Medical Examiners and ‘Manner of Death’

How Is a Suicide Determination Made?

By Dr. Amy Hawes and Dr. Darinka Mileusnic-Polchan

Medical examiners understand that a family may disagree with a manner of death determination.1 We are also acutely aware of the perceived stigma of a suicide manner of death determination.  Some medical examiners may allow a suspicion of suicide to be overridden by reluctance to impose that stigma.2 However, it is important to emphasize that cause and manner of death opinions are best offered in an unbiased manner free of undue influence from societal, legal or political pressures.3 This article addresses the need to balance medical examiner investigative independence with a family’s right to due process in challenging a manner of death.

Accurate cause and manner of death classification is imperative because death certification fulfills several major functions: informs families about specific conditions that led to death; provides local, state and national mortality statistics by cataloging morbidity and mortality; indicates priorities for funding programs and policy making for public health and safety issues; and, serves as the legal and administrative documentation of the death. Without objective mortality data about the circumstances of death, it is impossible to identify risk and risk-groups accurately, and thus design, target and evaluate appropriate clinical, public health and justice system interventions.4

Given the understanding that suicide fatalities are likely grossly underestimated in death certificate data,5 misclassification of true suicides as other manners of death may have significant adverse impacts in intervention efforts and resource allocations. 
 

Who Certifies Manner of Death?

Medical examiners and forensic pathologists are physicians who possess the necessary specialized knowledge, training, skills and experience for standardized death investigation, and are responsible for medicolegal death investigations by Tennessee statute. 

For people who die under suspicious, unnatural or unusual circumstances, which includes cases of known or suspected suicide, medical examiners have authority to investigate and certify cause and manner of death.6 This gives medical examiners the mandate to look into, document and classify manner of death objectively. 

Fortunately in Tennessee, regional forensic centers that perform autopsies are required to be accredited by the National Association of Medical Examiners (NAME).7 This inspection and accreditation process ensures that death investigation and forensic pathology is professionalized, basic medical examiner community standards are being met, and that the accredited offices adhere to basic tenets of standardized medicolegal death investigation. 
 

Manner of Death: A Medical Opinion

There are few issues that are potentially more problematic in medicolegal death investigation than determining circumstances surrounding death, also known as manner of death (MOD). MOD determination, especially suicide, can be particularly difficult for many reasons, and decades of debate about it among medical examiners continue.

Potential difficulties in MOD determination include: administrative and procedural variations among medical examiner offices; ambiguities in case facts or investigative information; family, political or law enforcement influence; variations in medical training; and, true differences in professional judgement and practice.8 Professional guidelines must be used in conjunction with professional judgment in all fields of medicine, and MOD classification is no different.

MOD is determined after a complete investigation based on scene information, medical history, examination of the body and additional studies such as toxicology. According to NAME, MOD “was added to the death certificate in 1910 by public health officials to assist in clarifying the circumstances of death and how an injury was sustained — not as a legally binding opinion — and with a major goal of assisting nosologists who code and classify cause-of-death information from death certificates for statistical purposes.”9 Accurate manner of death information is imperative for determining the scope of health and safety concerns and to help ensure they receive funding and policy priorities.

In most jurisdictions, there are five options for manner of death: natural, accident, homicide, suicide and undetermined. There is no one authoritative text or widely recognized single standard for cause and manner of death classification in all situations.10 The general recommendations for classifying manner of death are as follows11: 

Natural: Solely due to natural disease process or aging (heart attack, cancer, emphysema, cirrhosis of the liver, etc.).

Accident: Injury or poisoning caused or contributed to death with little to no evidence that it was intentional (blunt trauma from a car crash, hip fracture from a fall, drug overdose from recreational drug use, drowning, etc.).

Homicide: Results from a volitional act by another person, including legal determination of acts of “self-defense.”

Suicide: Injury or poisoning from an intentional, self-inflicted act that was meant to, or has an inherently high risk of, causing death.

Undetermined or “could not be determined”: Either insufficient information is available to choose one of the above manners of death, or there are equally compelling arguments to be made for two or more manners of death.

Importantly, the medical determination of the manner of death is independent from the legal determination. For example, medical examiners typically classify motor vehicle related deaths as “accident,” but that does not prevent legal proceedings against an impaired driver in the collision for some charge of homicide or manslaughter.

