TITLE: AUTOPSY REQUEST AND AUTHORIZATION POLICY: RI #19 _____________________________________________________________________________ I. PURPOSE

To establish appropriate protocol for autopsy authorization. II. POLICY

A request and authorization for autopsy procedure will be completed for all deaths requiring an autopsy that occur within any/all IH-DM facility.

III. RESPONSIBILITIES/AUTHORIZATION/PROCEDURE

A. Deaths Occurring at ILH, IMMC and Blank

Autopsy procedures for deaths occurring at Iowa Lutheran Hospital, Iowa Methodist Medical Center, and Blank Children’s Hospital are performed by the Pathology Department on the Iowa Methodist Medical Center campus.

B. Autopsy Requests

Autopsy procedures will be performed on deceased patient bodies upon request of the patient’s nearest of kin, or as determined by deaths reportable to the medical examiner according to the Code of Iowa, Chapter 331, Section 802, Part 3 (refer to addendum #1, “Notification of the Medical Examiner - Deaths Reportable to the Medical Examiner”).

1. Physicians

The attending physician or his/her designee will request authorization for an autopsy for deaths that meet medical staff criteria (refer to addendum #2, “List of Indications for Autopsy”).

2. Nursing

a. If the physician is not requesting the autopsy, the nurse will notify Patient

Registration that an autopsy is being performed and document this on the Death/Organ Donation Record.

b. The nurse, chaplain, or a designee will assist to obtain appropriate signatures

on the Autopsy Request and Authorization Form.

C. Autopsy Authorization

Before an autopsy may be performed, written authorization for an autopsy must be made.

1. Guidelines for Autopsy

The authorization for autopsy must be signed by the nearest of kin to the deceased, in this order:

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a. Spouse b. An adult son or daughter c. Either parent d. An adult brother or sister e. A guardian of the person of the decedent at the time of his or her death f. Any other person authorized or under obligation to dispose of the body

In case of kin with equal rights, each should sign. If all cannot sign, there should be preference given to the one who has the legal custody of the body and who has the duty of disposing of it; to the one who lives in the state or community over one whose residence is more remote; and to one who has attained majority over one who has not. If a minor is next of kin, he can consent only through a duly-appointed guardian.

If there is a known controversy among those having equal rights of consent, the autopsy should not be performed.

Please notify the Patient Registration at IMMC whenever an autopsy permit is signed and send the authorization and chart to the IMMC laboratory.

If you have any question concerning the permit, whether embalming should be done, the timing of the autopsy or other questions, contact the pathologist on call.

If no one with authority to permit an autopsy is physically available at the time of death, written authorization may be provided in the form of a telegram or facsimile from the designated individual.

Written authorization for an autopsy must be signed by the nearest of kin to the deceased following this list and will be available at the time of death:

2. Minors

Autopsies may be authorized by a legal guardian, a parent, an adult brother or sister, a grandparent, or an aunt or an uncle, in the order stated.

3. Adults

Autopsies may be authorized by a legal guardian, a spouse, an adult child, a parent, an adult sibling, a grandparent, or an aunt or an uncle.

Alternatively, the Autopsy Request and Authorization form itself can be faxed to a nearest surviving relative for signature (witness required).

In the case of fax authorization, the authorizing person should also fax a copy of a valid driver’s license or some other form of photo and signature identification for confirmation of the fax. If authorization is given by a guardian, a copy of the guardianship appointment documents should also be obtained.

Telegram or fax authorizing autopsy should be addressed to the Patient Registration. The telegram or fax should take the following form:

“I (name of authorizing relative), the (relationship to deceased) of (name of deceased) hereby give consent to perform an autopsy with the following restrictions: (name of inclusion category)”

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D. Autopsy Authorization Exclusion

If the authorizing relative wishes to exclude from examination some organs or body parts, the following inclusion categories should be used on the request form:

Inclusion Category Organ Included Unrestricted All Head Brain Chest Heart, lungs, esophagus, thoracic rib cage, breasts Abdomen Liver, gastrointestinal tract, spleen, kidneys, adrenals,

pancreas, gall bladder, mesentery and vessels Organ specific (i.e., heart only)

Only the specified organ will be examined

Other Contact pathologist

E. Autopsy Request Procedure

1. Autopsy request procedures to follow when death has occurred at Iowa Methodist

Medical Center or Blank Children’s Hospital are according to Report of Death and Disposal of Body (see IH-DM Policy RI #18).

2. Autopsy request procedures to follow when death has occurred at Iowa Lutheran

Hospital is listed below:

a. The nursing unit will notify IMMC Patient Registration at extension 241-6320 that an autopsy has been requested and IMMC Patient Registration will notify the pathologist.

b. The nursing unit will notify the designated funeral home for transport of the body from ILH to IMMC morgue.

c. Following completion of documentation, the patient’s chart/record will be sent to Medical Records (ILH campus) for disassembly. The following chart information/documentation will be promptly copied and sent via IH-DM Security to the IMMC Pathology Department at the time of transport of the body:

1. Signed Autopsy Request and Authorization Form 2. Patient Data/Registration Sheet 3. History and Physical 4. Emergency Department Documents 5. Consultations 6. Progress Notes 7. Obstetrical Delivery Notes when applicable 8. Death Note

When documentation is received by the IMMC Pathology Department, the autopsy procedure will follow.

