Determine that the consent for autopsy is proper

Observe the requirements for determining that the death need not be reported to the medicolegal authorities

Inspect the consent form to determine if the form follows, in good faith, a proper informed consent

The person giving consent for autopsy MUST be the legal next-of-kin

The priority for next-of-kin is established in law, and it does vary. In some jurisdictions , there can be a “common law spouse,” who may be the legal next-of-kin, while other jurisdictions do not recognize such a status

In general, but not in every jurisdiction, the top priority for consenting an autopsy goes to the lawful spouse, and no other person can give consent, even if the spouse is “estranged,” “legally separated,” “incarcerated,” or “of unknown whereabouts”

If a spouse does not exist because the patient was never married, or the spouse has died, or there is a finalized legal divorce, then in most jurisdictions the consent is next obtained from an adult child , if an adult child exists

For a patient without a spouse, and without an adult child, the autopsy consent becomes extremely unclear in many jurisdictions

For pediatric autopsies , the ideal consent is from the mother. If mother is herself a child, it is best for the consent to also be cosigned by the maternal grandmother of the infant. Lesser levels of signature present potential problems, especially if the consent is only signed by the alleged father, where paternity has not been established by any mechanism other than the name on the birth certificate

After confirming the consenting person, check the consent form to see if there are any restrictions placed on the autopsy examination

A complete autopsy is an unrestricted examination of the body and at least includes the brain and internal organs of the neck, chest, abdomen, and pelvis

For autopsies that are restricted by consent to particular organs or body topography (i.e., “chest and abdomen only” or “chest only”), the examination is restricted or limited to the organs within only the consented body cavity

If the autopsy has a medical issue wherein the diagnosis cannot be established due to the limitations of the dissection, it is always best to call the physician who requested the autopsy to see if that physician was aware of the restrictions and aware of the impact that will have on the quality of information obtained by the autopsy

In a “chest only” autopsy, there will not be an examination of the liver, even if the liver is visible during the dissection. There will not be an examination of the larynx even though the intrathoracic portion of the trachea is examined

The clinicians need to be aware if restrictions prevent answering specific questions about locations of therapeutic devices such as the endotracheal tube or a vena cava filtration device

Retention of organs and tissues after an autopsy , especially the brain, is a controversial practice

Before the autopsy, review the procedure manual or discuss the tissue retention policy with autopsy staff, and comply with the policy. Most pathology residents will be working at institutions where complete retention of organs is the ordinary practice, yet distribution of those retained organs and tissues is strictly regulated

Laws pertaining to organ and tissue donation vary across the United States and worldwide

The consent to obtain tissues, for medical or commercial donation, even corneas, from the body before or after autopsy, is determined by the tissue bank facility, usually coordinated with the autopsy facility

The consent to obtain tissue must include a specific “release of confidential or protected health information” clause, so that the pathologist examining the body can discuss the medical history and results of autopsy tests with the procurement agency

Commonly, the organ or tissue facility will contact the pathologist on the day of the autopsy to discuss gross autopsy findings. If this does not happen, there may be circumstances where it is appropriate to try to contact that facility directly. A very common scenario is that there has already been corneal donation, and then the autopsy discloses medically unsuspected and undiagnosed caseating granulomas in the body. That finding may affect utilization of the corneas, and the information, even though preliminary, incomplete, and not confirmed evidence of infection, needs to be assessed by the tissue facility

Ultimately, consent for collection of medical, commercial, or research human tissues is to be provided by the tissue bank, not the pathology lab

It is always incumbent upon the physician conducting the autopsy to coordinate the autopsy, and access to the body, with any organ or tissue procurement agency once that agency has proper consent

Historically , decades in the past, there were autopsy facilities in America where loose, even verbal, agreements were struck to permit commercial vendors to obtain human pituitaries and human placentas, as well as other body parts, from hospital autopsy rooms, sometimes including fees paid to pathologists for obtaining these tissues. Pituitaries were purchased by pharmaceutical companies to make extracts of human hormones for medical treatment, and placentas were used to extract human chorionic gonadotropin for reagent test kits and fertility drug synthesis. These practices largely or completely disappeared decades ago. Today, specific informed consent, validated and monitored by an institutional review board, may be required before the pathologist gives any autopsy specimen to anyone else outside the immediate reach of patient care for the patient at autopsy. A training institution may have an internal mandate to require specific consent and IRB management for autopsy tissue procurement for human subject research. It is common among pathology resident training facilities to have IRB-approved procurement procedures for research specimens, especially as related to the use of experimental in-dwelling surgical or diagnostic devices where there may exist an approved research protocol to retrieve the device from the patient’s body after death for scientific examination of the device. Every pathology resident should understand that autopsy requests for research specimens are quite routine, but never simple, and there are mechanisms and requirements and procedures that must be monitored by hospitals and academic institutions to sustain ethical use of autopsy specimens for research. Careful understanding of the scope of the autopsy consent is necessary, to stay strictly within the boundaries of that consent when obtaining specimens for research, teaching, or commercial enterprise. A resident leaving training and entering into private practice is expected to know that ethical standards apply to autopsy tissue research

Review and approve the consent

Prepare for the autopsy with a review of the hospital chart, as mandated by CAP and Residency Review Committee (RRC) requirements

Determine if there are any clinical lab tests, such as microbiologic cultures, that might be pending when the patient died

Determine if the diseases indicated in the clinical history will require any sort of specialized dissections as outlined above under “Restrictions on Examination”

If spinal dorsal root ganglia or eyes are going to be needed to establish a diagnosis, then the time to prepare for that dissection is during your review of the medical history