Insights of Validating Death Certificates through Clinical Autopsies

Special Article: Autopsy

Austin J Surg. 2023; 10(4): 1312.

Insights of Validating Death Certificates through Clinical Autopsies

Schubert D1,3; Christ H2; Fries JWU3

1Medical Training Center, Department of Medicine, University of Bielefeld, Bielefeld, Germany

2Institute for Medical Statistic, Informatic and Epidemiology (IMSIE), University of Koeln, Koeln, Germany 3 Institute of Pathology, University Hospital of Koeln, Koeln, Germany

*Corresponding author: Jochen W.U. Fries Professor of Pathology, Institute of Pathology, University Hospital of Koeln, Koeln, Germany. Tel: +49223858840; Fax: +492214786360 Email: Jochen.fries@uni-koeln.de

Received: September 11, 2023 Accepted: October 11, 2023 Published: October 18, 2023

Abstract

Background: With decreasing autopsy numbers, the cause of death listed in the death certificate is only based on an external inspection, which is increasingly criticized as insufficient. This investigation analyses 447 death certificates from the archives of the University Hospital of Koeln, Germany and their corresponding autopsy reports from the Institute of Pathology.

Methods: For this analysis, quality assurance protocols, death certificates, clinical/autopsy notes, and final autopsy reports were used. Cases were categorized: 1. in four validation classes (Goldman criteria, identifying unknown diseases with therapeutic relevance as cause of death); 2) in four nosological causal chains (WHO ICD10; type: linear/ divergent/ convergent/ complex).

Results: Differences in diagnoses between death certificate and autopsy report occurred in 32% (143/447 cases). In 7%, only the autopsy identified the cause of death (Goldman, type 2a). Nosological causal chains were established in 21% (linear/divergent) vs 28% (convergent/complex). Myocardial infarct, septicemia and cardiac insufficiency caused death in more than two thirds of cases. Diabetes and obesity did not play a major role as cause of death.

Conclusion: Autopsies are highly advisable if death occurs within 48 hrs. of admission and as sudden death in the hospital setting. Regular interdisciplinary autopsy conferences are important for quality control, assessing cases of the convergent/ complex type. The position of an autopsy commissioner as mediator between relatives, clinicians and pathologists seems recommendable in a hospital setting. While an electronic patient file is still controversial, medical data collection as source of information in emergencies by the patient’s medical practitioner seems advantageous.

Keywords: Death certificate; Autopsy report; Goldman criteria; Nosological causal chains; Autopsy commissioner; Electronic patient file.

Introduction

In Germany, about one million people die per year. Board certified medical doctors are oblieged by law to prepare death certificates. Basic diseases, their consequences and a resulting death occuring from a natural event have to be certificed. The massive development in medical knowledge and procedures over the last 30 years and procedures as well as the change in population structure (age increase, ethnicity) has increased the complexity of daily medical practice. In addition, lack of knowledge of the previous medical history of the patient and his preexisting diseases and comorbidites may lead to wrong conclusions. Thus not unexpectedly, during the last decade, the quality of the death certificate and its relation to an autopsy (so called internal body examination) has been increasingly criticized.

To recognize potential problems, the Health Ministry of North Rhine-Westfalia, Germany has suggested to study autopsy-based death certificates versus their respective autopsy reports. Previous analyses focused on particular patient collectives like newborns [1] liver transplantation [2,3], posttraumatic events [19] or intensive care patients [5-7]. An analysis in a community-hospital [8] revealed that a complete agreement between death certificate and autopsy report was only found in 42%. However, a study in a university clinic setting as hospital with all currently available surgical and medical devices regarding the agreement or disagreement between death certificate and autopsy report and its reasons based on nosological causal chains has not been done. We performed this study to analyse the reliability on the diagnoses in a death certificate, the need for autopsies based on the recognition of clinical relations, show problematic clinial scenarios and propose ways to improve potential pitfalls.

Material and Methods

Death certificates were validated using clinical autopsies by a team (a board certified anesthesiologist/intensive care specialist (DS) and a board certified pathologist being 20 years head of the autopsy service in the Pathology department of a university hospital). Reports were used from 1420 autopsies performed from 2005 to 2014 at the Institute of Pathology, University hospital of Koeln, Koeln, Germany, one of the largest university hospitals in Germany. Only 447 could be analyzed further due to incomplete/missing clinical information and/or death certificates. Potential diagnostic insights were standardized using case-related quality assurance protocols built on death certificates; applications for autopsy; notes from case discussion between clinicians and pathologists; the autopsy protocol itself and the final autopsy report. This analysis was done in two parts.

Part 1:

Cases were categorized into one of the 4 valuation classes [9] with respect of their role in the cause of death and their diagnoses comparable with those during the life of the patient.

• Class I error: Misdiagnosis that may have affected survival and probably would have required alteration tretatment.

• Class II error: Misdiagnosis that did not affect survival and would not have required alteration of treatment

• Class III and class IV errors: Missed minor diagnoses unrelated to the disease course

Part 2:

Advances in medical knowledge and technology, and the degree of multimorbidity makes the analysis of the cause of death considerably harder than before. As recommended by the WHO, we used the new ICD10 (International Statistical Classification of Diseases and Related Health Problems), where death should be considered the result of a multiple cause chain instead of a single event. In ICD 10, four nosological chains causing death should be used [10,11].

1. Linear type: the classical, monocausal chain (i.e. aspiration – pneumonia – death)

2. Divergent type: a chain whose basic disease is caused/characterized by two different disease processes (i.e. diabetes: macro- / microangiopathy; nerve paralysis and “diabetic foot” etc.).

3. Convergent type: a causal chain with a common final denominator (e.g. hypertension/diabetes/fatty acid disturbance: all causing microangiopathy leading potentially to cardiac infarction).

4. Complex type: several parallel existing diseases with an independent and equally strong contribution leading to death (e.g. inflammatory bowel disease and prostatic abscess both leading to septicemia).

5. All cases were subjected to nosological causal chain evaluation.

The following statistical analyses were performed:

i. Quality assurance protocols were established quantifying the diagnostic gain using autopsies by differentiating the relationship between basic/essential versus secondary illnesses

ii. Frequency distribution of valuation classes (according to Goldman; methods, part 1)

iii. Frequency of nosological causal chains

Results

Patient Data

We analyzed death certificates and autopsy reports from 447 patients, 192 men (43%) and 255 women (57%) (age distribution see Table 1). Patients came from either the university clinic (353; “inpatients”) or as outpatients/emergency cases (94) (see Table 2). The majority in both groups constituted patients from cardiology (inpatients: 44.4 vs emergency patients: 50%) and the GI department (inpatients: 22.3%). General surgery patients were dominant as emergency patients (41.5% vs. 12.1% as inpatients); patients from oncology were the next largest group for inpatients (14.7%). A more detailed differentiation was not possible in the emergency cases.