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F. Autopsy Procedure

1. After the signed Autopsy Request and Authorization form, chart information, and identification of the deceased is obtained, the autopsy procedure is initiated.

2. The patient’s chart is given to the Pathology secretaries. They assign the patient

an autopsy number and log in all necessary patient information. 3. The pathologist and Pathologists’ Assistant, when involved, review all charts and

pertinent data before the autopsy. 4. The pathologist will make every reasonable attempt to contact the attending

physician prior to the performance of the autopsy. 5. The diener logs in the autopsy in the Morgue log book. 6. The pathologist and, at his discretion, the Pathologists’ Assistant perform the

autopsy. This includes the external appearance, in situ organ inspection, evisceration with recording of data or dictation, (i.e., organ weights, presence of body fluids, gross autopsy notes such as tumor or congenital defects, etc.). Biological tissue specimens for analysis are obtained and may include blood cultures, cytogenetics or toxicological material. Photographs may be taken at this time.

7. When completed, the pathologist, or under his supervision, the Pathologists’

Assistant dictates a concise clinical history and gross examination with organ review (see attached format).

8. The “Provisional Autopsy Report” of preliminary gross autopsy findings is sent to

the attending physician and all other consultants as well as the referring physician within two working days.

9. All tissue samples are trimmed and sections are submitted to Histopathology for

routine microscopic examination. 10. All tissue cassettes must be clearly labeled with the identifying autopsy number. 11. The Histopathology Department should be completed with their portion of the

autopsy within ten working days from the date of receipt of tissue blocks. Note: If there is a brain, these sections should also be completed within ten working days from the date of receipt of tissue blocks.

12. The Pathologist and/or Pathologists’ Assistant then collects the Provisional

Autopsy Report, slides, and any other data such as various cultures, postmortem radiographs, cytogenetics or toxicological reports. These are examined, reviewed and given to the pathologist for final examination.

13. The pathologist dictates the Final Diagnosis and Summary and Microscopic

Examination. These descriptions should be clear and concise with adequate notation of all pathologic findings.

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TITLE: AUTOPSY REQUEST AND AUTHORIZATION POLICY: RI #19

ADDENDUM #1 ______________________________________________________________________________ NOTIFICATION OF THE MEDICAL EXAMINER - DEATHS REPORTABLE TO THE MEDICAL EXAMINER (Code of Iowa, Chapter 331, Section 802, Part 3) 1. A person’s death that affects the public interest as specified in subsection 3 shall be reported to the county Medical

Examiner or the state medical examiner by the physician in attendance. The appropriate Medical Examiner shall notify

the city or state law enforcement agency or sheriff and take care of the body.

2. A death affecting the public interest includes, but is not limited to, any of the following:

a. Violent death, including homicidal, suicidal, or accidental death, b. Death caused by thermal, chemical, electrical or radiation injury, c. Death caused by criminal abortion including self-induced, or by sexual abuse, d. Death related to disease through to be virulent or contagious which may constitute a public hazard, e. Death that has occurred unexpectedly or from an unexplained cause, f. Death of a person confined in a prison, jail or correctional institution, g. Death of a person who was pre-diagnosed as a terminal or bedfast case who did not have a physician in

attendance within the preceding thirty days; or death of a person who was admitted to and have received service from a hospice program as defined in section 135J.1, if a physician or registered nurse employed by the program was not in attendance within thirty days preceding death,

h. Death of a person if the body is not claimed by a relative or friend, i. Death of a person if the identify of the deceased is unknown, j. Death of a child under the age of two years if death results from an unknown cause or if the circumstances

surrounding the death indicate that sudden infant death syndrome may be the cause of death or k. Dearth of a person committed or admitted to a state mental health institute, a state resource center, the state

training school, or the Iowa juvenile home. Iowa does not have a “24 hour rule” requiring that medical examiners be notified of any death occurring within 24 hours of hospitalization. When in doubt, notify the medical examiner. They c

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TITLE: AUTOPSY REQUEST AND AUTHORIZATION POLICY: RI #19

ADDENDUM #2 ______________________________________________________________________________ LIST OF INDICATIONS FOR AUTOPSY (Based on College of American Pathologists 2007 Guidelines. Ref: College of American Pathologists rev. August, 2007)) 1. Cancer patients in who there is no prior tissue diagnosis or the source of the primary is

unknown. 2. Patients dying of internal bleeding not identified as the source.

3. Patients with infections of undetermined type and/or source including those potentially related to bio-terrorism.

4. Transplant patients and organ and/or tissue donors.

5. Deaths associated with blood component transfusions.

6. Patients with known or suspected therapeutic complications that may have contributed to death

(e.g. pharmacotherapy, radiation therapy, chemotherapy, and/or surgical or other invasive procedure).

7. Patients who have participated in clinical trials (protocols) approved by the institutional review

board. 8. Death in which there is a known or suspected congenital malformation, genetic disease,

syndrome or undefined metabolic disease. 9. Patients with suspected environmental exposure or occupational exposure. 10. Death where there is no adequate clinical explanation. 11. Deaths occurring at any age in which it is believe that an autopsy would disclose a known or

suspected disease which may have a bearing on survivors.

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