departments

include pathologists who are not only

willing, but who take professional

interest and pride in performing

autopsies. Regionalized (or centralized,

depending on how one looks at it)

autopsy centers, established through

partnerships or consortia, may be one

workable option.

Clinicians, through their informing

of families about the autopsy and

requesting permission to perform one,

play a key role in the use of the autopsy

to investigate deaths which occur in

medical institutions. We believe that

families should always be offered the

opportunity for an autopsy when death

occurs in the hospital and that one

should be performed if the family

requests or consents to it, even if the

physician or medical staff has minimal

or no interest in the case. This may even

include autopsies on patients who die

outside the hospital but who have an

ongoing medical record in the

institution.

Part of medical practice is to help

prepare families and patients for death.

It seems reasonable to recommend that

physicians discuss the role of the

autopsy with patients and their families,

and to encourage family members to

discuss, prior to death, the patient’s

wishes regarding autopsy. Remember,

family consent is usually needed to

perform an autopsy after the death of a

hospitalized patient. If the family does

not know the patient’s wishes, their

decision is made more difficult. Many

patients desire that their death bring

about some good. That’s why many are

willing to donate their bodies for study

or to donate organs and tissue for

research or transplantation. The autopsy

is another way for a patient or family to

contribute to medicine and society, or to

provide information that may be helpful

to the family or other survivors.

Agencies and organizations who

pay for health care need to shift their

thought process from one which only

recognizes treatment of living patients

toward one which recognizes that the

autopsy can contribute to the overall

quality of medical practice. The autopsy

could provide information that might be
Series 3, No. 32 [ Page 41

used to rethink certain treatments or

procedures to modify their use, redefine

the indications for certain procedures, or

even evaluate payment strategies for

clinical procedures. These agencies

would be wise to come up with a

cohesive plan to ensure that pathology

departments and pathologists are

adequately funded and staffed to

perform an appropriate number of

autopsies based on the number and

types of deaths at a particular institution,

or in a particular region.

Summary

Having not changed in recent

history, the human body continues to

lend itself well to the autopsy procedure

and the documentation and interpretation

of postmortem morphologic, cellular,

and chemical changes. The use of

autopsy findings in conjunction with

other scientific methods and

investigative techniques remains as

valuable today as it was centuries ago,

both in daily practice and for scientific

endeavor. Although the rate of our

learning through the autopsy may have

slowed, the quality of information

obtained remains high. The values and

uses of the autopsy are limited mainly

by our lack of imagination or our

passive or active unwillingness to find

facts in pursuit of scientific truth.

CPR or DNR for the autopsy? DNR

status is reserved for those situations in

which hope has been lost and the

chance for meaningful survival seems

over. The autopsy meets neither

criterion. CPR, therefore, seems

indicated. Successful CPR for the

autopsy will require the effort of

pathologists, clinicians, institutions, and

payers. It is our ethical, scientific, and

medical obligation to revive the autopsy

to an appropriate level of utilization. Let

the CPR begin! Breathing life into the

autopsy will also revitalize the practice

of medicine.

NOTE: Volume 160, November 13, 2000. Randy

Hanzlick, M.D., Emory University School of

Medicine, Atlanta, GA; and the Autopsy

Committee of the College of American

Pathologists, Northfield, IL.

References

1.	 Dalen JE. The moribund autopsy: DNR

or CPR? Arch Int Med. 1997;157:1633.

2.	 Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Autopsy and Medicine:

Case of the Month (#1, Aug). Arch Int

Med. 1997;157:1645.

3.	 Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Autopsy and Medicine:

Case of the Month (#2, Sept). Arch Int

Med. 1997;157:1798.

4.	 Lee EY, Cibull ML, Hanzlick R, and

the Autopsy Committee of the College

of American Pathologists. Autopsy and

Medicine: Case of the Month (#3, Oct).

Arch Int Med. 1997;157:2044.

5.	 Davis GL, Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Autopsy and Medicine:

Case of the Month (#4, Nov). Arch Int

Med. 1997;157:2296.

6.	 Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Autopsy and Medicine:

Case of the Month (#5, Dec). Arch Int

Med. 1997;157:2557.

7.	 Pfeifer EA, Bjornsson J, Hanzlick R,

and the Autopsy Committee of the

College of American Pathologists.

Autopsy and Medicine: Case of the

Month (#6, Jan). Arch Int Med.

1998;158:14.

