The Post Mortem External Examination
Determination of the Cause and Manner of Death
Background: The post mortem external examination is the final service that a physician can render to a patient. Its purpose is not just to establish medical diagnoses, but to provide facts in the service of the judicial process and the public interest. Its main tasks are the definitive ascertainment of death, determination of the cause of death and assessment of the manner of death.
Methods: Selective search and review of relevant literature on cause-of-death statistics, judicial principles, and the performance of the post mortem examination, with emphasis on determination of the cause and manner of death.
Results and discussion: An important duty of the physician performing the post mortem external examination is to know the patient’s history. Thus, in principle, the treating physician is the most suitable person to perform the post mortem examination. In most cases of death (perhaps 60% to 70%), the treating physician will be able to give reliable information on the patient’s underlying illnesses and the cause of death, based on the patient’s history and circumstances at the time of death. Problems arise when death is unexpected and the post mortem external examination alone does not suffice to establish the cause of death. If the cause of death cannot be determined, this fact should be documented, and the manner of death should likewise be documented as undetermined. The autopsy rate in Germany is less than 5% of all deaths, which is very low.
The Royal Bavarian Instructions for Post Mortem Examination of 6 August 1839 are succinct on the objectives of the medical examination after death: “The purpose of the examination after death is, first, to avoid the burial of those who merely appear to be dead, and, next, to prevent the concealment of violent death and medical bungling; and also to give suitable assistance, first, in the discovery of contagious and epidemic diseases and, next, in the production of accurate lists of deaths.” This canon of objectives, fulfilled by determining the occurrence, cause, and time of death, together with an assessment of the manner of death and information as to whether any contagious disease as defined by the Infection Protection Act was present, remains unchanged to this day (1, 2).
In the context of the examination after death, the physician is required to report a death in the presence of any of the following, which are sufficient grounds to break medical confidentiality:
- Unnatural or unexplained manner of death
- Unknown identity of the body
Any factor or condition requiring reporting under the Infection Protection Act.
The quality of external postmortem examination has been under criticism for decades. The central point of criticism, from the judicial aspect, is incorrect assessment of the manner of death (natural versus unnatural or unexplained), which according to the investigating authorities fails to ensure that unnatural deaths will be identified. There are a multitude of structural problems concerning the post mortem external examination, for example:
For certain groups of cases, the certifying physician is objectively inadequate to the task, and is not allowed the flexibility to seek possible solutions. No pre-training is given in how to handle problem cases. Coroner's autopsies are not carried out in cases where the cause of death could not be established at the medical external examination after death. Medical duties are conflated with criminological duties. Possible conflicts of interest arise—particularly when physicians in general practice are involved, who also have relatives of the deceased among their patients. Focusing of reportable cases of death on those where a third party may be guilty. Systemic failure of the system for determining cause of death, with lack of an intermediate authority between the physician and the investigating authority, analogous to the coroner system in England and Wales (which enables deaths to be investigated irrespective of any suspicion of third-party guilt) (2–5).
This contribution aims to:
Explain, based on the fundamental data on deaths in Germany, the requirements that form the core of the medical external examination for death certification: determination of the cause of death and assessment of the manner of death Give tips on how to recognize unnatural causes of death Provide an overview of the legal requirements and duties laid on the physician carrying out a medical examination for the purpose of death certification.
Causes of death as shown by cause of death statistics
In 2007, 818 271 deaths were reported in Germany; according to the Federal Statistical Office, in 784 962 cases the cause of death was natural. Even just for the place where death occurred, there are no uniform data for the whole of Germany; but more than 50% of deaths today occur in hospital (according to own data), about 25% at home, and around 15% in care homes. The remaining 10% are divided up among transport accidents, work accidents, etc.
In 2007, of 17 178 573 inpatient admissions, 6 092 198 were cases belonging to the field of internal medicine. The second largest number of admissions—3 592 386 patients—were to departments of surgery. Within internal medical departments, most deaths were in cardiology, followed in order by gastroenterology, hematology, and geriatrics (eTable gif ppt, eFigure gif ppt). Out of a total of 818 271 deaths in 2007, 258 684 were due to cardiovascular conditions, the most common of which was ischemic heart disease (148 641 deaths). The second most common group of causes of death is malignant neoplasms, with 211 765 deaths. It should be borne in mind that deaths for the various disease groups vary considerably among age groups.
