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Autopsy in Forensic Nursing

By Bonnie J. Laverdiere, RN, CNOR

On The Edge – 2011

Autopsy in Forensic Nursing

The word often sends shivers down most people’s spines.
The images that the mere mention of the word brings to mind are not the same for a forensic nurse or forensic scientist. An autopsy, to them, can help save lives by discovering the cause of a death. In deaths involving infections, homicides, traumas, among other things, an autopsy gives investigators the first pieces of a puzzle that will eventually lead them to solve a death. But what is an autopsy? What role do nurses take to better understand and help discover the cause of death? And, most importantly, what does an autopsy teach us about living?

History of autopsy

The word autopsy simply means “to see for yourself” (Burton, 2005). Burton (2005), also mentions that the ancient Egyptians around 3000 BC confined human dissections to the mummification process and death was treated from a magico-religious perspective. Autopsies at that time were confined to happenstance, if a gladiator was injured during a fight by a saber-slashing, the wound was observed. Aristotle (384-322 BC) thought that the dissection of animals could offer information that would be comparable in the understanding of human anatomy, and hoped for a better understand how the human body works.

Doctors practicing medicine, at that time, were limited to treating only the external body and had little understanding of the functions and organs of the internal body. Burton (2005) goes on to write, Herophili (c. 325-280 BC) did public autopsies and vivisections on criminals (while alive), learning and teaching anatomy. Human dissection was otherwise forbidden, because the sanctity of the body as a whole was believed to be very important in the afterlife. According to Burton (2005), Galen, during his work in the Roman Empire (129-216 AD), learned the bone structures of the human body from skeletal remains that had mistakenly been made available after a flood had uncovered a grave and also from carrion birds that had cleaned bones.

After approximately five centuries, the methodology of the autopsy becomes more familiar, more related to the practices we currently use today. Some of the available information about this part of the history differs in origins, as the science was evolving in different locations. In Burton’s (2005) article, the first autopsy to determine the cause of death was thought to have been done in Italy about the year 1286 AD.   . The Chinese Handbook “Hsi Yuan Li” was written in the mid-thirteenth century, this book addressed 1) types of wounds, 2) drowning versus submersion in water, and 3) death by burning versus death by fire in postmortem examinations as discussed in Schramm’s article “Forensic Medicine” (1991). The “Hsi Yuan Li” was used until about the nineteenth century, this shows the development of an autopsy being used in determining the cause and mechanism of death. “The first recorded autopsy in the New World was performed in Haiti, in 1533” (Schramm, 1991), this autopsy was done on Siamese Twins to determine if they shared one soul or had individual souls.  There still remained some magic or religious elements to the practice.

The autopsy continued to influence medico-legal investigations and went on to become the Science it is today. In Antonio Benivieni’s textbook, “De abditis nonnullis ac mirandis morborum et sanationum causis”, published in 1507, the focus was on autopsy reports (Burton. 2005). The autopsy began emerging from an unacceptable practice to a science. Medical science began to recognize the importance of understanding the reason or cause of death and used autopsies to further advance medical science and medical education.

Autopsies were used to aid in the knowledge of anatomy by medical students. Karl Rokitansky and Johann Wagner and Lorenz Biermayer were believed to the first “professors of pathology” (Burton, 2005). They used the bodies of criminals and the bodies that were “robbed” from grave sites, where the majority of cadavers came from. This is also where the term, “graveyard shift” is thought to have originated from as family members would sit by the grave of a deceased family member and watch over them so as not to have the body taken from its resting place to go to the medical schools where it would become a teaching tool.

