J A M E S R . G I L L , M . D .

C H I E F M E D I C A L E X A M I N E R , C O N N E C T I C U T

L I S A P A O L I L L O , E S Q .

S V P & G E N E R A L C O U N S E L , N E O G

Saving Lives: Organ Donation in Medical-Legal Cases

Agenda

Legal Background

Medical Examiner (and District Attorney) Role

Restrictions in Pediatric Cases

Organ Donation in cases under investigation by MEO

Legal Background

Uniform Anatomical Gift Act

Governs authorization for deceased donation

Governs MEO (and DA) role in organ donation

MEO and OPO shall cooperate to “maximize the opportunity to recover anatomical gifts for transplantation, therapy, research or education.”

Massachusetts: District Attorney approval required

OPO must provide notice to the MEO (and DA) of authorization to recover anatomical gift if donor died under circumstances within jurisdiction of MEO (and DA)

UAGA

The CME (and DA) may approve or deny removal of the anatomical gift

Within a time period that ensures the preservation of the anatomical gift for transplantation

Attend recovery if donation would otherwise be denied

If deny recovery, explain the reasons for determining that the organs may be involved in the cause of death.

Immunity from liability if act in good faith

Medico-Legal Cases 2013-2016

576

49 40 17 3

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700

PediatricHeartbeating

Referrals

Pediatric OrganDonors

ME Cases ME Restrictions Full Restriction

MEO CASES

MEO investigates the circumstances surrounding deaths due to

Unnatural means

Natural means requiring further investigation

Forensic Pathology

Subspecialty in pathology involved in the examination of the living and the dead in order to provide an opinion concerning the cause, mechanism, and manner of disease, injury, or

death.

Physicians in USA

~1,000,000 Physicians

~500 Board Certified Forensic Pathologists

4 years college

4 years medical school

3-4 years residency in pathology

1 year fellowship in Forensic Pathology

National Examinations

Death Investigation System Needs:

Authority to take charge of the body

Autopsy without permission

Subpoena power (e.g., medical records, HIPAA exemption)

Reportable Deaths (CT)

Accidents, suicides, homicides (All unnatural).

Poisoning, drug abuse, addiction.

Disease with potential public health threat.

Deaths resulting from employment.

Sudden and unexpected deaths not caused by a readily recognized disease.

DOA or within 24 hours of admission to hospital (“No Case”).

Death under anesthesia, in operating or recovery room, following transfusions, or during diagnostic procedures.

Medical Legal Investigators

Death reported and MLI does

initial investigation

Hospital vs. Scene Death

Writes report of circumstances,

scene (photos)

Next morning (9 AM): ME reviews case and decides if autopsy

24/7, 365 days a year

Medical Examiner

Certify Cause and Manner of Death

Identification of decedent

Testify: Homicides, civil actions

Public Health (meningitis, statistics)

Educate

On-Call ME (24/7): Organ/Tissue Donor Permission on OCME deaths

MANNER of DEATH vs.

CAUSE of DEATH

Cause of Death

The Disease and/or injury responsible for

the fatality.

Proximate Cause

That which in a natural and continuous sequence, unbroken by any efficient

intervening cause, produces the fatality and without which the end result

would not have occurred (etiologically specific).

Cause and Manner

There is NO time limit for the cause or manner of death.

Explanation of how the cause arose.

Manner of Death

Manner of Death

Natural

Unnatural

Homicide

Suicide

Accident

Therapeutic Complication

Undetermined

Benefits of Autopsy

Establish Cause of Death

Assist in Determining the Manner of Death

Produce Accurate Vital Statistics

Identify New and Changing Disease

Monitor the Public Health

Benefits of Autopsy

Reassure Family Members

Instruct Medical Students and Physicians

Compare Premortem and Postmortem Findings

Assess the Quality of Medical Practice

Evaluate the Effectiveness of New Therapies

Special Cases

Infant (eyes)

Homicides (stab wound of chest)

Hospital notifies NEOB of

potential donor

Preliminary phone screen & registry checked

Donation Coordinator notified of

referral

Verification of registry, chart

review

Determination of medical

suitability with CDOC

Declaration of Death by

Neurological Criteria/Family

decision to withdraw support.

Huddle with hospital staff:

Pre-family approach huddle

Family meeting/ Obtain

Authorization

Notify/Confirm notification of MEO, DA re:

Potential Donor Under Jurisdiction

Obtain Clearance from MEO/DA

Ongoing support for

family Organ allocation

Organ specific evaluation &

testing

Donor management

Organs accepted by transplant

centers

Coordinate recovery time &

schedule OR

Moment of Silence, family

statement, organ recovery

Post mortem care

Confirmation of organs & follow

up testing

Follow up with MEO/DA on

requested information

Overview of Donation Process For Organ Donation Cases

Organ allocation

Hospital identifies

potential donor

MEO Cases

Reporters

Physicians

Law Enforcement Officers

State's Attorneys

Prosecuting Attorneys

Funeral directors

Embalmers

How do we move forward in pediatric cases under investigation by the MEO/DA cases?

MEO/DA and OPOs both serve important public purposes

Information is the Key

Medical Records (Progress Notes, Imaging Reports)

Imaging (CT, X-Ray, MRI)

Laboratory Testing (Blood Tests, Tox Screens)

Photographs

Attending Physician Discussion

CMO Discussion

Attend Recovery

Cooperation