Autopsies: A Pathologist’s Explanation
Guest: Dr. Michael Caplan – Pathology, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Michael Caplan, who is Assistant Professor of Pathology here at the Medical University of South Carolina. Dr. Caplan, let’s talk, now, if we could, about autopsies. I’m sure that somebody out there, listening, is picking up on this podcast because they’ve been confronted with the decision about whether someone they love needs an autopsy. What is the function of an autopsy?
Dr. Michael Caplan: Well, I’ll start, Dr. Austin, by defining what an autopsy is. It’s actually a word that comes from the Greeks, which means to see with one’s own eyes. And, really, that’s what it is. An autopsy is an examination on a deceased individual; a postmortem examination, to use another term, that attempts to, as faithfully as it can, reconstruct the events that led to that person’s death. Put another way, it’s an examination which attempts to identify the cause of death; the disease or injury which set in motion the sequence of events which led to that person’s death.
But it also does much more than that. It also tries to identify, depending on the kind of case it is, the manner of that person’s death; whether it was a natural death due to disease, or whether it was a death due to an injury of some sort. It attempts to look at the role of other agents, such as drugs or medicines, in that person’s death. It tries to look at the effects of treatment of disease. And so, really, it’s a way for you to look at a person’s body and organs and try to infer, by structure, or by the derangements in the structure, what kind of functions, or problems in function, may have been going on in that person’s organs.
Dr. Linda Austin: Not all autopsies are done exactly the same way. I understand there’s such a thing as a partial autopsy?
Dr. Michael Caplan: That’s correct. A partial autopsy is basically a limited autopsy which focuses on a particular organ or organ system that may be specifically of interest. For example, there might be a person who died of heart failure, but the next of kin, a loved one, may be interested particularly in a nodule that was in that person’s lung. And it may be that only the lungs would be examined at the time of autopsy.
So, if there’s a specific limited question that’s involved, then sometimes we will do a partial, or limited, autopsy. That tends be done more commonly with medical, or hospital, autopsies, where the permission is given by the next of kin, or the family. In forensic autopsies, or medical/legal autopsies, those are almost always complete, and not limited, so that there won’t be any compromise of the evidence that could be provided from the exam.
Dr. Linda Austin: Now, you mentioned forensic autopsies as an example where you’re doing an autopsy because there may be a criminal prosecution, and you have to be sure about why that person actually died. What are some other common scenarios where an autopsy must be performed?
Dr. Michael Caplan: Some of the most common ones would be any death in which an injury has occurred. It doesn’t have to be criminal. It could be just a motor vehicle accident, or a fall, or a drowning, or a drug intoxication, suspected, okay? Any of those scenarios, by law, those deaths must be reported to a medical/legal official. And in the state of South Carolina, we have a coroner system. We have 46 counties, and coroners in each county. Coroners are lay officials; they’re not physicians, that are elected. So, those deaths must be reported to those coroners. Those coroners, in turn, have the discretion as to whether or not they want to authorize performance of an autopsy.
Dr. Linda Austin: How about other scenarios?
Dr. Michael Caplan: Other scenarios might be just an explained or unexpected death in an apparently healthy person. That is, somebody who was carrying out their usual activities of daily life, and then they have a witnessed collapse in front a family or friends, or they may just be found dead; and you may have idea why they’re dead. So that would be another scenario in which the coroner might elect to authorize an autopsy.
Some other ones might be a death in a prisoner, or somebody in custody, where, because prisoners don’t have the same rights that, you know, free people have, there’s always that perception, or possibility, that there may have been some injury or some foul play involved. So, as a matter of our public safety function, and forensics; coming from the word forum, which means public place, those deaths would also be referred to the coroner, and an autopsy might be performed.
A couple of additional scenarios would include a death occurring under suspicious circumstances, or where there’s no identity; for example, a body found, maybe, at a construction site, or a shallow grave, for example. And then one other category would be if there’s a suspected communicable disease, such as tuberculosis or meningitis, but the diagnosis has not been made. Those, also, would be referred to the coroner.
Dr. Linda Austin: It used to be that the cause of death might be listed as old age; you don’t really see that anymore. Is there an age cut off in which, even if there’s an unexplained death, an autopsy is not performed?
Dr. Michael Caplan: That’s very interesting. I’ll answer that; two questions. First of all, old age, actually, is a legitimate disease recognized by what we call an International Classification of Diseases (ICD). If a person over the age of 90 dies, and an autopsy is done, and doesn’t reveal an identifiable cause of death, that is actually a legitimate diagnosis.
But the other part of your question, Dr. Austin, is that it depends on the jurisdiction. In especially busy offices; especially medical examiners’ offices, the medical/legal officials; physicians or pathologists, where you have a very large catchment area, sometimes an arbitrary age will be used. For example, in San Antonio, Texas; in Bexar County, they use an age of 60 years old. In other words, if an individual is found, or has a witnessed collapse, under apparently benign circumstances; there’s no significant suspicion of any foul play, more often than not, the medical examiner will certify the death without performing an autopsy.
But again, that’s discretion. There may be an unusual case of somebody over that age, if there’s some suspicion of something other than natural; or there may be some person who has such well-documented disease that even if they’re found dead, under the age of 60, they won’t do an autopsy. So those are guidelines, only.
Dr. Linda Austin: Can a family member always request an autopsy for private reasons?