The “Anatomy Act” in 1832 “gave the unclaimed bodies of paupers dying in hospitals and workhouses” (Burton, 2005) and “executed murderers” (Roach, 2003) to be dissected by anatomists, due to the high demand for bodies at that time. Murders were often committed for the bodies; this was due to the fees paid for corpses according to Burton (2005). The science of autopsy has been on the decline in medicine. There are still religious reasons for the family to decline an autopsy (when it is not in connection to a crime) and there is not as much teaching of this science in the medical schools. “Hospital autopsies, as elsewhere, have become a rarity and therefore can no longer be used for undergraduate medical training” (McNamee, 2009). Why the decline of autopsies? “It has been said that hospitals are trying to save money by avoiding autopsies, since insurers don't pay for them, or that doctors avoid them in order to cover up evidence of malpractice” (Gawande, 2001).  The forensic autopsy is the strongest link that will sustain the autopsy as a science.

As explained in Lynch (p. 363, 2006) the major difference between the clinical autopsy and the forensic autopsy is that the clinical autopsy tends to be more orientated to the internal examination, while the forensic examination is more focused on the external evidence that may have been the cause of death.

Autopsy as a tool in death investigation and death prevention

Where does the information for a forensic autopsy and the understanding of death investigation come from? One source is on a farm. In the book “Death’s Acre” by Dr. Bill Bass and Jon Jefferson, they write about experiments done on corpses that explain processes, for example, the decomposition of the body , the life span of insects, and the impact of trauma to the body. While the experiments performed on this “farm” are gruesome, they are done with care and respect for the bodies in the interest of forensic science. The information made available from these experiments have helped to solve many cases that otherwise may have gone unsolved. There are other books that describe the development of the science from all aspects of discovery, including “Dead Men Do Tell Tales” by William R. Maples and Michael Browning, which focuses on forensic anthropology.

The available forensic journals and books are numerous and the research that has been done in this field aid in the investigation of interpersonal violence, gunshot wounds, motor vehicle accidents, as well as medical malpractice investigations.  Serial killers have been identified and apprehended through the use of forensic science. The CDC and National Institute of Justice (NIJ) have published reports that demonstrate the benefits of autopsy in the prevention  of deaths, whether it is through identifying a contagious disease in epidemic or pandemic portions or through the information that supports to the use of seat belts and airbags to make automobile travel safer.

Process of an autopsy

The “traditional” autopsy, used for both forensic cases as well as medical cases, includes the same basic steps. With an understanding of the cause of death, there is also an increased “accuracy of death certificates and vital statistics” (Shkrum & Ramsay. 2006).   It should be noted that, “Death is not the end of a physician-“patient” relationship” (Shkrum & Ramsay. 2006), nor is it the end of a nurse patient relationship. It can in fact, be their first interaction with the medico-legal team investigating their death. The Center for Disease Control (CDC) has established guidelines as to when an autopsy should be performed; they include trauma, violence, unattended death, infant deaths, and death in the result of a fire, just to name a few (www.cdc.gov).

The first steps in determining the cause of death often begin at the scene of the patient’s or victim’s death, wherever the death occurred (at home, on the highway, in a hospital, or any other location). In a forensic death, a body temperature is taken at this time to help determine the time of death? The surroundings are evaluated and many questions considered. Was the death an accident? Was it malpractice? Was it murder? Was it perhaps due to natural causes? These are only some of the questions that must be answered, but only after the most important question has at least been addressed. Who is this patient?

The investigation begins with the following in mind “Questions to be answered in the autopsy” as listed in Koehler & Wecht, (2006):

  • WHO is the deceased?
  • WHERE did the injuries and ensuing death cure?
  • WHEN did the death occur?
  • WHAT injuries are present (types, distribution, pattern, cause and direction)?
  • WHICH injuries are significant (major vs. minor injuries, true vs. postmortem injuries)?
  • WHY and HOW were the injuries produced? What were the mechanisms causing the injuries and the actual manner of causation?
  • WHAT actually caused the Death?”

The examination begins with a visual search for injuries; these are photographed. Radiology studies are taken if they are deemed necessary and in some cases, such as massive trauma from a motor vehicle accident or a known suicide, this may be the end of the postmortem examination. The categories of death include; natural, suicide, accident, homicide, and undetermined. The time of death can be aided by establishing the levels of rigormortis, livermortis, and algormortis.

