The Yale Autopsy Service

An autopsy, also known as a post-mortem examination, is a specialized surgical procedure used to determine the cause and manner of death. The cause of death is the medical reason explaining why a patient passed. The manner of death is the circumstances surrounding the death. Connecticut recognizes the following manners of death: natural, accident, homicide, suicide, and unknown. Only deaths due to natural causes are examined at Yale New Haven Hospital. All other manners of death are referred to the Office of Chief Medical Examiner (OCME) for further investigation.

Autopsies continually advance our understanding of disease. What we learn from autopsies allows clinicians to better understand disease processes, accurately diagnose diseases, improve therapy, and potentially aid other patients who are currently suffering from a similar disease. There are many reasons why families choose to pursue having an autopsy done. Consent for an autopsy at Yale includes diagnostic, education, quality improvement, and research.

Many people believe that autopsies should only be performed when there is uncertainty as to the cause of death. Although this is a valid reason for an autopsy, it is not the only reason. The purpose of an autopsy is two-fold: 1) to thoroughly evaluate the presence and extent of human disease in patients and 2) to evaluate the effectiveness of therapeutic procedures for the benefit of patient families, our staff, and the future practice of medicine. The personnel involved in the autopsy are able to see the physical manifestations of human disease during the post-mortem examination. The results of the autopsy are also used to develop quality assurance data and health care quality outcome measures for the Yale New Haven Hospital.

An autopsy can be reassuring for the family. As part of the autopsy consent process, the family has the option to place limitations on the both the retention of organs and the extent of the autopsy. Please note that any limitations may compromise the diagnostic value of the autopsy, or may limit the usefulness of the autopsy for education, quality improvement, or research purposes. These items are discussed below.

Autopsies are diagnostic by nature, and can help a family learn more information about the disease processes that caused a patient’s demise. For example, an autopsy could identify an unknown primary cancer, or it can allow doctors to perform examinations that were not feasible when the patient was alive. An autopsy offers clinicians the best opportunity to obtain a more complete understanding of why the patient passed.

Autopsies provide an opportunity for clinicians, residents, medical students, pathologists’ assistant students, forensic science interns, and our staff to learn more about various disease processes and how they manifest in the body. Tissue may be used in certain programs at the Yale School of Medicine to further the education of students. In addition, some cases are used in various presentations to help others understand rare and complicated cases. All educational tissue procured from autopsies is utilized in accordance with the Health Insurance Portability and Accountability Act (HIPAA) privacy laws.

The Joint Commission for the Accreditation of Health Care Organizations (JCAHO) requires that the results of autopsies be incorporated into the quality assurance program of the hospital. Autopsy clarification/discrepancy information is recorded to document instances in which the autopsy examination added to, clarified, or altered the clinical understanding of the case.

Each clarification/discrepancy is graded by assigning it to one of the following levels:

1. Indicates that the case had no clarifications or discrepancies.
   
   
2. Major unexpected finding or clarification contributing to the patient’s death.
3. Major unexpected finding or clarification that did not contribute to the patient’s death.
4. Minor unexpected finding or clarification contributing to the death of the patient.
5. Other minor unexpected finding or clarification that might have eventually required treatment.

Yale New Haven Hospital supports a variety of ongoing research projects. The Tissue Procurement team ensures that all protocols are vetted, and are responsible for acquiring the necessary tissues for these projects. Occasionally, the autopsy is limited to recovery of tissue for a particular program. If the clinician’s contact information is included on the consent, the autopsy staff can coordinate with the clinical team to ensure proper recovery and preservation of the tissue.

The restrictions on the autopsy consent dictate whether the autopsy is considered to be a technical only. A technical only autopsy is done at the exclusion of diagnostic, education, quality improvement, and research purposes. There are a variety of reasons that the autopsy would be considered a technical only autopsy. Examples include 1) the removal of hardware to be sent back to the manufacturer for testing, and 2) the removal of brain or other tissue to be sent out to another facility.