Up until the age of 40 years, unnatural death is more frequent than death from disease (internal cause of death); not until after the age of 40 do deaths from malignancy and cardiovascular disease become more numerous than unnatural deaths.
These data from the German Federal Statistical Office derive from coding of the entries in the death certificate on the underlying disease and immediate cause of death, and only the underlying disease is taken into account in cause of death statistics. In the State (Land) Statistical Offices, by contrast, the statement of underlying disease is not automatically used in the cause of death statistics: the coders examine the entries on each death certificate, determine the underlying disease, and code this underlying disease in accordance with the ICD regulations. Against the background of increasingly multifactorial death processes, however, monocausal representations of deaths only partially fulfill the needs of cause of death statistics and the data derived from them about indicators of health (6, 7).
Agreement between cause of death diagnosis on death certificate and at autopsy
Numerous studies have been published on the validity of clinically determined cause of death as entered on the death certificate in comparison to patho-anatomical findings. The Görlitz study (1986–87), with a nearly 100% rate of autopsy (1060 deaths, in 1023 of which an autopsy was carried out), showed disagreement between certificate and autopsy findings in a total of 45% of male deaths and 48.8% of female deaths. Among hospital deaths, there was disagreement about the underlying disease in 42.9% of men and 44% of women; among deaths in care homes the figures were 63.2% of men and 57.8% of women; and among deaths occurring elsewhere (at home, in public, etc.), 41.3% of men and 50.7% of women (1, 8). Among iatrogenic deaths the rate of disagreement between underlying disease as determined clinically and at autopsy was as high as 72%, and disagreement about the immediate cause of death was 45.8% (5).
Numerous studies have differentiated and operationalized the discrepancies between clinically determined cause of death and that determined at autopsy (major mistake, class 1; major mistake, class 2; minor mistake) (Box 1 gif ppt). According to various statistics, class 1 major mistakes, which have consequences for treatment and survival of the patient, occur in 11% to 25% of deaths, while class 2 major mistakes, which have no consequences for treatment and survival, occur in 17% to 40% of deaths (9).
According to a meta-analysis by Shojania et al., class 1 major mistakes have reduced in the past 40 years but still occur in about 8% to 10% of deaths (10, 11). Here it must be borne in mind, however, that the rate of agreement or disagreement between clinically and autopsy-determined cause of death depends on many variables, such as:
- The definition of the cause of death
- The evaluated disease class
The patient group under investigation (outpatient, inpatient, specialized hospital)
- The duration of the hospital stay
The predictability of the death (expected vs. unexpected)
- The autopsy rate (1, 3, 9, 12, 13).
No comparison between clinical and autopsy-determined cause of death that takes account of these variables in a differentiated way has yet been carried out, and none is to be expected under the current regulatory framework in Germany for performing clinical autopsies. This is true particularly for outpatient deaths, which are almost never subjected to autopsy except when ordered by the courts.
The concept of diagnostic error would correspond to the class 1 major mistake. A diagnostic error is assumed to have occurred when, at the end of the diagnostic decision process, a disease is definitely presumed to be present in a patient when in fact it later proves not to be so, a treatment is initiated that is not appropriate for the disease recognized at the later date, and the failure to recognize the disease that is actually present has led to a worsening of the patient’s prognosis (1, 3, 12).
A medical examination for certification of death must always be carried out when a dead human body is found (Box 2 gif ppt) and without delay once the report of the death has been received. The general requirements for medical certification of death are summarized in Box 3 (gif ppt). Establishing definitively that death has occurred is straightforward. Cessation of vital functions can be diagnosed with certainty by the following:
Presence of definitive signs of death (livor, rigor, advanced postmortem changes) or Failure of attempted resuscitation for around 30 minutes, confirmed by about 30 minutes of flatline ECG despite the carrying out of appropriate measures and after ruling out general hypothermia or intoxication by central depressant drugs Brain death (under clinical conditions can only be determined during assisted ventilation) Physical trauma that is incompatible with life.