The external examination is done at this time and to help to determine whether an internal examination will proceed. If the internal examination is to be performed, this will include visualization of the organs, done through the infamous Y-incision. The organs are weighed and fluids are collected. There may be a need of toxicology studies to be done and blood and urine are taken for this purpose. When the abdominal cavity organs have been processed, the brain is exposed to examine whether this is part of the cause of death. The autopsy report is written and the information is given to the appropriate law enforcement agency, if foul-play is determined to have been involved.

There are new ways of exploring the causes of death using the available improvement in medical technology. One new tool in the autopsy is the laparoscopic approach. This has been performed when the injuries have been thought to have been contained to the torso. According to study described in the article by Catheline, et al (1999), the post-mortem examination was performed laparoscopically followed by a traditional autopsy and the results were very similar. The negative aspect is the cost due to the use of special equipment.  The positive aspects of laparoscopic autopsy is the fact that when the family realizes that the procedure is less invasive, they are more likely to give permission, whether they had declined for religious and/or cultural reasons or out of fear of the body being “mutilated” by the traditional procedure.

The traditional procedure has also been altered by the advent of computerized tomography angiography (CTA).  It is thought to be another form of diagnostic tool, providing a better view of the vascular system postmortem. Studies were performed involve in both methods of autopsy and the end results were confirmed with the traditional method. The “minimally invasive CTA, as part of a virtual autopsy, can complement a classic autopsy of even replace it if necessary” (Flach, et al. 2010).

“The medical examiner, pathologists, and other forensic investigators aren’t responsible for interpreting the evidence and creating an entire narrative. Their job is to find the evidence, preserve it, and report it accurately; hopefully they’ll be able to determine manner of death in the process.” (Genge. 2002, p. 175)  What happens when they do not provide accurate findings?

What is the future of autopsy and how is it regulated?

“To maintain a high standard of practice in forensic pathology, a pathologist must participate in peer-review, self-evaluation, and continuing education programs” (Shkrum & Ramsay. 2006). When an autopsy is done, the evidence collected can mean the difference between the victim and suspected perpetrator receiving justice or being eliminated from suspicion. Are all autopsies done with ethical consideration? No. There have been multiple reports of medical examiners forging documents. An example of this was reported in The New York Times, December 18, 2009, “supervision of a major crime laboratory was so poor that it overlooked evidence of pervasively shoddy forensics work, allowing an analyst to go undetected for 15 years as he falsified test results and compromised nearly one-third of his cases”.  The cases that were involved are being re-examined to determine if there were false convictions. There were some instances of those who were falsely convicted and later found innocent and released. The analyst hung himself after the investigation began, leaving many unanswered questions.

The Innocence Project (www.innocenceproject.org) is an organization that is concerned with using evidence to free those wrongfully convicted. The science available at the time of their conviction has made great strides and this organization has had success in overturning wrongful convictions.

There have been numerous incidences over time that has led to questions regarding the practices leading to results that convict. The earliest questionable autopsy was the case of John Wilkes Booth in the article Dr. John Frederick May and the Identification of John Wilkes Booth’s Body (1998). The identity of the body was limited to a surgeon, acting as an expert witness; he had removed a tumor from Booth’s neck and subsequently used the scar from this procedure as an identifying characteristic of the man who had assassinated President Lincoln.  There were several discrepancies noted in the report such as his height, which leg he had broken years before, and whether Booth was freckled. This report leads one to believe that the body of the deceased was in fact not the body of Booth.

In Koehler and Wecht’s (2002) book “Postmortem”, they discuss several other cases that continue to be disputed, and the fact that President John F. Kennedy’s autopsy remains controversial. There are famous cases that appear to have never been fully explained. This is why “pathologists are already subject to both internal and external quality assurance and audit” (Rutty, 2006)

Perhaps, this is where nursing can assist in the process. “Throughout the world, the forensic nurse practitioner is beginning to have a significant impact on the day-to-day work in the investigation of injuries, assaults, rape, and abuse, both in adults and children as well as the investigation of death” (Rutty, 2006)

Nursing’s role in the Autopsy

The earliest recorded role of forensic nurses was reported “as early as the 13th century within the United Kingdom, when they were involved in examination to confirm the virginity of women who were marrying into royalty and for evaluations of sexual assault victims” (Rutty. 2006). 

