1 and 2: I would also not autopsy and would sign out as ASCVD, but not without growing reservations. I always feel a bit fraudulent doing this. I understand the reasoning – everything points towards a natural death, there's nothing additional giving cause to question that, so why expend the resources? (You guys didn't say WHY you'd sign out as ASCVD, so I'm assuming that's more or less your reasoning; I'd be interested in your thoughts if otherwise.) That argument is very reasonable and I agree with it. But why default to ASCVD? OK, I understand that ASCVD is the most common cause of natural death at that age. You could even go one better and say it's the most common cause of death for people at that age who have no indicators of any other disease. But there's a bit of circular reasoning in that proposition. If we assume these cases are ASCVD and sign them out as ASCVD, then of course ASCVD is going to be the most common cause of death for these cases. There have been enough cases where I was on the fence, debating about whether to external and sign out ASCVD or post, and posted, only to find something else, like COPD, PE, or something on tox, or nothing. (And I kick myself for doing the post.) Likewise, even when I've posted and ended up with ASCVD anyway, usually there's a thing or two for Part II. Ideal world of course we'd autopsy all these cases. Reality is we can't. So we have to resort to this kind of corner cutting, which, again, I think is reasonable. But, in cases where you're convinced there's nothing but natural causes, and there's no compelling reason to cut, why not use a phrase like "Undetermined natural causes" and manner Natural? This seems more intellectually honest, and it avoids muddying the statistical waters by defaulting to a diagnosis that hasn't been proven. Also, if we put this out there, it may, as I said in the previous post, make the FP resource situation more clear and provide some motivation for more allocation. Does anyone think we'd be losing anything important by eschewing the ASCVD default and opting for "Undetermined natural causes"?
3 and 4: I would do a full post on these. Again, with some reservations. I was trained like mlw03. You're either convinced it's natural, and do external only, or you do a full post. No partials. (Although I saw this maxim violated often enough, eg. the head only suicide GSW) The argument here is as mlw03 characterized: You need the full context to interpret specific testing. That sounds nice. But I can't help but think it's a bit spurious. For example, in diagnosing clinical patients, it's never all or none. You're always doing a partial exam. The art is to do a "complete partial." Why not the same with autopsies? I've been counseled that the partial post is a set up for problems down the road, but I've never gotten a good explanation of what those problems might be. I would be curious to know, from those who do do partial autopsies, has this practice ever gotten you in hot water?
As far as family wishes go, I agree that you have to do what you think is necessary to carry out your mission as a forensic pathologist. If it's that or going against family wishes, then family wishes have to give. There's ambiguity here too though. For example, a lot of families don't like the notion of retaining organs, such as the brain. But there are times when doing a complete neuropath exam, which, it is assumed, includes fixing the brain, etc, is forensically necessary. So, despite family wishes, the brain stays. However, is there any evidence supporting the proposition that examining a fixed brain, as opposed to a fresh one, is essential? It seems to have gone more or less without say that you have to fix the brain. But maybe not. I will say that if family wants a post, and it's a case I might otherwise external, I will post. I'm communist enough to believe in universal health care. And to my mind autopsies are part of health care.
Thanks for your replies.
