|Director:||M. Beatriz S. Lopes, M.D.|
|Attending Staff:||Robin LeGallo, M.D.|
|M. Beatriz S. Lopes, M.D.|
|Thomas W. Tillack, M.D.|
|Mark Wick, M.D.|
|Manager:||Pat Toms, HT (ASCP) 982-4293|
|Admin. Assistant:||Pat Rohm 924-9183|
|Location:||Hospital Expansion Project, Level 0|
Every year despite our best diagnostic and therapeutic efforts, approximately 1,300 patients die at the University of Virginia Hospital. The Clinical Staff Bylaws recommend that an autopsy be requested in all hospital deaths. The Autopsy Service is charged with providing timely and accurate postmortem examinations for the benefit of patients' families, the institution, the attending physicians and housestaff.
Autopsies are performed between 8:00 a.m. - 3:00 p.m. Monday through Friday and 8:00 to 12:00 noon on Saturdays and Sundays. For an autopsy to commence, the body, the permit and the chart or a Clinician knowledgeable about the case must be available during these hours. If there is an emergent need for either fresh tissue or for transport of the body to a distant site for funeral preparations, this can be arranged through the director.
Indications for Autopsy:
While a request for autopsy should be made in every hospital death, the following criteria indicate situations in which autopsies are particularly warranted:
1. To help explain unknown or anticipated medical or surgical complications
2. When the cause of death or a major disease is not known with reasonable clinical certainty
3. To provide reassurance to the family and/or the public regarding the death
4. When there is unexpected or unexplained death that is apparently natural and not subject to the medical examiner's jurisdiction
5. In a natural death possibly subject to, but waived by, the medical examiner, such as person dead on arrival at hospital
6. In a death in which the patient sustained or apparently sustained an injury while hospitalized
7. When an unexpected or unexplained death occurs during or following a diagnostic procedure and/or therapy
8. To disclose a known or suspected illness that may have a bearing on surviving family members or recipients of transplanted organs (e.g., genetic disorders or unsuspected cancer)
9. In death resulting from high-risk infection or contagious disease (for public health concerns)
10. In death known or suspected to have resulted from an environmental or occupational hazard (for compensation or public health aspects)
11. In obstetrical death (death of the mother around delivery)
12. To confirm or further define a prenatally diagnosed condition after termination of pregnancy
13. In pregnancy loss (miscarriage, spontaneous abortion, or intrauterine fetal demise) or stillbirth
14. In neonatal (death within 28 days of life) or pediatric death
15. To correlate anatomic findings with imaging or other diagnostic studies
16. For educational purposes or in an unusual case
17. When the patient participated in a clinical trial or protocol
18. To obtain tissue for research purposes
Modified from: Hutchins GM et al. Practice guidelines for autopsy pathology. Archiv Pathol Lab Med 118;19-25,1994.
Medical Examiner's Autopsy Cases:
While autopsies should be requested in all hospital deaths, certain cases require initial review by a Charlottesville/Albemarle County Medical Examiner (PIC 1367). Deaths outside the hospital or within 24 hours of admission to a hospital and potential mal-practice cases are not necessarily medical examiner cases. Deaths under the jurisdiction of the M.E. include:
3. Accidental death (even long after the initial injury)
4. Sudden death in apparent good health
5. Death unattended by a physician
6. Suspicious circumstances surrounding the death
7. Sudden Infant Death
In these cases, the medical examiner must be contacted first in order to have a ruling as to whether an official autopsy (to be performed at the Chief Medical Examiner's Office in Richmond) is required. In these cases, the interests of the Commonwealth supersede those of the family and an autopsy may be performed without the family's consent (and may even be done against their wishes). If the medical examiner determines that an autopsy is not required by the Commonwealth, the family may then be approached regarding an autopsy at the University of Virginia.
Permission for Autopsy:
All autopsies require a completed "Permission for Autopsy" form before the procedure can be performed (obtainable from the Decedent Affairs Office). A surgical consent form cannot be substituted. Hospital autopsies are performed only with the permission of the appropriate individual based on Virginia Statute (see below). Exceptions to this rule are medical examiner's cases in which the family's consent is irrelevant (see above). The order of priority of next of kin, listed on the autopsy permit, is as follows:
1. Any person designated in a written, notarized advanced directive to dispose of the decendent's remains (Virginia Statute § 54.1.2825).