Dr. Michael Caplan: Yes, they can. But the only qualifier to that is that often times the family will have to pay. So, for example, if that patient was an inpatient at an academic teaching hospital, such as MUSC, and the family gives permission, they would never have to pay for that autopsy.
The scenario in which a family might have to pay would be if the family member, or decedent, died at home; not at the hospital, and wasn’t being seen by a doctor affiliated with an academic hospital, and they wanted an autopsy. They might have to pay for a private autopsy, or if the case was potentially a coroner’s case, but the coroner declined jurisdiction. One other example would be if the family decided that they didn’t feel comfortable having the autopsy performed at the hospital where their loved one was treated. They might elect to have that autopsy performed at another site.
Dr. Linda Austin: So, for example, if they were concerned about malpractice, they might request an autopsy at another site? Is that right?
Dr. Michael Caplan: That is correct.
Dr. Linda Austin: And that could be very important if it were a case that went to trial; that autopsy would be most important?
Dr. Michael Caplan: That’s correct. Yes.
Dr. Linda Austin: What are some of the common concerns that family members have about an autopsy that would be helpful to address?
Dr. Michael Caplan: There are the immediate concerns, and then there are the delayed concerns. I think the immediate concern, the overriding one, is preservation of the dignity of their loved one. One of the most common reasons that I’ve encountered in families’ initial reluctance to provide permission for autopsy is that they’ve suffered enough, or that their body will somehow be altered in a way that will compromise their appearance.
The answer that I always give, since a long time ago, is that nothing about the autopsy will ever interfere with an open casket at a funeral. The body is treated with dignity. We make standard incisions. We make what we call Y-shaped incisions, going from the tips of the shoulders down to the middle of the chest, then down to the pubic bone. Even the incision to gain access to the brain is made behind the ears and is not visible in an open casket. So, what I always say, if a person is not viewable in an open casket, it’s not based on what the autopsy did; it’s based on their condition before the autopsy. So, that’s one of the biggest concerns.
Another concern is the delay. You know, how long is it going to take to obtain closure? And that’s certainly a legitimate concern. Sometimes we may be able to tell right away what the cause of death was, even that day. And I would say, you know, depending on the kind of case, anywhere from a third to, maybe, sometimes even more, you can know right then and there what the most likely cause of death was.
The other subset, though, we cannot always tell. And that’s when we may have to do additional studies, such as toxicology, looking at tissues under the microscope; which we perform even if we do have an answer, what we call ancillary studies. So the delay in closure is another issue; and along with that, obtaining the death certificate. Families need the death certificate for insurance reasons, and to be able carry out the affairs to go on with their lives.
I would say those are the two biggest reasons. And then, you know, one other reason is that sometimes there’s a religious objection to autopsy. Two religions that I can think of, offhand; and I don’t want to exclude any, are Orthodox Judaism and Islam. Those are two religions where there are religious objections to autopsy. But those are the main objections, or concerns.
Dr. Linda Austin: How about delayed regret that one did not have an autopsy? Are those situations that you hear about also?
Dr. Michael Caplan: They certainly are. And as a matter of fact, we will sometimes receive calls from family members inquiring whether there’s any way, or any potential value, to performing an autopsy months to years later, after their loved one has been buried. They may even regret that they had the first autopsy done at a particular site; they want to get a second opinion.
But to address your first issue, yes, there sometimes is delayed regret. And oftentimes it will be either that they weren’t in a receptive state of mind, but, you know, most commonly, they simply weren’t asked. Sometimes that rationale is that this isn’t a good time to ask for an autopsy. Well, there’s never really a good time to ask. However, I think if it’s presented in a fair and even way, and the benefits are provided as to what sorts of questions might be answered, it’s best done on the very front end.
Dr. Linda Austin: Well, maybe it’s one of those things, just like a living will and power of attorney, that people need to think about ahead of time, and have some discussion, so that, at the moment of crisis or tragedy, it’s not one more thing that you’ve never thought about before.
Dr. Michael Caplan: That’s a really good point. And as a matter of fact, there are some situations in which those discussions are initiated before the patient dies. I know where I did my training, in Michigan, all the children with congenital heart disease, many of the families had discussions with the pediatric cardiologists and cardiac surgeons to give permission; consent for autopsy afterwards. We also see that in patients that have dementias, in which there’s a dementia network, a collaborative network, where those patients will give permission before their death. I think that’s a wonderful idea.
Dr. Linda Austin: It’s a hard idea; hard to grapple with.
Dr. Michael Caplan: It’s a hard idea too.
Dr. Linda Austin: Although, not so different from organ donation, for example, which we typically do talk about. One final question: autopsies for research purposes, is that something that goes on here at MUSC?
Dr. Michael Caplan: Yes, it is; not for forensic autopsies, because that’s purely medical/legal. But for the medical autopsies, when the next of kin is giving consent, inclusive within that consent form are provisions for research studies, should that be necessary. This is usually coordinated with treating physicians. For example, I know that we have a subset of patients that we’ve done autopsies on that have scleroderma, which is a connective tissue disease that often affects the lungs, and they get what we call pulmonary hypertension, where the pressure in the lungs is very high. That’s one example that comes to mind where a tissue is provided for potential research studies, where the next of kin does give permission for that. But there are many other examples as well. And I think it’s potentially very important, because that can be a very rich resource for study; not only with regard directly to the patient, but to related disease processes.
Dr. Linda Austin: Dr. Caplan, thank you so much. This was an excellent discussion.
Dr. Michael Caplan: Thank you very much.
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