8.	 Hutchins GM, Hanzlick R, and the

Autopsy Committee of the College of

American Pathologists. Autopsy and

Medicine: Case of the Month (#7, Feb).

Arch Int Med. 1998;158:219–20.

9.	 Hanzlick R, Nichols L, and the

Autopsy Committee of the College of

American Pathologists. Autopsy and

Medicine: Case of the Month

(#8, March). Arch Int Med.

1998;158:426.

10.	 Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Autopsy and Medicine:

Case of the Month: Complications of

therapy, nursing homes, and the elderly

(#9, April 1998). Arch Int Med.

1998;158:695–6.

11. Hanzlick R, Hutchins GM, and the

Autopsy Committee of the College of

American Pathologists. Autopsy and

Medicine: Case of the Month: Private

autopsies (#10, May 1998). Arch Int

Med. 1998;158:947–8.

12.	 Hanzlick R, Baker P, and the Autopsy

Committee of the College of American

Pathologists. Autopsy and Medicine:

Case of the Month: Institutional

autopsy rates (#11, June 1998). Arch

Int Med. 1998;158:1171–2.

13. Bjornsson J, Hanzlick R, and the

Autopsy Committee of the College of

American Pathologists. Autopsy and

Medicine: Case of the Month: Negative

results of autopsy and elusive

cause-of-death (#12, July 1998). Arch

Int Med. 1998;158:1399–1400.

14.	 Hutchins GM, Hanzlick R, and the

Autopsy Committee of the College of

American Pathologists. Autopsy and

Medicine: Case of the Month:

Speculation and competing causes of

death (#13, August 1998). Arch Int

Med. 1998;158:1593–4.

15.	 Smith AE, Hutchins GM, Hanzlick R,

and the Autopsy Committee of the

College of American Pathologists.

Autopsy and Medicine: Case of the

Month: Making amends (#14,

September 1998). Arch Int Med.

1998;158:1739–40.

16.	 Havlik DM, Irvine R, Hanzlick R, and

the Autopsy Committee of the College

of American Pathologists. Autopsy and

Medicine: Case of the Month: Allaying

apprehension (#15, October 1998).

Arch Int Med. 1998;158:1971–2.

17.	 Collins KA, Lee J, Hanzlick R, and the

Autopsy Committee of the College of

American Pathologists. Autopsy and

Medicine: Case of the Month: Death

and distraction (#16, November 1998).

Arch Int Med. 1998;158:2183–4.

18.	 Collins KA, Nichols CA, Hanzlick R,

and the Autopsy Committee of the

College of American Pathologists.

Autopsy and Medicine: Case of the

Month: Not-so-obvious uses of the

autopsy (#17, December 1998). Arch

Int Med. 1998;158:2429–30.

19.	 Baker PB, Hanzlick R, and the Autopsy

Committee of the College of American

Pathologists. Autopsy and Medicine:

Case of the Month: Death and devices.

Arch Int Med. 1999;159:21–2.

20.	 Davis A, Fields A, Hill C, Hanzlick R,

and the Autopsy Committee of the

College of American Pathologists.

Autopsy and Medicine: Case of the

Month: Unavoidable outcomes versus

misadventures. Arch Int Med.

1999;159:646–7.

21.	 Hanzlick R, McKenney J, and the

Autopsy Committee of the College of

American Pathologists. Autopsy and

Medicine: Case of the Month:

Education of the pathologist. Arch Int

Med. 1999;159:907–8.

22.	 Hanzlick R, Mosunjac MI, and the

Autopsy Committee of the College of

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 

describe the data collection programs of the National Center 

for Health Statistics. They include descriptions of the methods 

used to collect and process the data, definitions, and other 

material necessary for understanding the data. 

SERIES 2.	 Data Evaluation and Methods Research—These reports are 

studies of new statistical methods and include analytical 

techniques, objective evaluations of reliability of collected data, 

and contributions to statistical theory. These studies also 

include experimental tests of new survey methods and 

comparisons of U.S. methodology with those of other 

countries. 

SERIES 3.	 Analytical and Epidemiological Studies—These reports 

present analytical or interpretive studies based on vital and 

health statistics. These reports carry the analyses further than 

the expository types of reports in the other series. 

SERIES 4.	 Documents and Committee Reports—These are final 

reports of major committees concerned with vital and health 

statistics and documents such as recommended model vital 

registration laws and revised birth and death certificates. 