Determining the cause of death
The immediate cause of death is given in Part Ia and the preceding causes—diseases that caused the immediate cause of death—in Parts Ib and Ic, with the underlying disease coming last. Finally, other important diseases that lead to death but are not connected with the underlying disease are given in Part II.
The chief significance of the cause of death is statistical: how many people die from a given disease. This is as opposed to the final cause of death, which gives information about what people suffering from a particular disease die of (7, 14–16).
According to Federal Statistical Office recommendations, if nothing precise is known, the entry “cause of death unknown” is preferable to vague speculation. Under no circumstances should constituent elements of every death process, such as “cardiac arrest,” “respiratory arrest,” or “electromechanical decoupling” be included in any part of the cause of death cascade, from underlying disease to the immediate cause of death.
Then, in the righthand column goes the duration (time interval) of the disease, taking as starting point the estimated onset of disease, not the time of diagnosis. The entries on time intervals also function as a plausibility check on the cause of death cascade.
If the cause of death given in Ia is not a consequence of further complications or underlying diseases known from the patient’s history, no further entries are needed, e.g.:
Ia: Cranial gunshot wound
In the prestructured entries on underlying disease and cause of death on the death certificate, according to the guidelines of the World Health Organization, physicians should mentally review the entire history of their patient’s illness. In particular, they should ask themselves whether a final morbidity was present that would be expected to lead to the patient’s death at the time given and in the circumstances described. “Hard” and “soft” causes of death should be distinguished: hard causes of death are present when the underlying disease of death and the immediate cause of death are closely related, appear in close sequence in time, and there is a close causal relationship between them, as for example in the case of a clinically diagnosed myocardial infarction that leads to cardiac rupture and thence to pericardial tamponade. Here, the underlying disease and the immediate cause of death are present within one organ system (linear type of death).
Soft diagnoses are present when the patient suffers from more than one underlying disease, none of which suggests itself a priori as the cause of death, and the cause of death remains multifactorial.
In evaluating disease conditions with regard to their potential to cause death, it is helpful to be guided by a classification of findings that has been usual in forensic medicine for over 90 years:
Group 1: Findings that, because of their severity and localization, are sufficient in themselves to explain the death of a person without further qualification; e.g., ruptured basilar artery aneurysm with fatal subarachnoid hemorrhage. Group 2: Organ changes that explain the death but not the acuity with which it occurred. One example would be acute coronary insufficiency. The morphological substrate, severe atherosclerosis, undoubtedly existed on the previous day, but an external stress such as physical labor in sultry weather was the added external event that led to the onset of death at the given time. Group 3: Deaths for which no explanation is found despite the most careful examination. Linear type of death: Underlying disease and immediate cause are within one organ system Diverging type of death: Organ-specific underlying cause, but non-organ-specific immediate cause Converging type of death: Underlying diseases in various organ systems lead to death via a final pathogenetic phase common to all of them Complex type of death: Underlying diseases in various organ systems with more than one non-organ-specific immediate cause of death.
If the cause of death remains unclear in a case of unexpected death of a healthy person, this should be noted on the death certificate. Federal Statistical Office recommendations on entering the cause of death and important terms are given in Table 2 (gif ppt) (20).
Finally, particular problems arise with deaths in old age or in connection with medical procedures. “Senility” or “old age” is not a cause of death. Retrospective examinations of deaths of over-85-year-olds and over-100-year-olds have shown that in each case morphologically ascertainable underlying diseases and immediate causes of death were present (6). If appropriate, the diagnosed diseases that contributed to the occurrence of death may be descriptively listed as a multifactorial converging type of death, in order to avoid “makeshift” diagnoses.
As regards deaths attributable to medical procedures, the first notable point is the considerable discrepancy between the deaths recorded in the federal statistics as due to complications of medical and surgical treatment and the data derived from epidemiological research on deaths due to treatment errors.
