1.1B AUTOPSY.pdf

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LEGAL MEDICINE 1.1B AUTOPSY

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AUTOPSY Greek Eye witness (auto - self; opsis - view) Necropsy Post-mortem Postmortem examinations provide factual, objective information to the decedent’s families that negate their suspicions and obviate their desire to pursue a lawsuit. (Bove 2002) TYPES Medico-legal or Forensic Hospital

HOSPITAL AUTOPSY - cause of death - internal exam more impt - consent from next-of-kin - any pathologist - clinical history

FORENSIC AUTOPSY - manner of death - external exam - no consent from kin - forensic pathologist - crime scene

BENEFITS OF THE AUTOPSY TO THE PUBLIC 1. Provides reassurance to the family. 2. Identification of any contagious or familial disease. 3. Evaluation for insurance benefits and workman’s compensation benefits. 4. The autopsy as an educational tool. 5. Identification of new or previously unrecognized disease. 6. The autopsy as a quality control tool

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AUTOPSY AS A QUALITY CONTROL TOOL Keep track of competence Develop clinical craftsmanship Sharpen diagnostic skills Increased diagnostic accuracy Check appropriateness of intervention

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IMPORTANCE OF DEATH CERTIFICATES Information provides basis for state and national mortality statistics used to:  Assess general health of population  Evaluate medical treatment success  Examine medical problems with higher prevalence in certain demographies and to identify where medical research can have the greatest effect  Identify public health problems and evaluate established programs to help these problems  Allocate healthcare services and follow up studies of infant and maternal deaths and infectious diseases  Identify disease cause  Evaluate diagnostic & therapeutic technique  Identify leading causes of death  Identify potential life - years lost to diseases or injury  Provide information for epidemiological studies  Identify geographical areas with increased death rates from certain causes of death  Serve as the primary means for evaluating health at the local level

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Discrepancy between clinical diagnosis and autopsy diagnosis: 10-45% EMOTIONAL DISCOMFORTS IN AUTHORIZATION OF AN AUTOPSY BY FAMILY  Discomfort with cutting the dead body  Fear of being disrespectful to the dead  Anxiety about offending nature  Fear of objections from next of kin  Concern about biomedical development  Resistance to revealing one's diseases  Anxiety about offending God  Distrust of doctors and healthcare system  Apprehension about the funeral being influenced  Fear of not being dead  Other discomforts

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4 TYPES OF EVISCERATION TECHNIQUES En Masse - Organs are removed as a single bulky aggregate En Bloc (Ghon) - thoracic pluck, coeliac pluck, intestines, urogenital pluck Virchow's - organs individually removed Rokitansky (in situ) - dissection occurs in situ with little actual evisceration

LOCAL REGULATIONS Code on Sanitation of the Philippines (P.D. 856) Implementing Rules and Regulations of Chapter XXI --> Disposal of Dead Persons

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DEATH CERTIFICATE REQUIREMENTS No remains shall be buried or cremated without a death certificate The D.C. must be issued by the attending government or private physician When no physician is in attendance, it shall be issued by: • city/municipal health officer • mayor • secretary of the municipal board • councilor of the municipality where the death occurred. The basis of the Death Certificate shall be an affidavit duly executed by a reliable informant stating the circumstances regarding the Cause of Death. The death shall be reported to the Local Health Officer within 48 hrs after death and the Death Certificate shall be forwarded to the local civil registrar concerned within 30 days after death for registration. SHIPMENT OR TRANSFER OF CADAVER Death certificate Transfer permit from local health authority of point of origin Properly embalmed remains Transfer permit from places the remains will pass Abroad: rules and regulations of the National Quarantine Office MEDICOLEGAL CASES If the LHO who issues a D.C. has reasons to believe or suspect that the COD was due to violence or crime, he shall notify immediately the authorities of the PNP or NBI concerned.

VIOLENCE OR CRIME PRESENT WHEN: Stab wounds Gunshot wounds Page 1 of 3

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1.1B AUTOPSY

Suicide Strangulation Accident resulting to death Actual physical assault inflicting injuries upon a person resulting in death Sudden death of undetermined cause In case the cause of death was due to violence or crime mentioned in the preceding subsection, the deceased shall not be buried until permission is obtained from the provincial or city prosecutor where the death occurred. In the absence of the city or provincial prosecutor, permission shall be obtained from: • Municipal or city judge • Municipal or city mayor • Chief of police DANGEROUS COMMUNICABLE DISEASES AIDS cholera Ebola Hepatitis Plague Yellow Fever Meningococcemia THE REMAINS (WITH COMMUNICABLE DISEASE): Buried within 12 hrs after death Not taken to any place of public assembly Only adult members of the family permitted to attend the funeral Placed in a durable, air tight and sealed casket Not granted permit for transfers.

