medical and forensic autopsy: fact and fiction

1. Medical and Forensic Autopsy: Fact and Fiction LSUHSC - Shreveport, LA Department of Pathology James G. Traylor, Jr., MD Associate Clinical Professor & Angela Grantham, MBA, BS MT(ASCP) Pathology Outreach Director Editor: Ms. Lisa LaChance

2. Why Should I Care? Final voice of the patient or victim Discussing autopsy with the family Eliminating myths Resources available Pathologist Pathology Outreach Director Coroner

3. Introduction To The Autopsy

4. Objectives Describe the role of the autopsy (medical, private and forensic) Discuss the impact and benefits of autopsy List causative factors in the decrease of autopsies nationwide

5. What is an Autopsy? Postmortem examination of the organs and tissues of a body to determine cause of death or pathological conditions.

6. Type of Autopsies Medical Forensic Private

7. Why do an Autopsy? Although the primary reason to perform an autopsy is to determine cause of death, there are other benefits to individual families, the practice of medicine, and the community at large.

8. Benefits of an Autopsy Allaying a family�s fears about what they could have done to prevent the death. Providing family members information about potential genetic diseases that may have implications for them. Medical education, training and research leading to improved health care. Providing information about preventable causes of disease and accident and other public health hazards.

9. Forensic Benefits In addition, there are forensic benefits of investigation of homicide, suspected homicide, other unexplained or suspicious deaths, and deaths apparently due to accident or injury.

10. Other Findings Studies have shown that in many cases even when cause of death seemed clear, the person in fact had medical conditions that were not apparent during their life.

11. Objectives of the Autopsy The autopsy has a different significance for each person, depending on their relationship to the patient and their role in medical care.

12. Purpose For Families To determine why death occurred To learn whether everything medically possible was done To determine what the likelihood is that other members of the family may be affected

13. Purpose For Non-family Members Layman unrelated to the deceased: Establish the cause of death in cases where death is unexplained or is poorly understood by the medical team Law enforcement officials: Attempts to clarify the circumstances of violent and unexplained deaths Provides documentation of the injuries

14. Primary-care physicians and non-surgical consultants: Provides a final determination of the diagnosis Provides explanation of doubtful observations Provides evaluation of treatment Surgical specialists: Provides information on such matters as why a postoperative death occurred, the condition of the suture lines, and the completeness of removal of a lesion Medical staff of a hospital, Hospital Administrator and governmental agencies monitoring health care: Provides a quality control mechanism, a final yardstick by which the care of a patient can be measured

15. Researcher: A source of new ideas as to cause of disease May also provide an evaluation of new procedures and new therapeutic agents, and an explanation of adverse reactions, with the hope that they can be prevented in the future All members of the medical team: Provides a learning experience: Medical student - a first understanding of the effects of disease Student, house staff and attending physician alike - the meaning of certain observations unexplained during life, such as a heart murmur, a shadow in a chest x-ray, or an abnormal laboratory result

16. Society in general: Benefits if autopsies could be used to compare the incidence of particular diseases in different geographic areas To survey the changing status of health and disease in the populace from year to year To evaluate the impact of environmental hazards To determine priorities among various research programs and effectiveness of sanitary measures in force

17. Limitations of the Autopsy Necessity of viewing care in �retrospect� Lessons learned may not carry over to current patients Cannot answer questions that you may have about your patient�s disease process unless you communicate with the pathologist In 1 to 2 percent of cases a definitive cause of death cannot be found

18. Postulated Causative Factors: Decrease of Autopsy Rates Improvements in diagnostic technology Fear of litigation Removal of defined minimum autopsy rate standards Lack of direct reimbursement Lack of standardization of the autopsy as a medical procedure with resultant lack of credibility as a valid outcome or performance measure

19. Forensic Pathology: An Overview

20. Outline Brief historical perspective Becoming a Forensic Pathologist Introduction to Medicolegal Case Work Louisiana Coroner Law Closing quote

21. Brief Historical Perspective Earliest application of forensic medicine had to do with the interdiction against suicide. 10th century suicide became a crime under the common law in England. 1184 the Council of Nimes made the condemnation of suicide part of the canon law of the Roman Catholic Church. Decisions as to manner of death seem to have been made mostly by an investigation of the circumstances without specific examination of the body.

22. Historians reported Antistius, a physician in Rome, examined the body of Julius Caesar and reached the opinion that, of the twenty-three stab wounds Caesar sustained, the only mortal wound was one in the chest. In China a handbook entitled Hsi Yuan Lu was published in about 1250 and contained limited brief outlines for the postmortem examination of bodies including descriptions of various wounds caused by sharp versus blunt instruments.

