Procedure to establish a cause of death can yield useful information

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be "The Informed Patient," with the podcast that features experts from Central New York's only academic medical center. I'm your host Amber Smith.

The autopsies we see in TV shows are usually forensic autopsies done when there's a suspicious, violent, or unknown cause of death. But there's another kind of autopsy called a clinical autopsy, and these are performed in a hospital to find and better understand someone's cause of death. Here with me to explain the value of autopsy is Dr. Robert Stoppacher. He's a professor of pathology at Upstate, and he oversees the University Hospital Autopsy Service.

Welcome to "The Informed Patient," Dr. Stoppacher.

Robert Stoppacher, MD: Thanks for having me.

Host Amber Smith: Let's start with an explanation of what an autopsy is. I know it's an examination of the body after death, but what's included in that exam?

Robert Stoppacher, MD: So, as you said, an autopsy is the process of examining an individual after that individual has passed away. More specifically, I tend to break it down into three different components. One is what we call the external examination, where we look at the outside of the body, looking for any disease that may be evident on the outside of the body, looking for any kind of medical intervention that that individual may have had, and in certain situations looking for any kind of injuries or trauma that may be present on the outside of the body.

After we document all of those findings on the outside through written documentation and through photographs, we perform what's called the internal examination. And that involves performing surgical incisions into the body and looking at all the internal organs, again, focusing on is there any disease that's affecting different organs or the entire body, and documenting that through the course of the examination and also through photographs.

The third part is what I term the laboratory component, and that has a little bit of flexibility depending on the nature of the case, but it will frequently involve examining tissue samples under the microscope because certain diseases, let's say, for example, if someone has a mass that we identify in the lung, for example, it's important to look at that under the microscope and through that means we can determine if it's A, cancer; B, some sort of infection. And if it is cancer, we can then further classify the type of cancer that it may be, just like would be done if someone has a biopsy when they're alive. And it's sent to the pathology department, and it's then examined microscopically to identify the type of cancer, if you will.

In addition to that portion of the examination, the lab portion also might involve doing any kind of laboratory tests. So, for example, if there's an infection, we may take cultures of that area to see what the bacteria is. Or, on rare occasions, we may collect blood samples for potentially toxicology testing, looking for the presence of medications, or drugs. The toxicology aspect is really more something that's used more commonly in the forensic setting, as you can imagine. In most hospital related deaths, medications, or certainly illicit drugs, are not really of significant concern in that situation.

And so we do all three of those components that form an autopsy, ultimately with the goal of trying to establish why that person died, or what we call the cause of death. And in most hospital-based autopsies and deaths, that's a natural process. So, for example, it's some natural disease that might be heart disease, or it might be a stroke, or it might be complications related to cancer or some sort of infection.

In contrast to the forensic setting, where oftentimes those deaths relate to some sort of violence or trauma. At some level, that's one of the big differentiators between what you term forensic autopsies and clinical autopsies. It's a different population that the autopsies are being performed on.

Host Amber Smith: So, for the clinical autopsies, which are mostly natural deaths, it sounds like you have a step-by-step procedure that you follow for each one. But how long does that take?

Robert Stoppacher, MD: It depends on the nature of the case. So, there may be very complex medical conditions that the individual has, that may be further complicated by prior surgery. So anatomically or during the physical process of the autopsy, it may be more intensive with respect to that dissection and identifying diseases and organs and so forth. So I would say on average, a clinical or hospital autopsy takes approximately 2 1/2 to three hours.

Host Amber Smith: Depending on what you find, I'm assuming?

Robert Stoppacher, MD: Right.

Host Amber Smith: So is it the same for an autopsy for a child versus an adult?

Robert Stoppacher, MD: In general, yes. The steps that are taken are similar. You know, that doesn't change. However, obviously, having a knowledge of infant or child anatomy is important, particularly when we're dealing with neonates (newborns) or other disease processes that may have required some sort of surgical procedure, such as congenital heart disease, or a disease of the heart that the child is born with.

But the general process doesn't change. However, it's having a knowledge of what diseases children are more likely to have. And as you can imagine, most of the time, because these deaths occur in the hospital, or the patients have been in the hospital for some period of time, there's lots of documentation as far as medical records and imaging, so X-rays and CT scans that give us a better understanding of what may be the issues related to that particular case that we need to focus on.