3. Adult child(ren)
5. Adult sibling(s)
6. Legal guardian
7. Individual authorized or under legal obligation to dispose of the body.
The decision to permit an autopsy cannot be delegated if the appropriate individual is legally competent to give consent. When there are two or more individuals of equal priority, the majority must agree to the examination although only one needs to sign the permit. A consent via telephone is permissible if two witnesses verify the request and "telephone consent" is placed after the consenting signature signed by the person obtaining consent. There must be two (2) witnesses for any autopsy consent.
Of particular note, the "Restrictions" section must be completed. If there are no restrictions, enter "None" and a full autopsy including examination of the central nervous system will be performed. Common restrictions include: chest and abdomen only (no examination of brain), abdominal cavity only, chest cavity only, and brain only. If the family so requests, the organs may be returned to the body cavity after portions have been retained for histologic examination. This request should be stated in the ‘restrictions' section of the autopsy permit but is not recommended since this prevents presentation of the organs at various clinical and teaching conferences and makes materials unavailable for additional studies if required. Note: The face and hands will not be altered by the autopsy procedure and requests of this nature need not be stated as a restriction.
Outside cases are those in which the patient has never been admitted to or seen as a patient in the University of Virginia Health System. In instances in which a UVA or outside physician, with the family's permission, is requesting an autopsy on a non-UVA patient, or in which the patient is part of a research project program in connection with the University of Virginia, the outside hospital or family may contract with the Department of Pathology to provide autopsy services. Approval for contracted outside cases must be obtained from the Director of the Autopsy Service before arrangements can be made through the Autopsy Office. The Department of Pathology does not contract for medical-legal autopsy cases.
The cost of an autopsy on a non-UVA patient is up to $2,800 and is borne by the family or outside hospital. Note: if the deceased was a patient at an outside hospital at the time of death but had been a patient in the University of Virginia Health System at one time, an autopsy may be considered and the autopsy fee may be waived. The director of the service has to be consulted in these such cases.
Obtaining Permission from the Family:
Families are frequently uninformed about the nature of an autopsy and its value to all parties. Consequently, they may give "uninformed denial" rather than informed consent when approached about permitting an autopsy. Discussions regarding the value of an autopsy may often begin before death, when death is imminent or inevitable, and the family has accepted that fact. Compassionately explain the following crucial facts regarding postmortem examination so that the family may make an informed decision:
1. The cost of an autopsy on a UVA patient is up to $2,500 and is borne by the institution and is not billed to the family. In essence, the autopsy has already been paid for. Of note, surgical pathology and laboratory examinations that are requested premortem will be completed and billed accordingly. In fetal and neonatal cases, the placenta will be examined and billed as a surgical pathology specimen. If a family wishes to have an autopsy performed on a non-UVA patient, approval must be obtained from the Director before arrangements can be made through the Autopsy Office.
2. After autopsy, the body will still be suitable for open casket burial.
Autopsy Turnaround Time:
Upon receiving permission for autopsy, the Decedent Affairs Office should be notified that permission has been obtained and the permit transmitted to that office. For an autopsy to commence, the body, the permit and the chart or a Clinician knowledgeable about the case must be available during autopsy working hours.
The requesting physicians will be contacted prior to beginning the autopsy to provide a brief clinical summary and specific questions they would like answered by the autopsy. A second call will be made when the organs are available for review with the Clinicians. A provisional anatomic diagnosis based on the gross examination will be available within two working days of the autopsy date and a final report including histologic analysis will be available within 30 working days for routine cases and within 60 total days for complicated cases.
Virginia Statutes Regarding Autopsy:
§ 54.1-2973. Persons who may authorize postmorten examination of decedent's body. - Any of the following persons, in order of priority stated, may authorize and consent to a postmortem examination and autopsy on a decedent's body for the purpose of determining the cause of death of the decedent, for the advancement of medical or dental education and research, or for the general advancement of medical or dental science, if: (i) no person in a higher class exists or no person in a higher class is available at the time authorization or consent is given, (ii) there is no actual notice of contrary indications by the decedent, and (iii) there is no actual notice of opposition by a member of the same or a prior class.
The order of priority shall be as follows: (1) any person designated to make arrangements for the disposition of the decedent's remains upon his death pursuant to § 54.1-2825; (2) the spouse; (3) an adult son or daughter; (4) either parent; (5) an adult brother or sister; (6) a guardian of the person of the decedent at the time of his death; or (7) any other person authorized or under legal obligation to dispose of the body.