In epidemiological research, for Germany 17 500 deaths per year are suspected as a result of treatment errors (21)—these figures accord with international data—whereas the Federal Statistical Office gives only 399 deaths as complications of medical and surgical treatment in 2007 (4, 22). Here there are clearly a considerable number of unrecorded cases. This raises the question of whether in relevant circumstances the attending physician should issue the death certificate or whether, irrespective of the existence or otherwise of suspicion, such cases should always be subject to official investigation.
Manner of death
According to cause of death statistics, around 4% of deaths in Germany are due to unnatural causes (Figure 3 gif ppt) (20). Around 10 000 a year are due to suicide, 6000 to accidents in the home, just under 6000 to transport accidents, and 526 deaths to physical assault.
Retrospective analyses of death certificates for which the manner and cause of death have been checked at autopsy suggest that unnatural deaths are around 33% to 50% more frequent than is reflected in the federal statistics, and that it should be assumed that there are around 81 000 unnatural deaths every year (1, 23, e2). From the judicial point of view, a particular concern must be the number of homicides that remain undiscovered by the medical death certification; a multicenter study suggests that every year around 1200 homicides remain unidentified on death certificates in Germany (23). This large number of unrecorded cases is repeatedly confirmed by incidental findings of homicide or even serial murders (including in care homes and hospitals). Six percent of hospital physicians regularly attest exclusively to a natural death; 30% check the box for natural death even in cases of violence, poisoning, suicide, or medical intervention (e3). In assessing the manner of death, the certifying physician decides whether a death will come to the notice of the investigative authorities at all. Assessing the manner of death is thus an extremely responsible task not only from the judicial point of view (detection of homicide), but also in terms of the interests of the bereaved (for example, compensation claims after a fatal accident). “Natural” is a death from an internal cause (disease), where the deceased person has suffered from a disease that can be precisely characterized and from which death was anticipated; the death occurred entirely independently of any external factors of legal significance. The prerequisite for attesting a natural death is thus the existence of an underlying disease of death known from the patient’s medical history with a poor prognosis as to survival.
“Unnatural,” by contrast, is a death attributable to an event caused, triggered, or influenced from outside, irrespective of whether due to the fault of the patient him- or herself or of a third party. Unnatural deaths, therefore, are those due to:
- Physical assault
- Accident (irrespective of whose fault)
- Treatment errors
- Fatal consequences of any of the first six points.
The interval between an external event at the beginning of the causal chain that leads to death and the occurrence of that death can thus be indefinitely long (it may be years). If the cause of death cannot be ascertained when the death certificate is issued, the manner of death will therefore also remain unclear.
Various regulations relating to the certification of death in different states (Länder) in Germany, and a draft outline for a federal-wide death certification process from the German Medical Association, envisage explicitly that attestation of a natural death requires examination of the naked body (e4). Section 3 of the Bavarian Interment Regulations, for example, says, “[…] determination of a natural death requires in every case that the medical external examination on which the death certificate is based be carried out with the body of the deceased completely undressed. This examination of the completely undressed body shall include all regions of the body including all body orifices, the back, and the scalp.”
Sensible though this requirement is, there is no doubt that it is almost regularly disregarded. If the physician fails to meet the required standard of thoroughness, however, he or she has committed a regulatory offence. On the other hand, it must be recognized that completely undressing a dead body in cases of expected death in hospital will not lead to any gain of further information and can face the certifying physician with objective problems (e.g., when complete rigor mortis is established and no support personnel are available to help). Furthermore, this requirement fails to take into account the difference between expected and unexpected deaths. The manner of death remains undetermined if the cause of death cannot be identified on examination even with the help of the medical history. The attestation of natural death always assumes that a clear cause of death can be given. In this connection, it is disturbing that around 50% to 70% of physicians certify a “natural” death for death following femoral neck fracture, 20% for deaths during injections, and 30% to 40% for intraoperative deaths (24).
