Department of Anatomical Pathology
January 2003

Notes for professionals about post-mortem examinations

1. Background

The death of a family member can be a difficult time for the involved professional as
well as the family. Asking next-of-kin to give permission for a post-mortem to be
performed is a delicate and challenging task. Experience indicates that sensitively
handled, a well informed discussion does not need to be distressing. Obtaining
consent for a post-mortem examination should be the responsibility of a senior
member of the team, not the most junior.

This document is to assist those who have limited experience in discussing post-
mortem and death with the family. It contains information to help doctors and other
health care professionals answer the questions of the next-of-kin when a post-mortem
is being considered. A number of doctors and health professionals will already do this
extremely well, and may already be familiar with most of this information. Written
information is also available for the next-of-kin and other family members to read
about post-mortem examinations.

Before discussing with the next-of-kin, the doctor should ensure they are familiar
with:

• The NSW Health Department Policy on Consent Associated with Post-
  Mortem Examination
• Why the post-mortem is necessary
• When the examination will be performed (contact the pathology department to
  find this)
• The incisions that will be made
• The possible outcomes and when results may be available.

It is preferable if the doctor has spoken to the pathologist to be clear about requests
from the pathologist for retention of organs and any particular queries that they may
have about the case.

All post mortem requests to the pathologist should be accompanied by a detailed
history. The doctor should indicate if there are any infectious diseases present. The
case notes will also need to be reviewed by the pathologist.

1.1    Assisting a grieving family

The way in which bereaved relatives are dealt with during the initial stages will
greatly affect the likelihood of resolving their grief in the longer term. Many will have
difficulty when faced with a post-mortem, and some key elements in assisting them
through this include:

• Being open and helpful
• Providing information as wanted
• Allowing the person to talk
• All families should be offered the support of counsellors at the time of request
  and by subsequent contact following the post-mortem. Where relevant,
  information including contact numbers of support groups such as relevant
  members of the clergy should be involved.

The next-of-kin should have the time for discussion and have their questions
answered honestly and accurately. Doctors are advised that if they are uncertain about
how to answer a question, it is better to consult with the pathologist than to guess. The
doctor should be familiar with the consent form and ensure the next-of-kin
understands each part of the form.

1.2    Coronial and non-coronial post mortems

In Australia post-mortems fall into two categories; coronial and non-coronial.
Informed consent is required in order to do a non-coronial post-mortem. Consent
should be obtained in writing, and the designated officer of the hospital must
authorise the post-mortem examination under the Human Tissue Act 1983.

A coronial autopsy is where a post-mortem examination has been ordered by the
Coroner under the Coroners Act 1980. Health care workers should be familiar with
the criteria for a death require notification to the Coroner. The complete criteria are
listed in NSW Health Department Circular 99/57 and include

(a)    the person died a violent or unnatural death
(b)    the person died a sudden death the cause of which is unknown
(c)    the person died under suspicious or unusual circumstances
(d)    the person died having not been attended by a medical practitioner within the
period of 3 months immediately preceding his or her death
(e)    the person died while under, or as a result of, or within 24 hours after the administration of, an anaesthetic administered in the course of a medical, surgical or dental operation or procedure or an operation or procedure of a like nature, other than a local anaesthetic administered solely for the purpose of facilitating a procedure of resuscitation from apparent or impending death
(f)    the person died within a year and a day after the date of any accident to which
the cause of his or her death is or may be attributable
(g)    the person died while in or temporarily absent from any of the following establishments and while the person was a resident at the establishment for the purpose of receiving care, treatment or assistance

• a hospital within the meaning of the Mental Health Act 1990
• a facility within the meaning of the Community Welfare Act 1987
• a residential centre for handicapped persons licensed under the Youth and Community Services Act 1973
• a residential child care centre licensed under the Children (Care and Protection) Act 1987; or

(h)    the person died in any of the following circumstances

• While in the custody of a police officer or in other lawful custody, or while
  escaping or attempting to escape from the custody of a police officer or other
  lawful custody
• as a result or in the course of police operations; or
• while in, temporarily absent from, a detention centre within the meaning of the
  Children (Detention Centres) Act 1987, a prison within the meaning of the
  Prisons Act 1952 or a lock-up, and of which the person was an inmate; or
• while proceeding to an institution referred to above, for the purpose of being
  admitted as an inmate of the institution and while in the company of a police
  officer or other official charged with the person’s care or custody.