If the physician or surgeon has actual notice of contrary indications by the decedent or of opposition to an autopsy by a member of the same or a prior class, the autopsy shall not be performed. The persons authorized herein may authorize or consent to the autopsy after death or before death.
In cases of death where official inquiry is authorized or required by law, the provisions of Article 1 (§ 32.1-277 et seq.) of Chapter 8 of Title 82.1 shall apply. If at the time of death, a postmortem examination is authorized or required by law, any prior authorization or consent pursuant to this section shall not be valid unless the body is released by the Chief Medical Examiner or one of his assistants.
A surgeon or physician acting in accordance with the terms of this section shall not have any liability, civil or criminal, for the performance of the autopsy. (Code 1950, § 32-364.4:1; 1973, c. 357; 1979, c. 720, § 54-325.8; 1986, c. 237; 1988, c. 765; 1998, c. 718.)
§ 54.1-2825. Person to make arrangements for disposition of remains. - Any person may designate in a signed and notarized writing, which has been accepted in writing by the person so designated, an individual who shall make arrangements for his burial or the disposition if his remains, including cremation, upon his death. (1989, c. 684; 1998, c. 718.)
PATIENT CONFIDENTIALITY POLICY
Purpose: Patient confidentiality must be preserved even after death. All employees of the University of Virginia Hospital are required to observe its general policies in this regard (see Medical Center Policy No. 0021R). In order to maintain appropriate patient confidentiality with regard to the autopsy, the following specific measures are to be followed:
Practices and Procedures:
1. Access to viewing an autopsy is limited (see Autopsy Viewing Policy) to individuals who have a formal relationship to the University of Virginia Health Sciences Center, either as a student or as an employee in the health professions, or individuals who have a legitimate legal relationship to the case.
2. In written or oral non-patient care presentations of the case, the patient's name will not be used.
3. Release of autopsy reports is limited to the parties indicated on the Autopsy Consent form. Copies for family members should be released through the Attending Clinician according to the University of Virginia Medical Staff Bylaws. A signed copy of the final autopsy report will become part of the patient's permanent record at the University of Virginia or the requesting institution. Reports and related materials can be released if subpoenaed as part of a legal action. A record of this release must be kept on file. Any exception for releasing reports must be approved by the Attending Pathologist and the Director of Autopsy.
4. Any questions related to patient confidentiality not addressed here should be discussed with the Director of the Autopsy Service, who will be responsible for a final decision.
Council on Ethical and Judicial Affairs, American Medical Association. Confidentiality of human immunodeficiency virus status on autopsy reports. Arch Pathol Lab Med 1992;116:1120-1123.
James DS, Leadbeatter S. Confidentiality, death and the doctor. J Clin Pathol 1996; 49: 1-4.
Rose EF. Pathology reports and autopsy protocols: confidentiality, privilege and accessibility. Am J Clin Pathol 1972; 57:144-155.
AUTOPSY VIEWING POLICY
Purpose: The patient care, teaching, and research aspects of any autopsy must be balanced against the need for patient confidentiality, minimizing possible exposure to pathogens and institutional liability for possible injury.
1. Only those individuals who are either health professionals or health professions' students at the University of Virginia Health Sciences Center will be permitted to view an actual autopsy.
2. The Director of the Autopsy Service may exercise his/her professional discretion in granting exceptions in individual cases.
3. Other interested parties may attend the Autopsy Gross Conference on Wednesdays at 2:00 pm with the permission of the Director of the Autopsy Service, or may make special arrangements with the Director of the Autopsy Service to view specimens at other times.
EXTRAMURAL CONSULTATION AND MEDICOLEGAL CASES
Purpose: Materials and information obtained from autopsies may require extramural consultation or be required for legal proceedings.
Policy and Practices:
1. Every autopsy should be considered as a potential medicolegal case and handled accordingly.
2. The Director of the Autopsy Service must approve the release of any materials from an autopsy to an extramural institution or individual.
3. Any extramural oral communications or written correspondence related to a case should be recorded and filed with the departmental copy of the final autopsy report. The Director of the Autopsy Service must be informed of any communications that suggest potential medicolegal issues. The Director of the Autopsy Service or his/her designee must review any written communications of a medicolegal nature prior to release.
4. The Director of the Autopsy Service must approve any outside consultation that will result in a charge to the Autopsy Service.
5. Original slides and paraffin-embedded blocks will not be released, unless required by law. Only copies of reports or recuts of slides will be sent if requested for consultative or medicolegal purposes. There may be a charge for providing these materials and services at the discretion of the Director of the Autopsy Service.