23. Written records of the development of forensic pathology in Europe begin in 1507, when a volume, subsequently known as the Bamberg Code, appeared. Twenty-three years later, a more extensive penal code, known as the Constitutio Criminalis Carolina, was issued by Emperor Charles V for all lands included in his empire. The two documents : Portrayed importance of forensic pathology in requiring medical testimony be integral part of proof and trials involving decisions about whether the manner of death was infanticide, homicide, abortion or poisoning Did not specify that complete autopsies were to be performed, but wounds were opened to determine their depth and direction

24. Latter half of the 16th century Ambrose Pare performed official medicolegal autopsies. Fidelis and Zacchia in Italy, in the early 17th century, were likewise engaged in anatomical dissections and reported analyses of injuries to internal organs. First formal lectures in forensic pathology were held by Michaelis and Bohn at the University of Leipzig where students were apparently instructed in the subject of violent death and simulated natural deaths.

25. As a result of advancements by these pioneers, the judicial authorities and the police in Europe soon began to call upon physicians to aid in the solution of fatal crimes, and most of the larger jurisdictions developed centers, commonly known as institutes of forensic medicine, where experts carried out their investigations. The historical development of medicolegal investigation in America can be clearly traced back to the English coroner system, which had developed in that country some 600 years before.

26. Appointment then included coroner�s duties and the term �coroner� is obviously a corruption of �crowner� applied to the individual charged under this law. Justices in eyre, apparently comparable to traveling circuit court judges of modern day, could order the coroner to perform duties of administrative or inquisitorial nature within the region for which he had been appointed.

27. Among these were the holding of inquests over dead bodies and �appeals�: Inspection of an individual�s wounds Recording the accusation against another individual If wounds appear likely to be fatal, arresting the accused individual. Coroner was also authorized by county courts to attach or arrest witnesses or suspects and to appraise and safeguard any lands or goods that might later be forfeited by reason of guilt of the accused.

28. Despite descriptions of duties, it appears that they were loosely drawn, and the coroner became concerned only with felonies that resulted in homicide or suicide or a felony resulted in a crown plea requiring enforcement. Interesting example of the latter is �outlawry�, where, if the accused still absented himself after public demand had been made for him to appear and surrender to justice on four occasions, the justices in eyre would declare him an outlaw. Thereupon his goods and chattels were forfeited to the crown and his head could be cut off with impunity by anyone. Other than the relegation of the function of death investigation to the coroner with loss of essentially all other duties, there was little development of the coroner system in England until the middle of the 19th century.

29. In 1877 a law enacted requiring an inquest be conducted: Whenever coroner had reasonable cause to suspect violent or unnatural death When cause of death was unknown Result - granted the coroner the widest authority to investigate cases and was indeed in sharp contrast to the continental system, where investigations were commenced only by the prosecutors or police officials

30. 1877 - Boston Commonwealth adopted a statewide system requiring coroner be supplanted by a physician known as a medical examiner. Unfortunately, the jurisdiction of the medical examiner was confined to �dead bodies of such persons only as are supposed to have come to their death by violence.� 1915 - New York City adopted a law eliminating the coroner�s office and created a medical examiner system, authorizing investigation of deaths resulting from: Criminal violence Casualties Suicide Sudden death while in apparent health When not attended by a physician Imprisoned Any suspicious or unusual manner

31. Becoming a Forensic Pathologist Graduating from medical school (4 years) and passing the three parts of the United States Medical Licensing Examination before being granted licensure in a given state Acceptance into a Pathology Residency Program with successful completion (currently 4 years of additional training which was previously 5 years)

32. Passing the board examination given by the American Board of Pathology (ABP) to become a board certified pathologist Applying to and being accepted into an approved Forensic Pathology fellowship program (subspecialty of pathology) which requires an additional year of training Successfully completing the fellowship and sitting for the board examination in Forensic Pathology given by the ABP to become a board certified Forensic Pathologist

33. Total Time Invested College 4 years Medical School 4 years Pathology Residency 4 years Forensic Fellowship 1 year _______ 13 years and $$$

34. Introduction:Medicolegal Case Work Five categories of medicolegal cases: Violent deaths, i.e., non-natural deaths (accidents, suicides and homicides) Suspicious deaths, i.e., those that may be due to violence Unattended deaths, i.e., those in which a physician is not in attendance Sudden and unexplained deaths Deaths in custody Note: Individual jurisdictions may modify these categories, either expanding them or contracting them.

35. Prevalence of medicolegal cases In most communities, approximately half of all deaths are reportable to a medicolegal office Of these, half (approximately 25% of all deaths) will be accepted as medicolegal cases Others are generally unattended deaths of individuals under the care of a physician who is willing to sign a death certificate, e.g., deaths in Hospices; at home; etc. Even if a case is not accepted, a written record of the report containing details of the death should be made and retained

36. Objectives of medicolegal examination: To positively identify a body Determine the cause of death Determine the manner of death To document all findings To determine or exclude other factors that may have contributed to the death or how the manner of death should be classified To collect trace evidence from the bodies in criminally related cases

37. Pathologist may subsequently be called to: Testify in Court to the findings Interpret their significance; how they occurred; the nature of the weapon used (if any) Determine time of death

38. Cause, Mechanism And Manner Of Death Deaths can be categorized as to cause of death, mechanism and manner. Cause of death is the disease or injury that produces the physiological disruption in the body resulting in the death of the individual, e.g., a gunshot wound to the chest. Mechanism of death is the physiological derangement due to the cause that results in the death, e.g., hemorrhage. Manner of death is how the cause of death came about.