Consent from the next-of-kin is not required for a Coronial autopsy. Appeals can be
lodged by the next-of-kin against the decision to perform a post-mortem. In cases of
Coronial post mortem, you should be familiar with the brochure from the Coroner’s
offices and ensure this is promptly provided to the relatives.

1.3    Informed consent from non-coronial post mortems

It is up to the doctor obtaining consent to ensure that:

• the next-of-kin approached is the appropriate person to consent under the
  Human Tissue Act 1983 (see below*)
• the consent is fully informed
• authority for the post-mortem is given by a designated officer of the hospital
  (this should not cause delay to the post-mortem examination).

*Order of senior available next of kin is as follows:

• In relation to deceased adults:
  1.    Spouse
  2.    Child (over 18 years of age) where above is not available
  3.    Parent where none of the above is available
  4.    Sibling (over 18 years of age) where none of the above is available
• In relation to a deceased child:
  1.    Parent of the child
  2.    Sibling who is over 18 years of age where a parent is not available
  3.    Guardian of the child at the time of death where none of the above
  is available.

Consent should cover:

1. The post-mortem. Whether it will be full or limited, including the need for
   retention of tissues and small samples for diagnostic histology and other tests.
   If a limited post-mortem is desired then the extent should be clearly stated on
   the consent form.
2. Retention of organs and tissue or parts thereof for scientific, therapeutic,
   teaching, and medical purposes according to the next-of-kin’s wishes.

The next of kin may not consent to all of this, however, they may consent to tissue
retention for appropriate examination of an organ. Those areas on the consent form to
which the next-of-kin do not agree should be crossed out.

The second page of the consent form contains the authority of the Designated Officer
and needs to be signed by him/her.

2. Information that next-of-kin may need.

The following notes may assist in covering all issues that need to be discussed with
the next-of-kin in order to obtain fully informed consent.

2.1 Reasons for a post-mortem

Post-mortems providing additional information about the cause of death would appear
to be the most obvious function. Note that only a Coroner can order a post-mortem to
determine the cause of death. Non-coronial post-mortem examinations can be done to
confirm the cause of death shown on the medical certificate or identify other
contributory causes. The information that can be gained can be summarised as
follows:

• It may provide confirmation of the clinical diagnosis
• May provide additional information about the cause of death
• May identify abnormalities that are important for genetic counselling
• May identify undetected disorders and detect emerging diseases
• May give information on complications of treatment
• Provides a quality control mechanism to identify if anything was missed and
  whether correct care was given.

Negative findings

In coronial cases where the cause of death is not know, it is important to remember
that, even after the most careful and detailed examinations, a specific cause of death is
not always found. Nevertheless negative information is still of considerable value in
counselling families. This may show that there was no treatable illness present. This
point should be raised with the next-of-kin.

2.2 The post-mortem procedure

All intravenous lines should be left in situ when sending the body to the mortuary
including for hospital post-mortem examinations.

The main incisions made at autopsy are in the middle from the neck to the pubis. A
second incision is made over the back of the head to examine the brain. After the
body is restored, and the deceased is suitably dressed, these incisions should not be
visible. The deceased will usually be available for the family to see and touch again.

Note: If for any reason the body will not be available for viewing after the post-
mortem examination, the next-of-kin must be informed of this prior to giving consent.
The opportunity to view the deceased before the post-mortem examination should be
arranged.

Tissue samples and organ retention

A post-mortem examination invariably requires a wide range of tissue samples to be
taken for histological examination, as well as some tissue and fluid taken for other
tests. These tests may include microbiological examination, genetic examination, or in
some cases, looking for metabolic disease.

In some circumstances, it is good practice to retain a whole organ for later detailed
examination. The brain is the most likely organ to be retained, and less often, the
heart. This is why it is necessary to discuss with the pathologist the need for retention
of organs prior to discussing and obtaining consent for post-mortem from the next-of-
kin. If discussion is carried out and the organ needs to be retained, then explanation
and consent can have been arranged prior to the post-mortem and negate the need to
go back and talk to the next-of-kin later on.