Nurses can assist in death investigation throughout the autopsy procedure using the nursing process. They bring with them vast experience and expertise from their nursing practice to the field of forensics. Nurses are able to “make a significant contribution to public health and safety as nursing embraced the continuum of the life cycle – caring for individuals at the time of death as well as the moment of birth” (Rutty, 2007). Nurses are able to help determine the cause of death when aiding in the forensic autopsy and can also search for clues at the scene that may otherwise go unnoticed by law enforcement officers. Evidence present at the scene may not be understood by non-medical professionals as a missing link to the cause of death.

Forensic nurses can help to recognize whether or not a death is in need of further investigation.  Forensic nurses looking for evidence at the scene of a death will find there is no limit to what may be learned at this starting point. For example, there may have been prescription medications not equal to what was dispensed and should have been up until the time of death, indicating possible overdose of medication; whether it was intentional or accidental needs to be further investigated.

The family of the victim should also be interviewed and their responses documented for future use concerning what was said and how they were reacting to the death. This may be the role of the forensic nurse, law enforcement, or both. There may be other clues at the scene that may aid in the autopsy and the investigation of the cause of death.

Forensic Nursing has been recognized as a valuable resource, “the Joint Commission on Accreditation of Healthcare Organizations (JACHO) has issued standards for emergency rooms and ambulatory services. The standards address all forms of abuse, including child abuse, sexual assault, domestic violence, and elder abuse” (Rutty, 2007). One of the most important aspects of the forensic nurse role   “Lynch believed many cases of death encountered in the clinical setting fell within the jurisdiction of the medical examiner or coroner and believed it vital for clinicians to be skilled in the documentation and preservation of evidence related to those cases” (Rutty. 2007). What does a forensic nurse do in a forensic death investigation?

In an autopsy, the injuries are the first visible source of information; they are assessed and meticulously documented and photographed for preservation of this valuable evidence. Evidence is useless unless recognized for its potential value, and properly collected and preserved.  Wounds must also be explored as to their potential cause and role in the death of the victim. For example, a stab wound may have missed vital organs, but nicked an artery causing enough bleeding for the patient to exsanguinations from the injury. A motorcycle accident victim may have no obvious external cause of death, but may have had a pelvic fracture that caused enough internal bleeding that led to the patient’s demise. There may be no internal injuries, only the bruising present on the neck of a strangled victim. Their assessment skills through their clinical nursing experience, gives them an advantage of recognizing any and all possible causes in a death investigation and assisting in an autopsy, making nurses extremely well qualified to participate and contribute in this procedure.  As experts in the areas of observation and documentation, nurses have the necessary skills and knowledge to assist and excel in this area as well.

Nurses are involved in the preparation of the body to be examined. They also have a background in laboratory testing and what test may be indicated as part of the examination. They are prepared to handle and take precautions in the presence of potentially hazardous biological exposures that can occur and have experience with dealing with family members during times of crisis.

In the case of the mother whose infant died, in “To hold or not to hold” (Baker& Crandall, 2009), making a death investigation mandatory, she was unable to hold her child one last time; as to preserve the available evidence and not allowing it to become contaminated. Nurses can also assist the family to understand the reason for an autopsy and to provide comfort to the parents and other surviving relatives of a homicide or suicide. “Forensic nurse death investigators bring a holistic perspective to the scene and incorporate a more inclusive focus of the deceased victim and the surviving loved ones left to grieve” (Vessier-Batchen & Douglas, 2006).  The presence of a nurse at the scene may begin to help the family in the process of “meaning making” and easing this time of “complicated grief” as discussed in Vessier-Batchen & Douglas (2006). It is mentioned also, that post-traumatic stress disorder (PTSD) has a high incidence in family members who have lost loved ones through homicides and suicides. Here, again, nurses can aid in caring for the family left behind.