Suicide, Medical Burden of Proof and Differing Standards of ‘Intent’

While there are various generally accepted definitions of suicide, admittedly, there is no universally accepted definition of suicide among medical examiners or forensic pathologists.  Most definitions include some variation of intent:
• “the decedent intended to die and delivered the means”12;
• “the mechanism was self-inflicted, and the decedent intended to die”13; and
• “determination of intent to kill oneself.”14

According to the guide to manner of death determination from NAME, determination of suicide is dependent on two main principles: acceptable level of burden of proof and the concept of “intent.”15 NAME states that the legal standard of “beyond a reasonable doubt” is not necessary for medical suicide determination; however, the evidence burden should exceed “more likely than not.” NAME further clarifies that “in general, requiring a ‘preponderance of the evidence’ is a reasonable practice when deciding whether to classify a death as suicide.”

Similarly, the medicolegal death investigation view of intent may differ from the legal viewpoint. The NAME declines to define intent explicitly but states:

Finally, one cannot escape the need to consider intent when classifying manner of death. However, the definition of, or need to consider “intent” may vary depending on the case. One basic consideration is beyond dispute: the concept of intent differs when manner-of-death classification issues are compared with other paradigms such as legal code and public health strategies. … The take-home point devolving from contemporary practice is that a singular definition and application of “intent” does not work in the context of manner of death classification.16

In other words, what may constitute “intent” for a proceeding in the legal context is not necessarily the same as for a medical MOD context. 

How do medical examiners and forensic pathologists determine what constitutes sufficient “intent” to determine suicide? In short, it depends on the circumstances of any one individual case, reliance on recommendations from NAME, and using peer-based quality measures. It cannot be done reliably using a checklist or other pre-determined necessary pieces of evidence that would apply to all cases. There are, however, several useful explicit or implicit indicators of intentionality such as: verbal or nonverbal expressions of suicidal intent; explicit preparations for death; signs of farewell; expressions of hopelessness; great physical pain; previous suicide attempts; attempts to avoid rescue; efforts to learn about means of death or rehearsing fatal behavior; and, serious mental illness including depression or bipolar disorder.17 

These indicators may come from witness reports, computer searches, social media, evidence of suicide directions such as Final Exit, previous suicide attempts, suicide notes, medical records, testimonials from witnesses, relatives, and caregivers, and recent life crises.18 

A common misconception is that a suicide note must be present to conclusively infer suicidal intent. In fact, suicide notes are present in only 20 to 35 percent of suicides.19 Although rare, it is known that suicide notes may be removed from the scene by family or other concerned parties prior to arrival of first responders, law enforcement or death investigators. Conversely, “suicide notes” in and of themselves are not always conclusive of suicide, as some written declarations found at a death scene are ambiguous in nature and require subjective interpretation of the writer’s state of mind.

A medicolegal suicide is a classification of professional opinion based on forensic investigative information after a complete investigation. It is never possible to “second-guess” what was in a decedent’s mind; we must rely on explicit or implicit evidence of intent, while acknowledging that there may potentially be more than one interpretation of some evidence. The determination of suicide is only made after careful consideration. Ultimately, the medical examiner may certify suicide after integration of the scene and other investigative information, medical history review and postmortem examination findings, if the totality of the evidence indicates the decedent intended to take his or her own life.

Suicide and Drug Overdoses

Deaths from drug overdose are perhaps the most difficult to determine manner of death. Drug-related deaths are often complex and require extensive investigation (interviews with family and friends of decedent, social media, scene findings, medical records, prescription history, prescription monitoring program, etc.).20 This information is used in conjunction with autopsy and toxicology to certify MOD. Depression, chronic pain, opioid-use disorder and medication abuse often coexist, which further complicates issues regarding intent. Toxicology results alone, such as a markedly elevated concentration of a drug, cannot be used to infer manner, because of drug tolerance and postmortem redistribution. In addition, an overdose investigation is further complicated by the rise of illicit fentanyl and fentanyl analogs, which may be difficult to detect in routine toxicology.

Given the ambiguity of definitions and circumstances of a particular case, one might argue that “undetermined” manner might be a better option.  Various studies show this falsely decreases the suicide rates and potentially harms public health and intervention efforts for suicide. This is especially true with overdoses, where undercounting of suicides is likely far more common than with other more overt and active suicide methods such as firearm deaths and hanging.21 In fact, some studies show that medical examiners are less likely to certify a death as suicide with knowledge that a decedent had a history of substance abuse.22 NAME recommends classifying “deaths from the misuse or abuse of opioids without any apparent intent of self-harm as ‘accident.’”23 The position paper also states:
... assigning ‘undetermined’ as the manner of death as a matter of course for deaths due to intoxication does not serve the public good, nor does this practice support efforts to intervene and prevent future intoxication deaths of a similar sort ... [r]eserve ‘undetermined’ as the manner for rare [emphasis added] cases in which evidence supports more than one possible determination.

