What Coroners and Medical Examiners Aren't Saying
Sudden Unexplained Death in Epilepsy:
What Coroners and Medical Examiners Aren't Saying
Traditionally a controversial topic discussed primarily by the neurological community, sudden unexplained death in epilepsy is now emerging more frequently in research literature, adding weight and validity to this once questionable entity. The forensic science field has quite a way to go, however, before it both recognizes and utilizes SUDEP as a final post mortem diagnosis in cases where it is appropriate.
Paul Schraeder, M.D., and colleagues recently conducted a study in which they sent a questionnaire to 2,995 coroners and medical examiners in urban, suburban, and rural jurisdictions in the United States. Their aim was to assess the practice of coroners and medical examiners in the United States in documenting SUDEP in death certificates. Of the 2,995 surveys sent, 80.7 percent (2,418 total) were sent to coroners and 19.3 percent (577 total) to medical examiners. However, the response rate was 15.9 percent (384) for the coroners and 21.8 percent (126) for medical examiners.
"I think the reason more medical examiners responded even though more coroners were sent questionnaires is that coroners are non-medical officials, so there is a quite a difference in educational backgrounds and therefore I would surmise that coroners did not have as much interest in this survey based on its medically-oriented focus," Schraeder said. "Also, many coroners are located in relatively unpopulated areas, such as rural areas where they may not be exposed to many incidents of SUDEP."
Schraeder's speculation is grounded not only in opinion, but also based upon the data he collected. In the study he found a significant difference in educational backgrounds between the responding coroners and medical examiners in that the medical examiners were more likely to have a pathologist or non-pathologist M.D. background (92 percent of medical examiners versus 26.5 percent of coroners). Most respondents who were trained as pathologists (83.5 percent) recognized SUDEP as a valid post-mortem diagnosis, whereas the percentage of non-pathologist physicians and non-medically trained respondents acknowledging the validity of SUDEP as a post-mortem diagnosis was much lower (63 percent and 58 percent, respectively).
Findings from the study also showed that despite the high rate of acknowledgement of SUDEP as a valid diagnosis, both coroners and medical examiners have a low rate of using SUDEP as a final diagnosis in death certificates when the diagnosis is appropriate. Comparison of urban and non-urban settings and title of coroner versus medical examiner did not yield any difference in the odds of respondents actually using SUDEP as a final diagnosis.
Schraeder links the infrequent use of SUDEP as a post mortem diagnosis amongst coroners and medical examiners to the variability in the way they usually indicate the cause of death of persons with a diagnosis of epilepsy. The cause of death in likely cases of SUDEP is often attributed to status epilepticus, respiratory failure, fatal seizure or cardiac arrhythmia.
"Forensic pathologists are well-versed in using epilepsy as a cause of death," said Ross Zumwalt, M.D., chief medical examiner of New Mexico. "They are not, however, used to using the term SUDEP. It's really more of a terminology thing that just hasn't caught on."
Zumwalt also asserted that medical examiners are trained to look at the underlying cause of death and are more likely to use the diagnosis of idiopathic seizure disorder than a term that implies uncertainty of cause.
"In the case of Sudden Infant Death Syndrome, for example, there has been a lot of controversy amongst pathologists who feel that if the cause of the syndrome is unexplained or undetermined then why not write down undetermined versus writing down SIDS as the final post mortem diagnosis?" said Zumwalt.
Zumwalt encourages the neurological community to address the two main forensic science organizations - the National Association of Medical Examiners and the American Academy of Forensic Sciences - if they believe the term SUDEP should be canonized as a formal post-mortem diagnosis.
Meanwhile, Schraeder asserts that insights gained from this study about how coroners and medical examiners approach the diagnosis of cause of death in persons with epilepsy will be useful in planning educational programs for coroners and medical examiners for improving the accuracy of final diagnoses.
"One of the main goals of such programs should be to increase awareness that SUDEP is one of the most common causes of death in epilepsy and that it should not be avoided as a final diagnosis," Schraeder said. "Any educational program, including continuing medical education activities, internet-based information, and written materials directed at coroners and medical examiners, should focus on the accuracy of data on death certificates."