Monthly Archives: April 2014

Recent AMA postmortem communication guidelines favor hospitals over patient rights

Justice image
Summary
In the fall of 2013, the AMA published new guidelines for communication between hospitals, coroners and families after an unanticipated or unexplained loss. These guidelines protect the interests of hospitals over the rights of families; and, in at least one state, the guidelines violate the law. Summary opinion: In need of revision.

The passages of concern are as follows:

“5. f. Upon request, the medical examiner should provide information to next of kin regarding options for obtaining an independent autopsy or a review of the medical examiner’s findings and conclusions….

6. e. Upon request, the hospital should provide information to next of kin regarding options for obtaining an independent autopsy or review of the hospital pathologist’s findings and conclusions.

7. When the medical examiner declines jurisdiction, and the hospital declines to conduct an autopsy, the hospital should provide information to next of kin regarding options for obtaining an autopsy elsewhere.”

Background
After a sudden or unexplained death, questions arise. When the state suspects a suspicious or criminal cause of death, the medical examiner will perform the autopsy. If there is no such concern, there may still be other parties interested in learning the information found through autopsy examination. These parties are typically the family and the medical provider (e.g., clinicians and hospital). At simplest, families may request an autopsy for purposes of closure — to learn why their loved on died. Hospitals and providers undertake an awesome responsibility in their care of patients. They may want to learn about undiagnosed medical conditions — undiagnosed despite the best medical care; or undiagnosed because the patient was previously well and not under care.

However, the time of loss is as complex as the system in which it occurs. Many times, the scent of litigation wafts in and out of what should ideally be tender interactions during a family’s difficult time.

Additionally, many families do not even know they have the right to request an autopsy. A larger fraction do not know they have the right to choose a service provider. The autopsy does not have to be performed at the hospital where the medical care was provided. Families who do know this sometimes opt to have their loved one’s autopsy performed at a location separate from where the care was provided. Rightly or wrongly, the decision is often guided by a “fox guarding the hen house” concern. Nonetheless, families are free to make a choice because they know they have one.

Concerns
These guidelines reflect the AMA’s understanding of the ever-present backdrop of litigation. They keep the autopsy under control of the hospital — where the patient death may have occurred. And, furthermore, the guidelines favor that the medical examiner participate with the same goal.

These guidelines keep families in the dark about service options thereby keeping the hospital “in control” of the case. They do not inform families that they may request an alternate service provider. They give the hospital “first dibs” on the autopsy. Only “upon request” will the hospital or coroner provide names of an “independent autopsy” service provider.

Furthermore, only when the hospital or medical examiner “declines” the case (e.g., neither wants the autopsy) are these institutions to recommend to the family that they may seek an independent provider or independent consultation.

While making no statement here in favor or against the practice of litigation, these guidelines are comparable to a hospital recommending their “in-house” lawyer review the family’s legal case before letting the family know they may seek their own counsel. While most families know they may find their own lawyer; most do not necessarily know they may find their own autopsy service provider. And these guidelines ensure that vulnerable families will continue to be kept in the dark.

Against the Law
Connecticut law (Sec. 19a-286) requires that hospitals inform families in writing that they may request an autopsy with a provider of their choosing.

“Any person authorized to consent to an autopsy….may make arrangements for an autopsy to be performed at any institution that routinely performs autopsies…. Information concerning the rights and responsibilities under this subsection shall be contained in the institution’s patient bill of rights….The institution shall provide such information in writing in a language understood by the person who assumes custody of the body of the deceased person prior to the signing of an autopsy consent form by the person who assumes such custody.”

The AMA, a national organization, therefore provides guidelines that would be illegal in this state. It does so by withholding rather than providing the family with information about service options at the time of death, unless certain criteria are met.

An alternative for the AMA
Lastly, if hospitals are interested in preventing litigation, the AMA should consider why families litigate. Medical mishap is but one factor. The quality of the relationships between families and providers is as important if not more so. And, for better of worse, a family’s perceptions (and misperceptions) drive their attitudes and behavior. Sometimes, it’s the difficulty and pain of a loss that turns into anger and blame. Law suits follow.