If on the one hand unnatural deaths are considerably under-represented in official statistics, on the other hand both physicians in private practice and those working in emergency departments report attempts by the police to influence them to certify a death as natural although no cause of death is apparent and hence the death ought to be certified as at least unexplained. In an anonymous survey of randomly selected physicians from the area of the Westfalen-Lippe Medical Association, 41% of physicians in private practice and 47% of emergency room physicians reported such attempts to influence death certification (24). The background to these attempts is that investigative authorities have a teleologically narrowed understanding of the term “unnatural death” as meaning “death in which there is a possibility of third-party guilt.” If a natural death is attested, no investigation is necessary. Indicators that a death may be unnatural may arise from the case history and findings: for example, sudden death without a known previous illness, “prima facie” accidents and suicides, farewell letters, etc. Findings that tend to indicate unnatural death are conjunctival hemorrhage, unusual color of livor, remains of tablets in the oral area, and signs of injury.
Unsuitable criteria for indications of natural death are age, especially when no pre-existing life-threatening diseases are known, and the absence of visible trauma.
As regards deaths in hospital, especially when the patient was under medical treatment for a long enough period, the mistake rate should also be relatively low; problem areas here are failure to recognize causal connections to traumas at the beginning of the fatal causal chain, and deaths related to medical procedures. In the inpatient setting, there are occasional reports of initially unrecognized series of killings by physicians or nursing personnel.
The danger of errors and scope for deception are no doubt greatest when the death is certified by private practice physicians in the home; typical mistakes and sources of error, in order of frequency, are:
- Careless examination of the body
- Consideration of the feelings of relatives.
Added to these, however, are sometimes also unfavorable external conditions, poor lighting, and simply not being adequate to the job, and there are no flexible solutions such as calling in qualified certifying physician. Physicians in private practice especially can find themselves with a collision of interests, since when they are also physician to the relatives of the deceased, attesting an unexplained death puts them at risk of triggering investigations that could lose them the relatives as patients. Compared to a physician in private practice, the hospital physician is in a more protected position (death in the medically dominated environment of a hospital rather than in the private area).
Problems that repeatedly arise in the hospital context are:
Deaths in connection with medical interventions, and Deaths following injury from a fall or other vio–lent events, in which the causal connection with violence from another person or other external event is not recognized and the death is wrongly certified as natural
For deaths that occur unexpectedly in the context of medical interventions, the manner of death should always be given as unexplained, so that an official autopsy can be carried out to investigate the underlying and immediate causes of death objectively. Only on this basis can an opinion be formed on any question of treatment error. Designating the manner of death as -unexplained or unnatural does not signify an admission of treatment error.
For physicians in private practice, the main problems arise when bodies are found at home, patients die unexpectedly, and deaths occur in old age.
If the cause of death cannot be established from external examination of the corpse or from interviewing any doctors previously involved in treatment, this should be recorded and the manner of death entered as unexplained. With old people, the question is always whether the history and severity of the diagnosed disease explain why death occurred here and at this particular moment. Mistakes and risks in medical examination of the body are summarized in Box 5 (gif ppt).
Whenever the cause of death cannot be established by external examination, an autopsy should be carried out, as is still usual in many of our neighboring countries in Europe. In Germany, the present autopsy rate is less than 5% of all deaths; the rate of hospital autopsies in particular has been dropping sharply in recent years, while judicial autopsies have remained relatively stable at 2% of deaths (compare autopsy rates of 20% to 30% in England and Wales, Sweden, and Finland) (25, e5). These autopsies, which are necessary for valid cause of death statistics and for the planned National Mortality Register, would however have to be adequately remunerated, which at present unfortunately they are not.
A complete (German-language) checklist for certification of death is given at www.aerzteblatt.de/v4/archiv/artikel.asp?id=39572 and in (e6).
Conflict of interest statement
The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.
Manuscript received on 25 March 2010, revised version accepted on
1 June 2010.
Translated from the original German by Kersti Wagstaff MA
Prof. Dr. med. Burkhard Madea
Institut für Rechtsmedizin
Stiftsplatz 12, 53111 Bonn, Germany
@For eReferences please refer to:
Institut für Rechtsmedizin, Universitätsklinikum Köln: Prof. Dr. med. Rothschild
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