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Royal Alexandra Emergency Department Procedure for Physician-Family Member Discussion of Autopsy

Purpose: To comply with the recommendations made by the Provincial Court of Alberta to the Minister of Justice and the Solicitor General in the Public Fatality Inquiry into the death of a patient in the Royal Alexandra Hospital Emergency Department (RAH ED).

Case date: February 1, 2012 Judgement date: January 15, 2019 Compliance by: December 31, 2019

Background and Context: On February 1st, 2012 a patient died in the RAH ED presumably due to post-operative complications.

The Inquiry found inadequacies in process in the care of this patient in three principle areas.

First, the patient was discharged on a weekend without the knowledge or approval of the primary attending surgeon who had intended to keep the patient in hospital several more days. The process of handover of care and communication of patient care plans is to be addressed by that service.

Second, the patient was discharged despite the objections and concerns of family members. This has been addressed in up dated hospital policies and procedures.

Third, and of relevance to the ED, there were several concerns regarding the discussion of autopsy in the RAH ED including timing of the discussion and the accuracy of the information provided to family members. This document addresses those concerns.

Recommendations pertinent to the ED: “A communication procedure regarding autopsy decision must be in place between family members and ER physicians.”

The Judge writes: “No evidence was presented that discussed how ER physicians address autopsy with the family. The Royal Alexandra Hospital should have a uniform process in place for physicians to rely on when they address autopsies. There should be a standard practice

for the discussion of autopsies with the patient’s family so that the family is able to take a fully informed position.”

“In this case, each family member testified that the discussion of the autopsy took place at the same time as the discussion regarding (the patient’s) withdrawal of life support, while (the patient) was still alive. This is highly problematic. Consideration of an autopsy should not take place while a patient is still on life support, nor right after a patient passes away. Families should be given some time to grieve and process the death of a loved one before the discussion about an autopsy is initiated. Had this conversation been more thorough and compassionately handled, the family could have made a reasonably informed choice.”

In Response to the Above Recommendations: Guiding Principles for Physician-Family Member Discussion of Autopsy

Discussion regarding autopsy should not take place: 1. At any stage prior to the declaration of patient death and the family being informed of the death.

2. Until the family has been offered the opportunity to be with their loved one.

The need for a discussion can be raised with the family after death with the indication that the physician can be summoned to have this discussion when the family is ready.

Discussion regarding autopsy should: 1. Take place in a quiet and private space or, if desired, in the care space where the patient remains. Both options should be made available to the family.

2. Endorse compassion and respect for the family

Autopsy Types (2) 1. Medical Examiners Cases: The Medical Examiner is an MD with a specialization in Forensic Pathology. When you “call the ME,” you actually speak to the Medical Investigator. They are medical professionals, often with a nursing or paramedicine background, who will discuss the case with you and determine if it meets the qualifications of an ME case. They may discuss with the ME to make this determination. The ME performs the autopsy.

If the death is one which falls under the purview of the Medical Examiner, the family should be notified of this and the reason why the Medical Examiner must be informed.

The family should be notified that the body of their loved one will be transported to the Medical Examiner’s office and that the Medical Examiner will make the final decision regarding the performance of an autopsy.

Many families will have no objections or concerns to this process.

However, if the family has any concerns regarding autopsy, the physician should relay those concerns to the Medical Examiner/Investigator. The family should be informed once you have alerted the Medical Examiner/Investigator to their concerns and informed that the Medical Examiner/Investigator will contact them to discuss. The Medical Examiner will attempt to honor family wishes when possible. For example, they may consider religious objections to autopsy. However, the family should be informed that the Medical Examiner has final jurisdiction over this decision and that family consent is not required.

The Medical Examiner will be responsible for completing the Medical Certificate of Death in these cases.

Circumstances under which the Medical Examiner must be informed of the death of a patient: From the Medical Certificate of Death: “If the Underlying Cause of death is not a natural disease or is an occupational disease, the death must be reported to a medical examiner (see section B on the instruction sheet).”

From section B on the instruction sheet: “Accidental, violent, or any unnatural deaths cannot be certified by the attending physician and must be reported to the medical examiner.

Checklist for Notification of the Medical Examiner       

Unexplained deaths.

Unexpected deaths when the deceased was in apparent good health or not under the care of a physician.

Deaths as the result of violence, accident, suicide or poisoning, irrespective of the time between the receipt of the injury and death.

Maternal deaths occurring during or following pregnancy that may reasonably be related to the pregnancy.

Deaths as the result of improper or negligent treatment.

Deaths that occur during an operative procedure or within 10 days of an operative procedure, or while under or during recovery from anesthesia.

Deaths in custody of any person.

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Deaths resulting from any disease, ill health, injury or toxic substance arising from a person’s occupation at any time (including deaths due to malignant mesothelioma).

Death of a formal patient of any mental health facility or any other institution defined in regulations under this Act. Death of a young person under child welfare custody.”

2. Cases which fall outside the purview of the Medical Examiner: A discussion regarding the availability of a limited, in-hospital autopsy for patients whose death falls outside of the realm of the Medical Examiner can be held with family members.

The request for such an autopsy is determined by the desire of the family and at the discretion of the Emergency Physician in a shared decision making process.

Some families may be reassured by your assessment of the cause of death and/or by your discussion with the Medical Examiner. They may see no need to proceed beyond that.

However, some families may have unanswered questions and feel that a limited, inhospital autopsy would be helpful to them. If this is the case, it is your responsibility to make arrangements for this to occur.

The Emergency Physician will be responsible for completing the Medical Certificate of Death in cases where the patient’s body is not sent to the Medical Examiner’s office regardless of whether or not a limited, in-hospital autopsy is performed.

Process for acquiring an in-hospital autopsy: This is not a common process for us and an option of which few of us are aware.

The process is detailed by the Chief of Laboratory Medicine (which includes Pathology) in a presentation which will be made available on the KEG Website.

Essentially, the request for a limited, in-hospital autopsy includes the completion of an Autopsy Consent Form with the patient’s next of kin, an Autopsy Consultation Request Form, the Medical Certificate of Death, and the Notice of Death (Notice of Death is completed by nursing staff). These forms are sent to Admitting during day time hours and Emergency Admitting during off hours. Admitting notifies Pathology and sends the paperwork to the lab.

These forms will be available with the Unit clerks on A & B side.

Compliance with Court Recommendations: In order to fully comply with the Court recommendations, this information must be available to Emergency Physicians on an ongoing basis and a process for ensuring Emergency Physicians are aware of this process are required. The details by which this will be accomplished are elucidated below.

Process for dissemination of this important information to the Royal Alexandra Hospital Emergency Medicine Physician Group and Location of this information for your on-going reference: -Emergency Physician group e-mail review and e-mail discussion of this document.

-presentation and discussion at two consecutive Emergency Physician group meetings of the case and this document.

-on going access to this document, as well as the process for limited, in-hospital autopsy, available on the Kingsway Education Group (KEG) Continuing Medical Education Secured Website.