Scalia's Death and the Value of Autopsy: A Teachable Moment

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Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

Back in the "good old days," I was proud to be part of the profession of American medicine—a culture of self- and peer criticism where truth was sought and told, and recognition of error led to individual and group improvement. If a patient was seen by a physician who took a history, conducted a physical examination and ordered tests, diagnosed a nonlethal condition, and provided treatment, and 2 days later that patient was found dead, the physician wanted to know what happened and how he could have done better. An autopsy often provided the answers. Doctors learned. Autopsy rates on hospital deaths in those days were in the 50% range.

In February 2016, a 79-year-old man who had just returned from a vigorous trip to Hong Kong saw his physician with complaints of a head cold and shoulder pain. Examinations and tests were done and treatment provided. Two days later that patient was found dead. If you were that physician, would you not want to know what happened? But no autopsy was performed. (Autopsy rates on nonviolent deaths in the United States in 2014 were down to 3.5%.)

I know nothing about Supreme Court Associate Justice Antonin Scalia's life or death except what I have read in news reports. It is not my intent here to go into historical detail. However, I do know a lot about the value of an autopsy.

What was the cause of death of Antonin Scalia on February 13 or 14, 2016? I do not know and neither do you. Nor does Presidio County, Texas Judge Cinderella Guevara, who said, from many miles away and without seeing the body, that he died of "natural causes" (which, of course, is not a cause of death at all), and then said that he had a "myocardial infarction." Nor does his putative physician, Rear Admiral Brian T. Monahan in Washington, DC, with whom Judge Guevara spoke by telephone.

I seize this event as a Teachable Moment about the autopsy, which has, sad to say, become almost nonexistent for most current American physicians and hospitals.

I wrote an editorial[1] about this in JAMA in 1998. Let us see how it applies to Justice Scalia in 2016.

Eleven Reasons Why Autopsies Are Performed

1. To Establish Cause of Death

Justice Scalia's death was sudden, unobserved, unexpected, unattended, alone in a bedroom during a 14-hour overnight period on an isolated ranch in West Texas. Various media have reported that Justice Scalia was obese and a cigarette smoker, and that he had diabetes and hypertension.

At the physician visit described earlier, he underwent MRI because of shoulder pain and was diagnosed with rotator cuff damage. He was said by his physician to be too weak to endure shoulder surgery, so instead he flew off to Texas for a hunting trip. Could the shoulder pain have actually been a symptom of an acute myocardial infarction followed a few days later by his sudden death? Errors in diagnosis are common—indeed, a large cause of successful malpractice filings.

How about cerebral hemorrhage? Ruptured aneurysm? Pulmonary embolus? Sudden death during sleep apnea? Rapid overwhelming infection? Seizure? Cardiac arrhythmia?

2. To Assist in Determining the Manner of Death (Homicide, Suicide, Accident, Misadventure, Natural, or Undetermined)

Sudden, unexpected, unattended death in the United States automatically becomes a medical-legal issue with local jurisdiction, no matter the identity of the deceased. Serious investigation by qualified forensic experts is always indicated. Autopsy should be performed in most instances. When a politically prominent person dies unexpectedly, I consider autopsy mandatory. In this case, a complete autopsy, including the brain, should have also included tests for blood alcohol and full toxicology, including prescription drugs.

Homicide? Who had a motive? Of course no American would wish Justice Scalia (or any other Supreme Court justice or high-level politician) dead. But millions of women who wish to own their own bodies, of LGBT Americans who wish to be able to marry, of the poor who wish to be able to vote without a picture ID, of citizens concerned about influence of money on politics, of members of the California Teachers Association, etc., have wished that Justice Scalia's legal arguments and votes were absent, past, present, and future.

Did the authorities at the scene even pull back the bedding and turn the body over?

Suicide? Seems pretty unlikely. No note or reported depression. No suspicious evidence at the scene. What medications were found in the room? No toxicology tests were done.

Accidental? Maybe aspiration? Airway? "Café coronary" after eating? Overdose of prescription drugs and alcohol? We have not been told what the decedent ate or whether and how much alcohol he may have consumed. We do not know what medications were found at the scene.

Misadventure? This is a term used in the United Kingdom, not applicable in Texas.

Natural? Maybe.

Undetermined? Based on information available to me at writing time, this is the best classification for his manner of death.

3. To Compare Premortem and Postmortem Findings

Obviously not done.

4. To Produce Accurate Vital Statistics

I can say that there is nothing "accurate" about his cause of death, even though I do not know what was actually written on his death certificate. They are the (highly contaminated) source of US Vital Statistics.

5. To Monitor the Public Health

Probably not applicable here, unless Justice Scalia's "head cold" was actually from some rapidly lethal infectious agent he brought back from Asia, which may have infected others since returning.

6. To Assess the Quality of Medical Practice

What diseases or disorders did he actually have? If he was treated appropriately, why was the outcome so poor? Might that unexpected fatal outcome have been a factor in his physician eschewing an autopsy?

7. To Instruct Medical Students and Physicians

Trying to do that right now.

8. To Identify New and Changing Diseases

Unknown. Maybe he did pick up some exotic infection in Singapore or Hong Kong a few days before. He was described as robust and energetic at the resort.

9. To Evaluate the Effectiveness of Therapies Such as Drugs, Surgical Techniques, and Prostheses

Not applicable in this case.

10. To Reassure Family Members

Opportunity missed. The family will never really know why their husband/father/grandfather died.

11. To Protect Against False Liability Claims and Settle Valid Claims Quickly and Fairly

Was Justice Scalia's sudden death an example of "failure to diagnose" an acute myocardial infarction and failure to treat it appropriately? Allegations of cover-up are always a concern when prominent people die, unless there is rapid and full disclosure to allay conspiracy theories and the like.

To end this downer column on a more positive note, the recent book Improving Diagnosis in Health Care, from the Institute of Medicine of the National Academies, includes this recommendation on page 374[2]:

GOAL 4: Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice.

RECOMMENDATION 4c: The Department of Health and Human Services should provide funding for a designated subset of health care systems to conduct routine postmortem examinations on a representative sample of patient deaths.

How nice finally to see serious support for the value of autopsies, and from such an influential source.

That is my opinion. I am Dr George Lundberg, at large for Medscape.


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