Hospital and Natural Death

Major discrepancies

Class I and Class II

Minor discrepancies

Class III and Class IV

Non discrepancy

Class V

Non-classifiable cases

Class VI

Class I

Knowledge of diagnosis before death would have led to changes in management that could have prolonged survival or cured the patient.

Class II

Discrepancies in major diagnoses whose detection before death would not have changed survival even with correct treatment. (could have changed something but wouldn’t have saved the patient)

Class III

Not directly related to cause of death, but with symptoms that should have been treated or would have eventually affected prognosis

Class IV

In minor occult diagnoses (non-diagnosable) but with possible epidemiological or genetic importance

Class V

Non-discrepant diagnoses

Class VI

Patient died immediately after admission with no diagnostic procedures, or refused any diagnostic procedures or treatment.

Why are Hospital autopsies less needed now

• Better medical understanding of many diseases

• More advanced testing leads to better pre-mortem diagnosis

• Fewer in-hospital pathologists doing autopsy

• Expensive for the Hospital to do

Why are Autopsies so important even at the hospital

• Opportunity to recognized misses diagnosis (patient treated incorrectly and die)

• Opportunity to recognize errors and reduce error rate in the future

• Opportunity for teaching and learning

Natural death

attributed to an illness or an internal malfunction of the body not directly influenced by external forces.

…aging-associated diseases

Health departments discourage listing old age as the cause of death since there is always a more direct cause although it may be unknown in certain cases and could be one of a number of….

Is smoking/ drug use considered natural death

Yes

Is an overdose considered natural death

No

What is not a cause of death

age (we always die of something that stops working/ malfunctions, not because we’re “too” old)

What makes a death “unnatural”

• Suspicious circumstances

• No preexisting condition that may explain the death

• Unexpected death of condition that was not clinically suspected to be serious

When is an autopsy a hospital autopsy

• When the patient’s manner and cause of death are felt to be outside the jurisdiction of the medical examiner

• A “natural death” with no suspicious circumstances

• Patient must have been in the hospital at the time of death

Why would someone in the hospital need an autopsy

• Sudden death with no suspicious circumstances

• Patient with multiple medical problems

• Information for family (genetic syndrome, cancer with genetic disposition)

• information for legal reasons (asbestos)

Who requests an autopsy at the hospital

• Family (next of kin)

• Physician

Who does a hospital autopsy

• Hospital pathologist

• Freelance pathologist who comes to hospital

• Outside pathologist

Autopsy Timeline

1. Autopsy Permit Review

2. Chart Review

3. Gross Exam

4. Internal Exam

5. PAD

6. Microscopic Exam

7. Final Report

Autopsy Permit

Legally binding consent giving permission to cut the body

Autopsy Permit Review

• properly filled out

• Next of Kin

• Signature

• Limit to post (Brain only, No brain)

Signature

The witness signature

Limit to post

usually don’t put organs back except for religious/ cultural reason

Next to Kin

1. Spouse

2. Children (normally starting with eldest legal offspring)

3. Parents

4. Siblings

5. Grandchildren

6. Grandparents

7. Nieces/ Nephews

8. Aunts/ Uncles

Chart Review (Medical record)

• Scene and circumstances

• What testing did the patient already have

• what was the clinical suspicion

• what medications, surgeries, etc..

Diener

Autopsy assistant, handle move and clean the corpse

What do the Diener do

• in some places the entire evisceration

• Remove organs for further study

Pathologist Assistant (PA)

Gross examination and autopsy

PA

• preparing tissue samples

• photography

• write rough draft of report

Resident

Pathologist in-training

Functions of Resident

• Autopsy rotations

• Perform most cases when they are present

• Report is still signed by an attending pathologist

Pathologist

• Performs some/ all cutting

• Writes report

Gross examination

Height, weight, hair, eye color, scars, tattoos

What do Gross Examination looks at

• Evidence of medical interventions (tubes)

• Evidence on the external skin of disease

Internal Exam

Y incisions vs U incision

What do Internal Exam remove

remove and measure fluid

What do Internal Exam observes

• Position of organs

• Organ gross appearance (color, masses)

Organ weight

depends on a lot of factors (age, sex, ethnicity, height, weight, other medical conditions..)