The brain is soft and special fixation over an extended period is needed to carry out
full histological examination. In cases where the brain is an important part of the
disease, or where the pathologist indicates that the brain may need to be retained, it is
necessary to obtain specific consent for whole organ retention. While this may seem a
difficult question to pose to the next-of-kin, experience has shown that relatives will
often consent, if they are provided with a full explanation as to its necessity. It can be
explained to the next-of-kin that the implications of not retaining organs is some cases
may mean that some important questions about factors contributing to the cause of
death may remain unanswered.

Conversely, extreme distress can be caused by later discovery that organs have been
retained without knowledge. In some circumstances even a short fixation of 2 days,
then return of the organs with delay of the funeral may be negotiated with the next-of-
kin.

Retaining tissue for transplantation or research projects

Specific informed consent will need to be obtained to remove tissue, such as corneas,
which may be taken after death for transplantation into a living person. Similarly if
tissue is to be retained for research, separate informed consent should be obtained
from the next-of-kin for this use. The research project should also have approval from
the institution’s research ethics committee.

2.3 Timing of the post-mortem examination

It is advantageous to perform a post-mortem examination as soon as possible after
death as delays may affect the quality of some results and it is also desirable to
provide results to the family as early as possible. However, it is not absolutely
necessary for all cases. In a few cases, where genetic or metabolic disease are being
investigated, specimens may need to be obtained within two hours of death. If this is
the case, it may be necessary to obtain consent for this in suspected cases prior to
death. Expert advise should be sought before discussing with the next-of-kin to clarify
what is required.

2.4    Limited post-mortem examinations

Some next-of-kin may be reluctant to give consent for a full post-mortem. Rarely,
there are circumstances in which a limited post-mortem may be of value, usually if it
is directed to answering specific questions. Incisions might then be more limited.
Whenever limited examination is being contemplated, discussion with the pathologist
is advisable. In some cases even a careful external examination, followed by X-rays
and photographs may be of use.

2.5    Providing feedback to the next-of-kin

The next-of-kin will want to know when they will have the results of the autopsy and
other tests. An initial report, based on naked eye appearances, will be available within
a few days. For a completed report with all test results available, the timing is usually
6-12 weeks.

You can arrange with the next-of-kin for the initial or final post-mortem report to be
sent directly to them with a covering letter advising them to take it to their doctor to
discuss it.

2.6    Options for the return and disposal of organs collected at post-mortem

Should organs be retained during a post-mortem, the following options are available
for the return and/or disposal of tissues and organs retained at post-mortem.

2.6.1    Return of tissue and organs to the body prior to the funeral. This may be
suitable if organs do not require fixation, or if the funeral can be delayed by a
day or two while histology is completed.

2.6.2    Dispose of body parts as clinical waste once testing is completed: This would
be done in accordance with the Waste Management Guidelines for Health
Care Facilities, August 1998, (NSW Health).

2.6.3    Returned directly to the next-of-kin for disposal: Body parts can also be
returned to a person (such as an undertaker) nominated by the next-of-kin.
Body parts should be returned in a sensitive manner and in an appropriate
setting at an agreed venue and time. Body parts should be placed in an
appropriate sealed sturdy and non-transparent receptacle.

2.6.4    Should the next-of-kin indicate the wish to reunite the body parts with the
buried body, the following options are available, and will generally involve
the services of an undertaker. It would be expected that the next-of-kin will be
responsible for the costs on most cases.

• The body parts can be returned to an undertaker and cremated. The ashes may
  be buried or scattered at the grace site, cemetery or niche wall, or some other
  site
• The body parts can be returned to an undertaker and the grave opened to place
  the body parts in a suitable receptacle onto or adjacent to the original coffin.
  This does not constitute exhumation of the body. So there is no department of
  health approval required, just agreement from the cemetery authority
• Other options include removal of the coffin lid to place the body parts inside
  the coffin. As above, this does not constitute an exhumation, however the
  next-of-kin may be excluded from the proceedings
• Infrequently, the next-of-kin may wish for the body to be exhumed and the
  body parts placed with the body in a new coffin for reburial at the same site or
  another. The local public health unit would need to be contacted for approval
  and the next-of-kin may be excluded from the exhumation proceedings.

SydPath, St Vincent’s Hospital, Darlinghurst, Sydney.
January 2003