< CRITICAL CHOICES FOR HEALTH CARE

WHEN IS A CORONER NEEDED? WHAT ABOUT AN AUTOPSY?

“The Coroner’s Office is a part of the Sheriffs Department and is under the direction of the Sheriff’s Commander… The Coroner Unit’s responsibility is to investigate all deaths reportable to the Coroner and determine the cause, manner, and circumstances surrounding reportable deaths. The (Sheriff) Coroner is a county-elected officer acting under the authority of provisions of the California Government Code and Health and Safety Code. There are specific laws that define the Coroner’s powers and which vest in that person, the right and duty to investigate certain classes of deaths. Taken from the Monterey County Sheriffs Office website at www.co.monterey.ca.us/sheriff

Not all deaths are reportable to the Coroner. Those deaths that are reportable fall into 25 categories. Those categories are:

1. No physician in attendance.

2. Medical attendance less than 24 hours (hospital or residence).

3. Wherein the deceased has not been attended by a physician in the 20 days prior to death.

4. Wherein the physician is unable to state the cause of death.

5. Known or suspected homicide.

6. Known or suspected suicide.

7. Involving any criminal action or suspicion of a criminal act.

8. Related to or following a known or suspected self-induced or criminal abortion.

9. Associated with a known or alleged rape of crime against nature.

10. Following an accident or injury, old or recent, (primary or contributory, occurring immediately or at some remote time.)

11. All deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, starvation, exposure, acute alcoholism, drug addiction, strangulation or aspiration.

12. Accidental poisoning, (food, chemical agent, drug or therapeutic agent).

13. Occupational disease or occupational hazards.

14. Known or suspected contagious disease constituting a public health hazard, including AIDS.

15. All deaths in operating rooms.

16. All deaths where the patient has not fully recovered from an anesthetic whether in surgery, recovery room or elsewhere.

17. All deaths wherein the patient expired within 24 hours of an operation or surgical procedure.

18. All deaths in which the patient was comatose throughout the period of the physician’s attendance, whether at home or hospital.

19. All solitary deaths.

20. All deaths of unidentified persons.

21. All deaths where the suspected cause of death is Sudden Infant Death Syndrome (Crib Death).

22. All deaths in prison, jails or of persons under the control of a law enforcement agency.

23. All deaths of patients in state mental hospitals.

24. Wherein there is no known next of kin.

25. Fetal deaths of older than 20 weeks gestational age.

Is an Autopsy Needed?

Once a death is reported to the Coroner, it is the Coroner’s responsibility to investigate the death and the determinations as outlined above. From this point, the Coroner may close the case as a “Physician Certified death” meaning that a physician has reviewed the circumstances and deemed that the death was of obvious natural cause. Only a fraction of the deaths reported to the Coroner result in a full autopsy.

While many may object to autopsy for religious or other reasons, some of which are discussed below, there is an argument for the continuation of autopsies and even the expansion of autopsies performed. Dr. Richard Horowitz, Professor of Pathology at UC and UCLA School of Medicine, states that “In up to 40% of autopsies, there is some finding that was not clinically suspected, and in many of those cases, the patients' lives might have been prolonged had the diagnosis been made. Yet, there is no outcry; no one seems to care that so few autopsies are now done.” Dr. Horowitz goes on to state that “Clinicians don't care because they fear that autopsies may expose their mistakes. Many pathologists don't care either -- autopsies take time and are not reimbursed. Hospitals and health systems don't care because autopsies don't improve their ‘bottom lines.’"

In those deaths where the Coroner needs further investigation, the coroner or medical examiner has the legal authority to order an autopsy without the consent of the deceased person's family (next of kin). If an autopsy is not required by law, it cannot be performed until the deceased person's family provides permission.

Family members may have concerns and strong emotions about an autopsy being done on a loved one. It is important that the family understand that the autopsy is a medical procedure performed respectfully and carefully, to objectively evaluate disease or injury that may be present and to determine the cause and manner of the loved one's death.

