The practicing physician and the Medical Examiner

The relationship between the King County Medical Examiner and the practicing physician can be mutually beneficial. The cooperation of physicians whose patients have become Medical Examiner cases is frequently instrumental to the Medical Examiner in making an accurate certification of the cause of death. This is particularly true in supplying medical and psychological history and medical records. The Medical Examiner is able to provide physicians with an accurate determination of the cause of death when an autopsy is performed. Many King County physicians have expressed confusion as to their duty to the Medical Examiner. The purpose of this section is to clarify that duty.

The Medical Examiner's responsibilities do not revolve solely around certifying criminal deaths or serving in the prosecution of criminals. In practice, and as provided by several Washington State Statutes, the Medical Examiner may inquire into all deaths impartially and solely to prepare a record of facts which are available to anyone whose lawful purpose requires them, whether these be criminal or civil, whether these serve the public or the individual. Furthermore, the Medical Examiner is charged with certifying causes of death which are reasonably accurate and acceptable for purposes of vital statistics.

When there has been no physician in attendance, there obviously is no one other than the Medical Examiner who can legally sign the death certificate. The Medical Examiner thus has clear authority to proceed in these deaths. When there has been previous medical attention, the attending physician may be required to provide the Medical Examiner with copies of medical records and other pertinent information that would assist the Medical Examiner in determining whether further investigation is needed (See pg. 5:3). Prior records and history form the basis of sufficient legal grounds for the Medical Examiner to authorize further investigation including an autopsy. The Medical Examiner will make the decision to accept or reject jurisdiction of a case based on the sum of the facts learned from the physician, and the circumstances of the death.

It is important to bear in mind that any query by the Medical Examiner or investigators into the manner or mode of medical treatment is done to ascertain whether there are sufficient grounds for the Medical Examiner to proceed, and not to judge or evaluate the adequacy or propriety of any particular treatment. Deaths where the Medical Examiner finds are not within the jurisdiction of the office will be referred to the physician whose responsibility it is to sign the death certificate.

If an attending physician is quite satisfied that the death is outside the jurisdiction of the Medical Examiner, and if that physician is willing to certify death, (see criteria as listed on pp. 3:5), the Medical Examiner need not be notified and the body can be released to a funeral home. If, in the opinion of the attending physician, criteria have been met which require the reporting of the death to the Medical Examiner, the physician shall report the death immediately by telephone to the Medical Examiner's Office (206.731.3232 Ext. 1). This number is monitored 24 hours a day. Frequently physicians/medical personnel notify the Medical Examiner of every death to relieve themselves of any responsibility for the determination of jurisdiction. Familiarity with the death reporting criteria will reduce unnecessary phone calls. Whenever a question exists, qualified Medical Examiner investigative personnel will make the assessment quickly and expeditiously.

The attending physician, upon learning that the Medical Examiner's Office has accepted the jurisdiction of the death, may report this to the family, make them aware that the body will be removed to the Office of the Medical Examiner, and that there is a probability a postmortem examination (autopsy), will be conducted. In those instances in which the Medical Examiner accepts jurisdiction, the body will be transported to the Office of the Medical Examiner by a medical investigator. There should be no removal of clothing or effects, or handling the body in any manner by persons not authorized by the Medical Examiner, or an Investigator from the Medical Examiner's Office.

If an attending physician wishes to attend the autopsy, this request should be made to the Medical Examiner. Every effort will be made to accommodate such requests.

Organ and tissue utilization

The Medical Examiner's Staff recognizes the value of organ and tissue utilization from deaths which come under the jurisdiction of the Medical Examiner. According to RCW 68.08.060 the Medical Examiner is authorized to retain tissues and/or organs only when there is a need to establish the cause and manner of death. Exceptions to this rule include the donation of certain human tissues that may be provided to the Eye Bank and tissue centers when such tissue is needed for transplantation. The controlling statute, RCW 68.08.300 requires that certain conditions be met before this tissue can be provided. One of these conditions is that a reasonable effort made to obtain permission from the next-of-kin. In all other instances, the surviving family or next-of-kin must give explicit authorization to any agency to utilize organs and tissue for other purposes.

Organ donation

A potential organ donor is a patient who has suffered an injury to the brain resulting in brain death. Such a potential organ donor will generally be maintained on respiratory and hemodynamic support until the Organ Procurement Agency has an opportunity to assess donor potential.

Once the Procurement Coordinator of the Organ Procurement Agency establishes this potential, it is necessary that the Medical Examiner Investigator be notified of the potential donor. The Medical Examiner Investigator can make an assessment of the circumstances of the injury and a determination made whether or not organ or tissue procurement authorization can continue.

Once an assessment has been made and all concerns of local law enforcement agency have been answered, then organ procurement authorization can continue. Generally, the only instances where the Medical Examiner will obstruct organ procurement are in homicidal deaths, particularly of infants or children where there may be hidden injury.

Each death must be evaluated on its own merit. Every effort will be made by the Medical Examiner to ensure there is maximum utilization of organs for donation. If the donation is obstructed by the Medical Examiner, the Organ Procurement Agency will be provided an explanation.