Autopsies have been performed on individuals of all religious backgrounds, and many major religions leave this decision to the next-of-kin. However, you may wish to consult with your priest, minister, rabbi, or other religious leader before providing consent for an autopsy. When necessary, the autopsy staff can coordinate with a specified religious leader to ensure the family’s religious needs are met.

Yale New Haven Hospital will perform an autopsy free of charge for patients that expire at Yale New Haven Hospital–York Street and St. Raphael’s Campus, Bridgeport Hospital (Bridgeport and Milford Campus), Greenwich Hospital (pediatric only), and Veterans Affairs Connecticut Healthcare System–West Haven, as well as any person who passes away outside the affiliate establishments but have been seen recently at the above institutions. Yale New Haven Hospital is not responsible for obtaining consents from these locations. Consent must be taken by a staff member at the affiliate location and sent to the York Street Campus through an established channel.

The Autopsy Service will accept requests for private autopsies for a prepaid fee. Please call for options and pricing. The Autopsy Service retains the right to decline to perform an autopsy on any patient.

The State of Connecticut requires that the Medical Examiner examine deaths due to accident, homicide, suicide, and unknown causes. Yale New Haven Hospital is required to report patient deaths that fit the established criteria concerning manner of death to The Office of the Chief Medical Examiner (State of Connecticut). Each case is reviewed and investigated by the trained Medicolegal Investigators. The Medical Examiner’s Office will determine if there is a need to further investigate the death. If a family requests an autopsy, and the case was reported to the medical examiner according to state regulations, we can perform the autopsy only if the medical examiner declines to investigate the case further.

According to Connecticut Statute Sec19a-286, the next of kin or person responsible for burial is authorized to give permission for a hospital autopsy. Permission may be given in person or through a witnessed telephone conversation. When consent is given in person, the “Consent for Postmortem Examination/Autopsy” must be signed both by the person entitled by law to control the disposition of the body and by a designated Yale New Haven Hospital staff member. Alternatively, consent may be given verbally over the telephone through a witnessed conversation with two designated Yale New Haven Hospital or affiliate staff members who will both sign the form. Veterans Affairs Connecticut Healthcare System–West Haven has their own autopsy consent form and process. Please contact them directly for their policies and procedures. The family may consent to a full, unrestricted autopsy, or may limit the extent of the autopsy.

Please note that a complete autopsy will not interfere with any funeral arrangements and that the Autopsy Service will honor any limitations placed on the autopsy. The family should consider what questions they have regarding the death of their loved one to determine what, if any, restrictions should be placed on the autopsy. If the family wants to know the cause of death, it is best to not place any limitations on the autopsy to afford us the best opportunity to determine the cause of death.

Statement 5 on the autopsy consent form reads: “I understand that I may place some limitations on both the retention of organs and the extent of the autopsy. I understand that any limitations may compromise the diagnostic value of the autopsy or may limit the usefulness of the autopsy for education, quality improvement or research purposes.” This statement means the family may either 1) grant permission for a complete autopsy, with removal, examination, and retention of material as the pathologists deem proper for the purposes listed in the consent, or 2) place restrictions on retention of organs or extent of the autopsy.

Please call the Autopsy Service if you have any questions regarding placing limitations on the autopsy.

The Autopsy and Morgue Service is open every day of the year to perform autopsies and release patients to funeral homes. An autopsy can be completed within one to two days depending on when the patient and consent are received. The morgue staff works with the funeral director of the family’s choosing to ensure the patient is available for funeral arrangements in a timely manner. The autopsy should not delay the funeral arrangements.