Issues for the family to consider when a loved one is to be autopsied are:

1. Organ or tissue removal for donation purposes generally requires separate permission from an autopsy.

2. If a family requests an autopsy, the consent form generally describes the details of the autopsy, especially with respect to retention of organs and tissues for teaching. The requesting family member should make sure that the details of the autopsy are fully understood.

3. A family can request that a hospital do an autopsy on a person who died there. In some hospitals, there is no charge for this service. In some teaching hospitals, a person who died outside of the hospital (for example, at a nursing home or at home) may be autopsied at the hospital at no charge. If an autopsy is required by law, there is no charge to the family. However, charges should be clarified before the procedure is performed since many hospitals charge for autopsies and insurance generally does not pay for autopsies.

4. An autopsy does not prevent the body from being viewed in an open casket. Generally, none of the incisions made during the autopsy will show after the body is prepared for viewing. The rare exception to this is with autopsies in which injuries on the face, scalp, or hands are evaluated. These autopsies may leave some marks that are visible during viewing of the body.

5. If an autopsy is being performed at the request of the family, the family may request that the examination be restricted or limited to certain parts of the body. It is important to discuss these restrictions with the pathologist to ensure that the requested examination allows the pathologist to answer the family's questions about the death.

6. Autopsies to determine natural causes of death are not done as often now as they were in the past. However, when death has most likely occurred from natural disease, an autopsy can uncover information that is very valuable to the deceased person's doctor and family.

7. Autopsy results may affect insurance settlements or result in legal action

The Coroner may also take charge of any and all personal effects of the decedent at the scene of the death and safeguard them until lawful disposition can be made. The Coroner may also notify family of the death.

The Coroner’s Unit and County Public Administrator office work together to ensure that indigents are buried, or by Board of Supervisors resolution in Monterey County, cremated. If estate funds are available to pay for the burial or cremation and the Public Administrator is administering the estate, the Public Administrator will make arrangements to pay the costs of burial or cremation from the estate. If no estate funds are available, the Coroner Unit is responsible to see that this duty is carried out at county expense.

The Public Administrator acts as administrator in estates where there are assets to distribute, no known estate plan (Will or Trust) and no immediately known heirs or next of kin can be found.

What About Religious Belief or Cyrogenic Freezing?

Some people may have an objection to autopsy due to religious belief or, as is becoming more and more popular today, some may want to be cryogenically frozen for resurrection at a later time. If the Coroner or Medical Examiner requires that an autopsy be performed, this may undermine arrangements made with regard to cryogenic freezing. Younger decedents are particularly at risk of autopsy since death at a young age is most likely to be the result of an accident, homicide, or sudden unexplained illness.

Some state legislators (California being one of those States) have moved toward restricting the power of the state to demand an autopsy. One statute which has been passed in at least five states (California, Maryland, New Jersey, New York, and Ohio) is the "Religious Objection to Autopsy." Simply, it gives people the right to attempt to prevent an autopsy of their remains by signing a certificate declaring that autopsy is contrary to their "religious belief." (A person completing such a form is not required to state what his/her religion is.)

In states that have passed a religious objection law, this form may be the most effective way to prevent autopsies and to limit the scope of those which are performed. If you or your family objects strongly to autopsy due to religious or other reasons, you may consider executing the California Certificate of Religious Belief attached. Remember, with this form as with all legal documents, work with your attorney to make sure it fits into your overall estate planning.

Keep in mind that the Coroner or Medical Examiner will not request an autopsy unless there is a clear and convincing reason for them to do so. If you execute a Certificate as mentioned above, you may be losing an opportunity for your family to benefit from the knowledge of a clearly diagnosed medical issue that may be hereditary or you may be “burying” evidence of some wrongdoing that would have otherwise been discovered and possibly prosecuted.

All things considered, if the California Certificate of Religious Belief is of interest, there is a copy attached. Weigh the consequences and speak with your legal advisor.