Since the Lifecenter Northwest (LCNW), the Northwest Tissue Center, and Lion's Eye Bank work conjointly in harvesting organs and tissue, permission that is obtained from family by LCNW generally includes permission for tissue utilization by the Northwest Tissue Center and the Lion's Eye Bank. The same criteria used for organ donation are applicable for tissue utilization.

Tissue donation

Postmortem tissue utilization does not have the same requirement as organ donation. Consequently potential tissue donors are not maintained on respiratory or hemodynamic support and death can occur outside hospital without undue interference with tissue utilization, particularly if the postmortem interval is short. There are deaths where tissue utilization can be performed some hours after death.

All requests of next-of-kin for permission to remove tissue are coordinated by a single tissue utilization agency. This is to ensure that only one telephone contact seeking permission is made with the deceased's relatives.

Consequently, any requests made of the Medical Examiner to obtain tissue for whatever purpose will be referred to the tissue agency, which functions as coordinator.

At the present time, the Northwest Tissue Center serves as that coordinator and can be reached by telephone at 206-292-6596 or 800-858-2282.

In addition to tissues, which are removed for transplant purposes, there are a number of requests made by medical researchers who are seeking fresh tissue. To facilitate this process, the requestor will be referred to the Tissue Utilization Coordinator to ensure that, if permission is granted by the family, the appropriate tissue will be procured according to the request.

It is incumbent upon requestors that they be able to immediately respond to the Medical Examiner's Office to receive tissue once a donor is identified. There is a misconception that tissue can be routinely procured by the pathologist during an autopsy and handled in a fashion to meet the needs of the requestor. Such an action does not take into consideration the purpose and procedure of a forensic autopsy done under statutory authority.

Any requirements that tissue be handled in a particular fashion or stored in a particular container will not be accomplished if the requestor or his agent is not physically present.

Consequently, it is the responsibility of the requestor to make the necessary arrangements to ensure that specimens are handled with minimal involvement by the Medical Examiner Staff. Such efforts will encourage success in tissue utilization.

Certification of death

When it has been determined that the death of a patient does not meet the criteria for the Medical Examiner to take jurisdiction and therefore certify death, completion of the death certificate becomes the responsibility of the attending physician.

Since the death certificate is a legal and not a scientific document, the physician is not required to establish a specific anatomical reason responsible for death. For that requirement, anatomical dissection or additional postmortem studies would be necessary in all deaths, which is clearly unmanageable and beyond the resources of the Medical Examiner and the medical community.

The requirement for certification is a statement of the general disease process or condition most likely responsible for death.

We have encountered difficulties with physicians who state that they are uncertain why a patient died although they have been treating the patient for years for a stable, although not necessarily life threatening condition. For example, a hypertensive patient, quite well controlled, who drops dead suddenly and in view of many witnesses. The physician may feel that the death is unexplained and requires an autopsy for specific anatomical diagnosis. However, this death would be viewed as outside the Medical Examiner's jurisdiction, since medical history provides adequate information for a reasonable cause of death, ie. hypertensive heart disease, and so should be certified.

A second example may be useful. A patient with diagnosed, long standing cirrhosis may die suddenly with no suspicion surrounding death. The anatomical lesion may be ruptured esophageal varices or pneumonia or pulmonary embolus. However, the certification requirement is simply cirrhosis, with the awareness that the terminal condition may not be established.

It is acceptable to use "probable" to identify a suspected final event, e.g., probable rupture of esophageal varices due to or as a consequence of cirrhosis of the liver.

If a specific anatomic cause of death is desired, the physician is free to seek autopsy permission from the family after clearing the death with the Medical Examiner.

Mechanisms of death frequently encountered on death certificates include cardiac arrest, cardiorespiratory arrest, etc. These common pathways of death are so general as to be meaningless for purposes of certification.

If a physician has difficulty in completing the death certificate, the physician should consult with the Medical Examiner's Office. If an accident or any type of violence such as a fracture due to a fall, causes or contributes to the death, the death is within the jurisdiction of the Medical Examiner.

When an autopsy is performed

The Chief Medical Examiner is authorized by statute, to perform an autopsy on any body within jurisdiction criteria. Autopsies are performed when, in the judgement of the Chief Medical Examiner, a medico-legal requirement exists which can only be satisfied by autopsy.

Generally, autopsies are performed if there is evidence of violence (recent or remote) or evidence of suspected unnatural death or a death that needs explanation.

The Medical Examiner will not perform an autopsy simply because the attending physician refuses to sign the death certificate and wants to know the extent of the natural disease process.

The Chief Medical Examiner has the authority to perform autopsies when clear jurisdiction of the death exists. The authority to perform autopsies is defined by statute and does not require concurrence of surviving family. Whenever possible, the wishes of the family will be considered and in some cases an autopsy will not be performed over family objections if they release the Chief Medical Examiner from his/her responsibility by signing a formal document opposing an autopsy.