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AUTOPSY & DISSECTION OF REMAINS Authorized to perform: – Health officers - provincial, municipal, city – Medical officers of law enforcement agencies such as PNP, NBI – Members of the medical staff of accredited hospitals. AUTOPSIES SHALL BE PERFORMED WHEN: When required by special laws…are those enforced and presently practiced by the authorities. Upon orders of a competent court, a mayor and a provincial or city prosecutor Upon written request of police authorities Whenever the solicitor general, provincial or city prosecutor as authorized by existing laws, shall deem it necessary… Upon request of the next of kin

REQUIREMENTS FOR AUTOPSIES IN ACCREDITED HOSPITALS: • The director or chief of the hospital shall notify in writing the next of kin of the death of the deceased and request permission… • When permission is granted or no objection is raised…within 48 hrs • If no next of kin, secure from local health authority

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HOUSE BILL NO.1899 Proposed Mandatory Autopsy Bill Death where the criminal violence appears to have taken place;

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Death by any accident or unintentional injury; Suicide; Death under suspicious, unusual, unnatural, or questionable circumstances; Death following an illegal abortion; Death related to occupational illness or injury; Death while in custody, in any jail or correctional facility or in any mental health or social welfare facility; Death where suspicion of abuse of a child, family or household member, older or disabled person exists; Death due to poison or acute or chronic use of drugs, alcohol and other similar or related substances; Death associated with diagnostic or therapeutic procedures; Sudden death when the decedent was in apparent good health; Death in any public or private conveyance; Fetal and infant deaths; Death in any emergency treatment facility, medical walk-in center or clinic; Deaths occurring under such other circumstances as the government' pathologist or medico-legal officer may include in the implementing rules and regulations. SEC, 14. Unlawful Issuance of Death Certificate. -- It shall be unlawful for any person to issue a death certificate of a person who died in a violent, suspicious, questionable, unusual and/or unnatural circumstances without complying with the required autopsy. EXTERNAL EXAMINATION The first time an external examination is carried out is upon discovery of a corpse. At this point the body should be checked for visible signs of injury and those injuries that are most likely to have caused subsequent death. At this stage both the Pathologist and Scenes of Crime Officer (SOCO) are present as well as authorized police personnel and the body is checked over in what is known as a preliminary examination. Whilst the Scenes of Crime Officer (SOCO) is taking photographs of the corpse and surrounding area - and in particular photographing wounds and injuries pointed out to him or her by the pathologist - the pathologist will examine these wounds and measure them. Clothing will also be examined for any signs of excreted bodily fluids and/or fibres. Once the body has been removed from the scene of crime and taken for pathological examination there is another external examination to be carried out before an autopsy can be completed. This examination is conducted to determine height and weight and also to facilitate the photographing of the corpse in its post mortem state. This is also done to ensure that no additional post mortem injuries have been sustained. The clothes of the deceased are thoroughly checked for fibres, hairs, bodily fluids and blood stains; as well as for tears and rips that might correspond to knife or gun attacks. The body is then checked for signs of rigor mortis (stiffening of the muscles post mortem) and lividity (settling of the blood post mortem); both of these conditions can be measured and used as a means of determining time of death. In addition to this these conditions can also be used to help determine whether or not a body has been moved post mortem prior to its discovery. Sometimes x-rays are taken at the external examination stage if there are visible head injuries.

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1.1B AUTOPSY

INTERNAL EXAMINATION A large and deep Y-shaped incision can be made starting at the top of each shoulder and running down the front of the chest, meeting at the lower point of the breastbone. This is the approach most often used in forensic autopsies so as to allow maximum exposure of the neck structures for later detailed examination. This could prove essential in cases of suspected strangulation. a T-shaped incision made from the tips of both shoulder, in a horizontal line across the region of the collar bones to meet at the sternum (breastbone) in the middle. This initial cut is used more often to produce a more aesthetic finish to the body when it is re-constituted as stitching marks will not be as apparent as with a Y-shaped incision a single vertical cut is made from the middle of the neck (in the region of the 'adam's apple' on a male body)

USEFUL INFICATORS FOR AN AUTOPSY QUALITY ASSURANCE PROGRAM  Discrepancies between pathologic & final diagnosis  Lack of documentation by x-ray, photography and other tests  Evidence of pathologic misdiagnosis in final autopsy reports  Specimens who no clinical information sent to Pathology  Number of: - Autopsies - Cases sent to reference autopsy, laboratory or registry - Incident reports - Patient complaints - Physician complaints - Staff complaints - Outstanding survey deficiencies (JCAHO, CAP, AABB, state) - Mislabeled specimens  Results of family satisfaction questionnaires  Infection rates   

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ETHICAL VALUE OF THE HUMAN CADAVER The person is intimately identified with his/her body, to the point that they are practically inseparable The way we treat the human cadaver influences the way we treat the person alive; to treat the dead body as a simple carcass, as a waste product, would mean implicitly to lower the evaluation standards applied to the person alive Desire to respect the memory of the deceased. The cadaver is the material carrier of an amount of events regarding the deceased person that persist in our memory. Disrespecting the cadaver would mean in a way to disregard the deceased person him/herself Moral-ethical imperative to respect the family’s mourning An improper attitude towards the cadaver would mean thus disregarding those close to the deceased one Moral-religious significance of the human body. Christian religion From a Christian point of view, the practice of allowing autopsies and one’s body for scientific research is acceptable and even to be encouraged if a true need exists. The teaching of Islam does not allow for voluntary autopsy because it is considered a desecration of a human person who was associated with the body. If the law requires it, however, then the next of kin may acquiesce to it.

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Medical negligence is based on standard-of-care issues rather than accuracy of clinical diagnosis. Misdiagnosis indicates lack of advanced medical technology. No significant relationship between accuracy of clinical diagnosis and outcome of the suit.

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LIABILITIES OF PHYSICIANS Administrative Criminal Civil

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SOURCES OF LIABILITIES OF PHYSICIANS Ethics of the Medical Profession in the Philippines Medical Act of 1959 as amended Civil Code Revised Penal Code Special laws

ADMINISTRATIVE LIABILITY “The practice of medicine is service to mankind irrespective of race, creed or political affiliation. In its practice, reward or financial gain should be a subordinate consideration.”

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