Host Amber Smith: So I know that you're in search of a cause of death, but when the deceased had a multitude of medical problems, how do you tell which of the diseases is the one that killed them?

Robert Stoppacher, MD: Well, that's a good question. And what, as I previously described, as we go through all the different organ systems in the process of performing an autopsy, if there's pathology or disease in a particular organ, and some of that disease may be what we call chronic or may be something that we might expect as someone ages. And that may be different than something that is superimposed on that, that drastically caused a change in their condition.

So, for example, someone with emphysema or COPD, chronic obstructive pulmonary disease, that disease is very evident when we do an autopsy. However, the fact that they may have pneumonia on top of that might give us a better understanding of why that individual died.

I think the other important consideration is even though we're pathologists and not clinical physicians who deal directly with patients, most of the time, we do have quite a bit of knowledge about clinical medicine and the correlation between what we're seeing at the autopsy and what the clinical symptoms and the clinical course of that patient were very important to look at in conjunction with one another. And that's probably the best way to determine what actually caused that individual's death, rather than other diseases that may simply be present. And in all honesty, oftentimes, it's some combination of multiple diseases that probably worked in unison to ultimately produce that death.

Host Amber Smith: How common is it to find something that surprises either you, or the family during an autopsy?

Robert Stoppacher, MD: It's not uncommon. Many times we will find something that was not identified throughout the life of that patient. Oftentimes those are, some of them may be what we call incidental. For example, it might be a cyst on the kidney or a cyst on the liver or something that's of relatively little significance. That's a relatively common occurrence.

In contrast, finding something that is completely unknown that is going to affect or may have caused that individual's death happens less frequently, but it does happen. I think there is sort of a misconception nowadays that with the imaging that we have -- CT scans, MRIs, and all the additional laboratory and diagnostic tests that are available -- that the autopsy is not useful.

And history has shown numbers wise that the rates of autopsies in teaching hospitals has dramatically decreased over the past two decades, even at the largest academic and teaching institutions. However, study after study has also shown that the autopsy remains the best way to identify diseases that may have been not identified in life or misdiagnosed in life. As I said, that doesn't happen that often, but it does occur on occasion.

Host Amber Smith: So what sorts of things do you look for that might be important for the survivors to know in terms of family medical history?

Robert Stoppacher, MD: So in the process, documenting diseases that exist that, as I mentioned, may not necessarily cause the death, but may be present, in those that did cause the deaths are certainly important pieces of information for surviving family members in general. So, when you go to your doctor, one of the things that they typically will ask you about is your family history. And they want to know about your parents or your siblings. And do they have any diseases, or what medical conditions do they have?

Having that information or obtaining that information through an autopsy is useful for surviving family members to know certain conditions that that individual had. That doesn't mean that all of those conditions are going to appear in family members because there's a lot of factors that play into, let's say, heart disease. There's lifestyle choices that affect how that happens such as smoking and other risk factors, but there is a family history component to it or a genetic component, if you will. But it's not an absolute, per se.

There's other less common situations where a disease has a very clear genetic abnormality associated with it. And I'll try and give you an example. There is an entity called hypertrophic cardiomyopathy. And that's a condition where there is a genetic abnormality in one of the genes that code or that dictate some of the proteins that are involved in the heart muscles. And when an individual has that abnormality, their heart becomes very enlarged and thickened. And that can predispose them for, obviously, problems with their heart, including what we call sudden death or cardiac arrest. That tends to be something that happens in relatively younger individuals. But if we're able to identify something like that, that clearly has a genetic component to it, we can do confirmatory testing and identify that gene and then help surviving family members potentially get tested for that disorder.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking to Dr. Robert Stoppacher. He's a professor of pathology at Upstate, and he oversees the University Hospital Autopsy Service.

Well, let me ask you a little more about the University Hospital Autopsy Service. Is this just for people who pass away in the hospital?

Robert Stoppacher, MD: Primarily, that's what the autopsy service does. It relates to or involves individuals that die at Upstate (University) or Community General hospital. However, our policy is that if someone was seen at any of the Upstate hospitals within the past six months, and dies outside of the hospital, let's say, at a nursing home or a rehabilitation facility or at home, for that matter, then we will perform the autopsy in those situations.