39. Manners of death are: Natural Accident Suicide Homicide Undetermined Unclassified A homicide classification does not necessarily indicate that a crime has been committed: Term of homicide is not synonymous with murder �Homicide� means that one individual killed another Classification of death as murder is done by a Court not a pathologist.

40. Manner of death is classified as undetermined when after an investigation of circumstances surrounding death, a postmortem examination and appropriate laboratory tests, there is insufficient information to classify the death as natural, homicide, suicide or accident. Some forensic pathologists use a classification of �unclassified� when the death does not fall into any of the aforementioned manners of death. Example - psychotic individual who decides they can fly and attempts to do so off a 200 foot cliff. Such a death is obviously not natural or homicide but is it suicide or an accident? Deaths formerly termed �therapeutic misadventures� may be listed as unclassified.

41. The average caseload, broken down by manner of death, for a large metropolitan medical examiner�s office: Natural 47.6 % Homicide 11.4 % Accident 28.5 % Suicide 10.7 % Other 1.8 %

42. Forensic Autopsy Versus An External Examination It is not necessary to perform an autopsy in all medicolegal cases. The reasons for performing an autopsy are varied. The most obvious ones are: To determine the cause of death when it is not known To document injuries To exclude other causes of death To determine and/or exclude contributory factors to the death. Note: Reason why autopsies are performed in most homicides, suicides and accidents

43. In some jurisdictions, autopsies are mandated in certain types of death. Autopsies should be performed on all homicides. The extent of the autopsy: Complete autopsy, at a minimum, involves removal and examination of the brain; the larynx and hyoid; the thoracic and abdominal viscera as well as collection of blood, urine, bile and vitreous, when available. In certain cases one may want to make an even more extensive examination, e.g., incise the legs looking for the source of a pulmonary embolus.

44. As a general rule, either no autopsy or a complete autopsy should be performed. Exceptions occur: Generally involve autopsies limited to the head Example - In cases where there is a well documented self-inflicted gunshot wound of the head and the bullet has not exited Purpose of this limited autopsy is recovery of the bullet All homicides should be completely autopsied.

45. Three Steps Of Medicolegal Death Investigation Step 1 - investigation of circumstances leading up to and surrounding the death. Obtain as much information as possible prior to examining the body. Postmortem examination of a body should never be conducted until one knows the circumstances of the death. Investigation of the circumstances of a death may involve: Investigation of the scene Talking to witnesses, next-of-kin and attending physicians Obtaining past medical records and/or police reports

46. Cases where homicide is suspected, talk to the police to find out any special examinations or tests that they may desire. Circumstances of death may determine to some degree the extent of the subsequent postmortem examination. Example - A complete work-up for rape would be conducted on the body of a young girl found semi-nude in an isolated area but not if she was fully clothed and shot walking home from school. Step 2 - examination of body, whether it be an autopsy or an external examination Step 3 - performance of laboratory tests (including but not limited to toxicology, ballistic test firings, etc.)

47. Handling Of Bodies At The Scene Handling Of Bodies From A Hospital Handling Of Bodies From The Morgue Identification Of Bodies The Autopsy Report External examination Evidence of therapeutic intervention Evidence of injury Internal examination Microscopic examination Toxicology Findings Opinion

48. Louisiana Coroner Law Louisiana Revised Statute 33: 1563. Duty to hold autopsies, investigations, etc. Coroner shall either view the body or make an investigation in all cases involving the following: Suspicious, unexpected, or unusual deaths Sudden or violent deaths Death due to unknown or obscure causes or in any unusual manner Bodies found dead

49. Death without attending physician within thirty-six hours prior to the hour of death Death due to suspected suicide or homicide Death in which poison is suspected Death from natural causes occurring in a hospital under twenty-four hours admission unless seen by a physician in the last thirty-six hours Death following an injury or accident, either old or recent Death due to drowning, hanging, burns, electrocution, gunshot wounds, stabs or cutting, lightning, starvation, radiation, exposure, alcoholism, addiction, tetanus, strangulation, suffocation, or smothering

50. Death due to trauma from whatever cause Death due to criminal means or by casualty Death in prison or while serving a sentence Death due to virulent contagious disease that might be caused by or caused a public �hazard�

51. Organ Procurement Chain of communication Coroner case � must have coroner�s authorization (Note: A coroner may choose to defer to the forensic pathologist to determine if harvesting will interfere with evidence or other crucial information that the autopsy can provide the investigators.) Non-coroner case � immediate next of kin must authorize organ donation to proceed. What can be harvested? Body condition and length of time since death are factors that can restrict type of harvesting performed Communication with the pathologist is critical to promote patient safety Harvesting should be performed prior to the body being sent to the morgue

52. Closing Quote �The search for truth is the essence of forensic pathology. This truth forms an essential link between the enforcement of law and the protection of the public in the administration of justice.� Spitz and Fisher�s Medicolegal Investigation Of Death Guidelines for the Application of Pathology to Crime Investigation