SERIES 5.	 International Vital and Health Statistics Reports—These 

reports are analytical or descriptive reports that compare U.S. 

vital and health statistics with those of other countries or 

present other international data of relevance to the health 

statistics system of the United States. 

SERIES 6.	 Cognition and Survey Measurement—These reports are 

from the National Laboratory for Collaborative Research in 

Cognition and Survey Measurement. They use methods of 

cognitive science to design, evaluate, and test survey 

instruments. 

SERIES 10.	 Data From the National Health Interview Survey—These 

reports contain statistics on illness; unintentional injuries; 

disability; use of hospital, medical, and other health services; 

and a wide range of special current health topics covering 

many aspects of health behaviors, health status, and health 

care utilization. They are based on data collected in a 

continuing national household interview survey. 

SERIES 11.	 Data From the National Health Examination Survey, the

National Health and Nutrition Examination Surveys, and

the Hispanic Health and Nutrition Examination Survey— 

Data from direct examination, testing, and measurement on 

representative samples of the civilian noninstitutionalized 

population provide the basis for (1) medically defined total 

prevalence of specific diseases or conditions in the United 

States and the distributions of the population with respect to 

physical, physiological, and psychological characteristics, and 

(2) analyses of trends and relationships among various 

measurements and between survey periods. 

SERIES 12.	 Data From the Institutionalized Population Surveys— 

Discontinued in 1975. Reports from these surveys are 

included in Series 13. 

SERIES 13.	 Data From the National Health Care Survey—These reports 

contain statistics on health resources and the public’s use of 

health care resources including ambulatory, hospital, and longterm care services based on data collected directly from 

health care providers and provider records. 

SERIES 14.	 Data on Health Resources: Manpower and Facilities— 

Discontinued in 1990. Reports on the numbers, geographic 

distribution, and characteristics of health resources are now 

included in Series 13. 

SERIES 15.	 Data From Special Surveys—These reports contain statistics 

on health and health-related topics collected in special 

surveys that are not part of the continuing data systems of the 

National Center for Health Statistics. 

SERIES 16.	 Compilations of Advance Data From Vital and Health

Statistics—Advance Data Reports provide early release of 

information from the National Center for Health Statistics’ 

health and demographic surveys. They are compiled in the 

order in which they are published. Some of these releases 

may be followed by detailed reports in Series 10–13. 

SERIES 20.	 Data on Mortality—These reports contain statistics on 

mortality that are not included in regular, annual, or monthly 

reports. Special analyses by cause of death, age, other 

demographic variables, and geographic and trend analyses 

are included. 

SERIES 21.	 Data on Natality, Marriage, and Divorce—These reports 

contain statistics on natality, marriage, and divorce that are 

not included in regular, annual, or monthly reports. Special 

analyses by health and demographic variables and 

geographic and trend analyses are included. 

SERIES 22.	 Data From the National Mortality and Natality Surveys— 

Discontinued in 1975. Reports from these sample surveys, 

based on vital records, are now published in Series 20 or 21. 

SERIES 23.	 Data From the National Survey of Family Growth—These 

reports contain statistics on factors that affect birth rates, 

including contraception, infertility, cohabitation, marriage, 

divorce, and remarriage; adoption; use of medical care for 

family planning and infertility; and related maternal and infant 

health topics. These statistics are based on national surveys 

of women of childbearing age. 

SERIES 24.	 Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy— 

These include advance reports of births, deaths, marriages, 

and divorces based on final data from the National Vital 

Statistics System that were published as supplements to the 

Monthly Vital Statistics Report (MVSR). These reports provide 

highlights and summaries of detailed data subsequently 

published in Vital Statistics of the United States. Other 

supplements to the MVSR published here provide selected 

findings based on final data from the National Vital Statistics 

System and may be followed by detailed reports in Series 20 

or 21. 

For answers to questions about this report or for a list of reports published in 

these series, contact: 

Data Dissemination Branch
 

National Center for Health Statistics
 

Centers for Disease Control and Prevention
 

6525 Belcrest Road, Room 1064
 

Hyattsville, MD 20782-2003
 

(301) 458–4636
 

E-mail: nchsquery@cdc.gov
 

Internet: www.cdc.gov/nchs/
 
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National Center for Health Statistics
 

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DHHS Publication No. (PHS) 2001-1416, Series 3, No. 32
 

01-0487 (10/01)