The autopsy process, including scrutiny of the consent, review of the patient’s chart, and a physical examination, only takes a few hours to complete. (See What is an Autopsy?) An autopsy is a highly specialized surgical procedure that will not interfere with any potential funeral arrangements. Tissue is retained for examination to allow the patient to be released into the care of funeral director so as not to delay funeral arrangements. Restrictions requesting a return of organs will temporarily delay the release of a patient in order to ensure proper retention of necessary tissue for diagnostic purposes. Following an autopsy, a provisional report is signed out within 2-4 business days and a final report is generated within 90 days. However, the final autopsy report may take longer than 90 days, depending on the complexity of the case and the need for additional studies. All personnel involved in the process strive to provide timely answers to the families.

The autopsy report can be requested at the time of consenting to the procedure by making note on the Consent that you would like to receive a copy. Once the autopsy has been completed, a report can be requested by completing the Autopsy Report Request Form. Please note that only the person who gave permission for the autopsy may receive a copy of the autopsy report. The request form must be completed, notarized, and mailed to the address on the form. Requests for reports will not be fulfilled without the original notarized form. This is to protect the decedent’s information and ensure only the person who gave consent for the autopsy is granted access to the results.

The autopsy report is highly technical. The Service recommends that the findings be reviewed with a clinician of your choosing to ensure understanding of the contents and how each aspect of the process relates to the others.

The Autopsy Service typically does not call the family or funeral home. It is the responsibility of the family to contract with a funeral home or cremation service to have their loved one released into the care of the facility of their choice. The family is not expected to coordinate this process, as the facility they have chosen will handle these arrangements.

The Connecticut Department of Consumer Protection has information on funeral homes and cremation services. Please contact a funeral home or cremation service regarding financial concerns and potential state or federal benefits. State of Connecticut Public Act 04-255 specifies what is expected of funeral directors in the state of Connecticut.

Yale New Haven Hospital cannot recommend a funeral home or cremation service.

A death certificate is a legal document that certifies a patient's passing and includes the date, time, and cause of death. The medical portion of the death certificate is to be signed by the physician (MD, DO), advance practice registered nurse (APRN), physician assistant (PA), or pathologist, according to Connecticut Public Act No. 04-255. Maureen Weaver’s 2005 article summarizes this public act.

The Autopsy Service makes every effort to ensure the medical portion of the death certificate is properly filled out to expedite the release of a patient into the care of a funeral home or cremation service. Since only the medical portion is filled out, the Autopsy Service cannot release the death certificate to the family directly.

The funeral home or cremation service will complete the demographic portion of the death certificate and file the completed document with Vital Statistics in New Haven. The funeral director provides the family with one certified copy of the death certificate. Please contact your funeral home or cremation service for more information or visit the Department of Public Health website for questions regarding how to obtain additional copies of the death certificate.

Organ, tissue and eye donation is regulated by state and federal legislation to ensure a safe and equitable allocation, distribution, and transplantation of donated organs. The U.S. Congress passed the National Organ Transplant Act in 1984 which established the Organ Procurement Transplant Network (OPTN) to maintain a national registry for organ matching. The Act also calls for private, nonprofit organizations to maintain this network. More information on this Act and organ donation can be found at the U.S. Government Information on Organ Donation and Transplantation website.

New England Donor Services (NEDS) is responsible for performing organ and tissue donation at Yale New Haven Hospital. NEDS screens all reported Yale New Haven Hospital deaths for suitability prior to contacting the family for consent and patient history.

While associated with Yale New Haven Hospital, NEDS is a separate entity that operates under the State of Connecticut Substitute House Bill No. 5407 Public Act No. 04-122. To learn more about becoming an organ donor at Yale New Haven Health.

Tissue procurement must occur within a specific time period following death; this window of time may vary for different tissues. A NEDS representative can explain the various time requirements for organ, tissue, and eye donation.

Organ procurement will delay the release of a patient to a funeral home or cremation service due to the process involved. The NEDS staff member who takes consent for organ donation should explain the predicted timeline based on which organs are expected to be recovered as well as any other potential delays. The Autopsy Service is not always made aware of these delays as the recovery of certain organs is performed in the operating room prior to transportation of the patient to the Autopsy Service.

