Death as Data: Autopsy and the Death Certificate

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Death as Data Autopsy and the Death Certificate

• Two basic goals
• value of the autopsy
• proper use of the death certificate

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Essential websites and URLS

• Bruce.case_at_mcgill.ca

National Association of Medical Examiners Death
Certificate Tutorials http//www.thename.org/Caus
eDeath/main.htm
A Canadian angle 1998 article from the
Canadian Medical Association Journal http//www.
cma.ca/cmaj/vol-158/issue-10/1317.htm
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Outline

• Autopsy history in three periods
• The fall of the autopsy 1960 onward
• Evidence of continuing relevance
• Some attempts to explain the problem
• Effects of falling rates
• An example of the effect
• Death certificate what it is, how it should be
  approached

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The autopsy in history

• Classical period test authority
• Pre-modern period (17-18C) emphasis on anatomy
• Modern period 19C on
• Rokitansky (gross autopsy)
• Virchow (added the microscope)
• Osler a modern example
• Ultimate recognition as prime goal a contribution
  to medical knowledge

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Falling Autopsy Rates

• From 50 in the 1960s to
• Much lower than 10 today, despite
• (for example) of three U.S. studies, an incorrect
  diagnosis of malignant tumors was shown in
• 36.5 of cases (1923)
• 41 of cases (1972)
• 44 of cases (1998, Louisiana)

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(No Transcript)
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Falling Autopsy Rates RVH 1998
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JAMA 1998 Louisiana study

• All autopsies 1986-95
• Outcome measure discordance in clinical vs.
  autopsy for cancer
• 1105 cases mean age 48 years (very atypical)
• 443 neoplasms at autopsy 250 malignant
• 111 wrong CLINICAL diagnoses of malignancy
  including 57 which caused death

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So what is wrong? 1. Why do the rates keep
falling in the face of continuing evidence of
error?

• Increasing reliance on imaging
• Fear of lawsuits? May explain USA but not
  elsewhere

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So what is wrong? 2. Changing patterns in
pathology

• Changing patterns in pathology and pathologists
• A new but worrying factor regard for autopsy
  practices as violating civil rights (lawsuit in
  UK over pediatric autopsies) reflects a constant
  fight over values over the years coupled with
  some abuses such as Burking

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So what is wrong? 3. Poor communication

• Suggestions of poor communication between
  pathologists and clinicians
• Wherever a special effort is made to educate
  rates increase, although this may be transitory.
  Rates can reach 100 in some centres!

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So what is wrong? 4.

• Suggestions of poor communication between
  pathologists and clinicians
• Poor pay, lack of curiosity, lack of professional
  attitude to reporting can lead to vicious
  circle of late reporting
• Clinical mortality rounds seem to result in
  higher rates when pathologists attend

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Is anything right?

• In academic centres cases with unknown cause
  still invoke requests for autopsy
• This means that almost every increasingly rare
  autopsy has become more interesting both for
  the pathologist, for teaching, and for
  publication, BUT...
• This applies only to academic centres

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Effects of falling rates

• Similar to effects of bad death certificate
  reporting
• National health statistics wrong
• Lack of Quality Control
• Problems for analytical epidemiology (garbage in,
  garbage out)

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Autopsy trends and their effect on disease
ascertainment an example.

• 1. What is this lesion?
• 2. How rare is it?
• 3. Difficulties in Diagnosis
• 1. Result in UNCERTAINTY (or
  guessing This could be X or possibly Y or)
• 2. Result in outright error (mainly lung ca)

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Special Procedures in Pathology Trends for 228
women with mesothelioma 1970-90

• Trends among 142 and 98 female cases diagnosed
  1970-1984 and 1985-1991, respectively.

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Effect of Autopsy Rate on Reliability and
Accuracy in Two Diagnostic Eras
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CMAJ ARTICLE

• 1. Improving the accuracy of death
  certification
• Eight case scenarios are presented
• Kathryn A. Myers, MD, EdM
• Donald R.E. Farquhar, MD, SM
• CMAJ 19981581317-23

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Ontario Death Certificate
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2. WRITING CAUSE-OF-DEATH STATEMENTS

• An On-Line Tutorial
• http//www.thename.org/CauseDeath/main.htm

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Why learn this now?

• Often, a physician's first encounter with the
  death certificate occurs upon the physician's
  first patient death when he/she is handed the
  death certificate form and asked to complete it.
• This usually occurs during the first year of
  residency.
• Many, perhaps most, are not told how and
  never learn!

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The cause-of- death statement contains two parts
Part I

• A)
• Due to, or as a result of
• B)
• Due to, or as a result of
• C)

PART I is designed so that a sequence of
conditions leading to death may be reported
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The cause-of- death statement contains two parts
Part II

• Part II. OTHER SIGNIFICANT CONDITIONS Conditions
  contributing to death but not resulting in the
  underlying cause of death in Part I

EXAMPLES hypertension, diabetes, chronic
obstructive lung disease, renal diseasediseases
pre-existing or co-existing with the MAIN
UNDERLYING DISEASE but NOT related to it
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PART I ONE CONDITION per line, starting with
the most recent condition on the top line and
going backward in time
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An example
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Variants problems

• Single Line Part I Format (missing data) e.g. no
  autopsy, patient dies at home, known to have
  prostate carcinoma
• uncertainty or presumption use probable
• ALWAYS REPORT CANCER!
• Can cheat on part two to record risk factor
  (smoking, asbestos exposure)

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Additional Information on the Death Certificate

• Usually a space to record TIME since onset of
  event
• Always indicate whether (a) an autopsy has been
  asked for and (b) whether the DC includes autopsy
  information
• In some places, can record occupation retired
  is NOT an occupation!!!
• Mandatory reporting violent death, certain
  infections varies with state

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Multiple cause-of-death coding

• All data to date are based on a SINGLE cause of
  death but
• Modern national statistics programs record ALL
  information on the death certificate and can
  derive
• multiple cause-of-death data

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http//www.thename.org/CauseDeath/main.htm (This
is the web address for the tutorial on death
certificates)