Insights of Validating Death Certificates through Clinical Autopsies

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.