Tissue and eye donation can minimally delay funeral arrangements. NEDS has the right to ask that a patient not be released to a funeral home or cremation service until their staff has had an opportunity to review the case and speak with the family about donation. This right is protected by State of Connecticut Substitute House Bill No. 5407 Public Act No. 04-122. If the family consents to tissue or eye donation, the representative from NEDS will explain the timeline for recovery and approximate the time that the patient will be ready for release to the funeral home. The Autopsy Service will work with the funeral home or cremation service to try to minimize any potential delay.

Donation does not interfere with the Autopsy Service's ability to perform an autopsy. However, the Autopsy Service will typically delay an autopsy on patients the NEDS has identified as a potential donor. This is to ensure the best opportunity for NEDS to recover all possible tissue as an autopsy will prevent recovery of some tissue due to the potential for contamination. After NEDS completes their recovery, the remaining tissue can be examined. NEDS will provide the Autopsy Service with a report on the analysis of the organ, tissue or eye recoveries to include in the final autopsy report.

The Autopsy Service is located in the Brady Memorial Lab at 310 Cedar Street. The Yale New Haven Hospital autopsy/morgue suite consists of an office, two autopsy rooms, a shared procedures room, a special procedures room, a refrigerated decedent storage room, and an observation room. The space is designed for the safety of the staff with negative pressure ventilation. The facility does not include a bereavement room because patient viewings should be done on the floor, prior to the patient being brought to the morgue or at a funeral home.

All decedents are released from the designated area by a licensed funeral director, licensed embalmer, or a forensic technician from the Office of Chief Medical Examiner. Patients cannot be released from the hospital floors directly. There is an area where patients may be kept outside of cold storage for those religions that do not allow patients to be cooled. There is also a separate exit that can be used to release these patients to the funeral home. The staff will do their best to accommodate any religious needs. Please contact the office directly to discuss those needs and how the staff can help facilitate.

Yale New Haven Hospital performs the most hospital autopsies in the state of Connecticut, with a 10-year average of 267 per year. Yale New Haven Hospital aspires to perform as many autopsies as possible as a service to the patients and their families. The Autopsy Service will perform an autopsy free of charge for decedents that pass away at Yale New Haven Hospital York Street and Saint Raphael Campus, Bridgeport Hospital, Greenwich Hospital (pediatric only), and Veterans Affairs Connecticut Healthcare System–West Haven. In addition, the Autopsy Service will perform an autopsy free of charge for decedents that pass away outside the affiliate establishments but have been seen recently at the above institutions. Yale New Haven Hospital also offers private autopsy for a prepaid fee. Please visit the Requesting an Autopsy page for more information on who may have an autopsy performed at Yale New Haven Hospital.

The Autopsy Service maintains a collection of tissue for educational purposes. Included in the autopsy consent is a statement that allows tissue to be retained for educational purposes. Statement 2 on the Consent for Post-Mortem Examination states, “I agree to the removal, examination, and retention of organs, tissues, prosthetic devices, and fluids as the pathologist deems proper for diagnostic, education, quality improvement, and research purposes.” Unless the family chooses to restrict the retention of tissue or the intended purpose, interesting cases or individual specimens are saved and stored for teaching purposes. The tissue is predominately used by the Yale School of Medicine Medical Degree Program. Occasionally the tissue is used for other additional teaching programs.

The specimens are collected from autopsy and surgical pathology tissue ready for disposal. Tissue is not retained from autopsies that have restrictions that prohibit utilization for educational purposes. Once tissue is selected based on the needs of collection, the tissue is anonymized so as to protect the patient’s identity.

This collection allows students, residents, and staff to see the physical manifestation of disease in the tissue. Some of the specimens are diseases that are now easily prevented or treatable if identified early.

This collection is not open to the public. It is meant for internal use by the residents, staff, interns, and Yale School of Medicine.