Nonetheless, there is the important option of actively rebuilding trust during these difficult times. And this comes from openness and communication.

The success of the current trend in “I’m sorry” laws supports this; as does the data for a hospital such as the University of Michigan, which routinely admits and addresses medical error. Litigation rates at the University of Michigan are well-below national average.

Recommendation
I recommend the AMA revise these guidelines with the Connecticut law in mind.

Let families know their options for autopsy service providers right at the time of the loss.

It is simply their right to know.

Maybe then the family will trust the hospital to do the case.

 

April Case: Liver metastases

Photo Cases Newsletter

Diagnosis: Liver Metastases

What is shown?
The picture shows two slices of the liver, each with a metastasis (arrows). These were the only metastases in the liver.

Where did the metastases come from?
They came from a lung cancer.

How did this patient die?
The patient died from the lung cancer (which blocked her breathing). The metastases did not cause the patient to die.

What is a metastasis?
When a tumor spreads through the blood to other areas of the body (where it takes hold and grows) this is a metastasis.

What do metastases mean for the patient in life?
Metastases mean the tumor is more advanced and often less likely to be curable. This is because surgery to remove the main tumor will still leave behind the metastasis somewhere else in the body. It also often means the amount of tumor is large. This can affect the success of other treatments (e.g., chemotherapy).

Is this always true?
No. Some tumors can still be curable even with metastases. It depends on the number of metastases, their size, where they are in the body, and if the anatomy allows for a surgical approach. Also the type of tumor matters. For example, some Hodgkin’s lymphomas, and a testicular tumor called seminoma can be curable even with metastases. Each case is different.

Is there any other reason to remove or treat a metastasis?

Yes, this can sometimes relieve symptoms (palliation).

In this case, how did the autopsy help the family?
Anxiety over possible suffering. The amount of tumor is often connected in the family’s mind to the amount of suffering. It is important for this reason to give an exact description of the amount of tumor, where it is located, and how it affected that organ. In this case, the majority of the liver was preserved, and the patient would not have had clinical liver problems. The metastases likely caused this patient no problems.

Guilt/anger over treatment issues: Families often need to know if the autopsy findings indicated that some treatment may have saved the patient “if only” it had been tried. They may feel guilty for not having “tried harder,” or angry with the medical system for the same reason. Here, the patient’s lung tumor overwhelmed her breathing and this was the cause of death. No treatment approach dealing with the liver metastases would have helped – they were not the cause of death. This relieved the family from their worry about the liver metastases.

Summary. The finding of metastases allowed for a discussion of the progress of the disease, but did not at all suggest suffering or a missed opportunity for treatment. This allowed the family to proceed with a sense of calm, peace, and understanding.

Urban Prep students visit with the Autopsy Center

photo 3Urban Prep students visited with the Autopsy Center on March 26 to learn about the field of autopsy pathology. As part of Urban Prep’s “Discover Our City Day,” over 600 of the Bronzeville students fanned out in chaperoned groups throughout the Chicago area to meet with varied professionals, including Dr. Margolis.

They learned about the autopsy procedure but also spoke of their own experiences with loss. Most had had experience losing a loved one, but had also seen death “in the street.” While professional aspirations ranged from engineering to sports-casting, all were curious about how an autopsy works.

A student joined Dr. Margolis in donning protective equipment: from shoe covers to plastic gown. A second student volunteered as our cadaver, coming “alive” again to point out an old scar on his forehead. As the “examination” proceeded, Dr. Margolis clicked through portions of his slide show, Science to Humanity: The Autopsy, to illustrate what the body would actually show during each part of the procedure. Pneumonias, heart disease, damage lungs from smoking appeared on the screen as the dissection progressed.

By the end of the presentation, the students began to share stories and ask questions about disease and illness they or their loved ones had experience. “My mother had pneumonia,” one student shared, after seeing a microscopic slide. He commented on her shortness of breath and long hospitalization. Another, heading towards a career in psychology, commented on the “closure” an autopsy can give.


High schools interested in organizing a presentation with the Autopsy Center should contact the Autopsy Center.