Section the organs look for

• classic signs of certain conditions

• unexpected findings

• take microscopic section

Preliminary anatomic diagnosis (PAD)

gross findings at the time of autopsy

When is the PAD released

within 24 hours of autopsy completed per CAP (College of American Pathology)

PAD

says exactly what you see

Microscopic Exam

Review of the glass slides that have been prepared from the tissue sections

Writing the repot

• Put together all the findings

• Clinical history

• External exam

• Internal exam

• Microscopic findings

• Special studies (blood test, microbiology)

• FAD with cause of death

Manner of death

Natural

Cause of death

• Diabetes

• Atherosclerosis

• Hypertension

• alcohol abuse

• Lung Cancer

• Hepatitis C

• etc.

Classification

How sure is the cause of death

Class 1 Classification

cause of death with 100% certainty

Class 2 classification

• No structural change immediately inconsistent with life

• Advanced disease is present sufficient for death

Class 3 classification

Something that might have killed them if other things are ruled out

Class 4 classification

• don’t know what else would have killed them

• no lethal structural findings

• no alternative explanation

• no real evidence

• sudden death in epilepsy

Class 5 classification

• No idea what killed them

• no autopsy finding or toxicology

Common cause of natural death

• Coronary artery disease “Atherosclerosis”

• Myocardia Infarction

• Hypertension

• Aortic Dissection

• Aortic Aneurysm

• Stroke

• Cancer

• Pulmonary Embolism

• Diabetes

• Chronic drug and alcohol abuse

• Emphysema

Coronary artery disease

Narrowing of coronary arteries, with or without calcification, with or without thrombus

What happens during Coronary artery disease

heart muscle doesn’t get enough blood and it dies, heart can’t pump or sudden arrhythmia

Myocardial infarction

heart attack due to sudden obstruction of coronary artery

Hypertension

High blood pressure

What causes Hypertension

Heart muscle gets thick because it’s working out, requesting more and more oxygen and suddenly doesn’t get enough causing it to die

Aortic dissection

complication of high blood pressure and atherosclerosis

Aortic Aneurysm

Dilation of the wall of the major artery in the body can rupture and rapidly cause death

Stroke (2 kinds)

Poor blood flow to the brain results in death of brain cells

1st kind of stroke

Ischemic stroke

Ischemic stroke

not enough blood, able to recover

Ischemic stroke caused by

• Blood clot

• Atherosclerosis

• People with genetic clotting diseases

2nd kind of stroke

Hemorrhagic stroke

Hemorrhagic stroke

too much blood, much harder to treat

Hemorrhagic stroke caused by

• Brain bleed

• A ruptured vessel

• High blood pressure

• People on drugs to keep them from clotting

Cancer

Second most common cause o death in the western world

Multiple categories of cancer

• Carcinoma

• Sarcoma

• Melanoma

• Lymphoma

Carcinoma

originates in epithelial tissues

Sarcoma

Connected tissue

Melanoma

pigment producing cells due to DNA damage, can look very wild

Lymphoma

white blood cells

where does Pulmonary Embolism start

Usually start in the legs

Pulmonary Embolism

A blood clot in the lung vessels

What is pulmonary embolism caused by

• cancer

• obesity

• immobility

Diabetes

High blood sugar

Type I diabete (juvenile)

• Pancreas is unable to produce insulin

• Likely due to autoimmune or virus

Type II diabete

Cells don’t respond to insulin properly (insulin resistance)

Diabetic Ketoacidosis

• High glucose results in burning ketones

• Acidosis, dehydration, brain swelling

Long term chronic changes-end organ damage

• Kidney

• Heart

• Brain

Chronic Drug and alcohol abuse

result in many chronic conditions leading to death

Emphysema

Cigarette smoke damages the walls of the small spaces in the lung