The forensic nurse is capable of helping the families to know what types of support are available to them and provide information in what the legal process involves, and what will be needed from them during this time of crisis. The nurse can act as an intermediate between the medical examiner and the law enforcement agencies, as well as (when authorized to do so) between the relatives of the deceased and the investigators involved in the case. The roles for the forensic nurse are numerous and dynamic.

There will continue to be new tasks the forensic nurse will incorporate into practice. Such as the case of nurses acting as coroner in some jurisdictions and reviewing medical records with the advantage of a medical background that law enforcement does not possess, allowing them the latitude to answer medical questions that arise at the time of death.

Within their scope of practice, nurses can interpret the data collected and aid in the documentation of the cause of death. The documentation process must be meticulously performed. The records of the autopsy may be necessary in court proceedings, as well as the photo-documentation of the body before, during and after the autopsy. Particular attention to detail must be paid.

The nurse may also become an expert witness for the prosecution or defense, if there is a criminal trial that results from the information obtained through the process of an investigation into the cause of death.  Nurses can also explain to prosecutors what the findings mean and after years of patient teaching, can further assist the jury in understanding the medical terminology and autopsy findings.

Nurses need to be unbiased in their testimony as well as in their evidence collection and throughout the entire investigation. There must be a level of accountability for their actions and methods of inquiry. Nurses must be open to the possibilities evidence presents to them. The International Association of Forensic Nurses (IAFN) together with the American Nurses Association (ANA) have established guidelines in the practice of the forensic nurse and these should be read and understood by all nurses in the area of forensic nursing, whether they are SANEs, Death Investigators, Legal Nurse Consultants, or any of the numerous other areas of practice in forensic nursing. These guidelines should be followed in conjunction with the ANA’s Code of Ethics for Nurse.

“Forensic nurses are different because they are taking care of individuals who are victims or perpetrators of either violent acts or traumatic occurrences, whereas nurses in the general population may take care of those same types of victims, but not on a continuous basis” (Kent-Wilkinson, 2009). Forensic nurses are also involved with increasing the public awareness of crime prevention and the legislative policies that affect from local to international policies on human rights and violence prevention.   

The forensic nurse uses a holistic approach to health care and involvement in autopsies and death investigation is only one of the many roles available to them. It is a field of nursing that may become a part of every nurse’s practice, and it should. Awareness of the issues is the key to ending the level of community and global violence as we know it today.

Below is a list of websites to begin learning more about this fascinating field and ways to become a practitioner.

Conclusion

With the knowledge gained through clinical autopsies and forensic science  we are better able to look at life and assess the quality of living. Through the use of autopsy to determine medical/clinical causes of a death, the advances in medical science have saved numerous lives. The immunizations created to treat contagious illnesses and with the invention of heart valves, prosthesis, surgical interventions, and other medical advancements that have increased the public’s lifespan.  The clinical autopsy has made life possible for many.

In the medico-legal autopsy, the causes of death are used to discover ways of combating violence. Nurses, with their unique expertise and knowledge, are an invaluable resource to crime and crime prevention. Whether they practice on a medical-surgical floor, in the emergency room, in the operating room, or any other area of health care, nurses are an influencing part of forensics. Forensic Nursing is becoming a part of every nurse’s practice and the need to know and understand the basics are essential to treating patients. The IAFN campaign, “Violence is a Healthcare Issue” holds true in life and in death. In all cases of life or death, nurses are still the patient’s advocate, and often their voice; they are entrusting us with their care.

References

Bonnie Laverdiere, RN, CNOR is an operating room nurse at Lahey Clinic Hospital in Burlington, MA, and a student at the University of Southern Maine in the RN-BSN program.

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