We also do a significant amount of what we call private autopsies that are from individuals not from the Upstate system, and those might be individuals that die in a hospital that doesn't perform autopsy examinations and they're interested in knowing, or simply in situations where the family wants to know more about the processes that resulted in their loved one's death, but they don't have the ability based on where the death occurred or where they lived to have an autopsy done locally.

Host Amber Smith: So can anyone request an autopsy, and how is it paid for? Does insurance cover it?

Robert Stoppacher, MD: So any Upstate patient or recently discharged Upstate patient, those autopsies are done at no cost to the family or the patient. That's part of the quality assurance program that Upstate has, and we do those autopsies at no charge. In contrast, the private autopsies that I talked about, that's usually something that is associated with a fee for performing those.

With respect to who can request an autopsy, there are very strict guidelines as far as consenting or providing authorization to perform an autopsy examination, and those follow what we call the legal next of kin.

So, legally, there's certain individuals that are your next of kin. I don't have a better way to say that. So, for example, a spouse would be the closest next of kin, followed by children, and as you can imagine, you go further out down the line. We follow that process in obtaining consent for an autopsy examination. I do want to point out, it's oftentimes that individuals may have a power of attorney or a medical proxy during their life as far as treatment decisions and so forth. However, those entities, if you will, die, no longer exist, when an individual dies. So a healthcare proxy does not exist, if you will, after that individual dies. And that's, in part, the reason why we use the legal next of kin as the individuals that would need to consent for and authorize the autopsy examination.

Host Amber Smith: Do you have advice for relatives who want to understand more about how their loved one died? What do they need to know about seeking an autopsy?

Robert Stoppacher, MD: It's important that patients and their families have an understanding of what an autopsy involves and what it can and can't accomplish. You know, we talked about an autopsy examination in the form, the different components of it and so forth. There are situations where we may do a limited autopsy examination.

So, for example, in a situation where a family's concern is really focused on if their loved one had dementia. And so we may only examine the brain through a specialist neuropathologist that looks at the brain in great detail. Or they may simply want to know if the mass that they found in the lung, shortly before the person passed away, is that cancer? And we don't necessarily have to do a complete autopsy examination, looking at every organ. Certainly that will provide the most information, but there are other opportunities, or other ways to get more focused answers.

And this process, I think, can benefit lots of families. It does not cause any significant delay in services or issues with respect to viewing or funeral services beyond that. So I think there's a lot that can be learned through an autopsy, and if there's questions that someone may have about an autopsy on their loved ones, certainly, first line would be to talk to their doctors that are taking care of them and ask them about it. And if they can't answer it, then they will reach out to us through the autopsy service, who are happy to talk to them or their physicians directly.

Host Amber Smith: That's good to know. Well, getting back to television, what have you seen on TV programs get right about autopsies? And what have you seen them get wrong?

Robert Stoppacher, MD: I mean, I think most of us have seen some sort of TV drama, be it NCIS or CSI, and you can insert whatever acronym you want, but certainly, there's a couple of things that are not accurate in those situations. One, the autopsy takes a little bit longer, and we don't get answers in the half-hour time slot that they're slotted. Same holds true for DNA testing and any other lab work. You can imagine, it has to be a little bit more, some license is given to make it more entertaining.

I think that the bottom line is the basic gist of what is done at an autopsy is relatively accurate. I think there's a little bit of license taken to allow people to explain exactly what happened based on the autopsy findings when it's not quite like that in reality. So, for example, you may see on a TV show that the medical examiner looks at a body and says they died three hours and 22 minutes earlier. When in all reality, that's not possible. And so I think it's a little bit sensationalized for obvious reasons, but the basic tenets of the autopsy aren't that far from the truth.

Host Amber Smith: Well thank you for making time for this interview, Dr. Stoppacher.

Robert Stoppacher, MD: Oh, you're quite welcome. Thank you.

Host Amber Smith: My guest has been Dr. Robert Stoppacher. He's a professor of pathology at Upstate who oversees the University Hospital Autopsy Service.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.