If medical examiners begin to default or skew toward undetermined or accident for manner of death for overdoses, or in the absence of a suicide note, it will be impossible to track the true incidence of suicide fatalities.

Medical Examiner Independence and a Family’s Right to Due Process

Medical examiners and forensic pathologists are well aware of the stigma of suicide and the potential social, religious, legal and financial implications of the certification of suicide. It is well understood that a suicide ruling may cause additional suffering and grief for family and next-of-kin. We also have a professional and ethical obligation to certify manner of death in an unbiased way. NAME states that medicolegal death investigation should be “objective and neutral,” and it is important that medical examiner findings should be free of “political or legal pressure by individuals or offices seeking to influence the pathologist’s findings.”24 The recommendations state that manner of death “should not be made to “facilitate prosecution, avoid challenging publicity, building a political base, or promoting a personal philosophy or agenda.”25

Families and next-of-kin have the right and need to understand how their loved one died.26 They should have the opportunity to discuss, in-person if requested, any concerns, disagreements or questions regarding the investigation with the medical examiner or forensic pathologist responsible for the determination of cause and manner of death.  

Medical examiner communication with family should be open, honest and timely. Family can often provide valuable information and insight regarding someone’s mental state, medical history, previous suicide attempts and emotional state when last known alive that may impact the manner of death ruling.  

Should a medical examiner discover new information, he or she should be willing to reconsider a MOD, if appropriate. Sometimes a medical examiner’s manner of death determination is in error, and critical review of cases is an important continuing quality improvement effort. However, a family’s satisfaction or agreement with the cause or manner of death is not a prerequisite measure for a professional and complete death investigation.27 Even after open communication and discussions, the medical examiner and family may still disagree about the most appropriate MOD. 

In Tennessee, families have several avenues of recourse if they disagree with the final medical examiner MOD determination. Discussion with the medical examiner or forensic pathologist who certified the death is the best initial step. Two, as outlined in Tennessee Department of Health Vital Records Rules, the next-of-kin may petition the municipal or county court in the county of the decedent’s death to amend any section of the death certificate.28 Third, as described in the previously described Tennessee Bar Journal,29 the family can petition the medical examiner, through a series of defined steps of appeal and mediation, to change a suicide MOD determination. 

Further Consideration

In summary, misclassification of suicide as “accident” or “undetermined” manner of death adversely impacts suicide mortality surveillance, which makes the identification of high-risk groups for targeted evaluation and interventions difficult. Medical examiners and forensic pathologists have the medical and scientific expertise to offer unbiased rulings for manner of death. Allowing physicians to continue to use professional medical judgment, investigative facts and recommendations from professional practice societies, peer-review and the Medical Examiner Advisory Council, rather than adhering to rigid statutory definitions or rules, will best serve the citizens of Tennessee.

Notes

1. A recent publication in the July 2018 Tennessee Bar Journal discussed perceptions and realities about manner of death certification by medical examiners in Tennessee (“Manner of Death: If ‘Suicide’ Is on a Loved One’s Death Certificate, You Can Now Seek to Change It,” by Yarnell Beatty, Tennessee Bar Journal, July 2018, vol. 54, no. 7). This article is a general discussion about death certification and is not intended to reference the details or offer opinions of any particular case.

2. “Operational Criteria for the Determination of Suicide,” Rosenberg, M.L., et al., Journal of Forensic Sciences 33(6), Nov. 1988.

3. National Association of Medical Examiners Position Paper: “Medical Examiner, Coroner, and Forensic Pathologist Independence,” Melinek J., Thomas L. C., Oliver W. R., Schmunk G. A., et al., Academic Forensic Pathology 2013 3(1): 93-98, https://name.memberclicks.net/assets/docs/00df032d-ccab-48f8-9415-5c27f1.... Last accessed July 23, 2018.

4. “Variable Classification of Drug-Intoxication Suicide Across U.S. States: A Partial Artifact of Forensics?” Rockett I.R., Hobbs G.R., Wu D., Jia H., Nolte K.B., Smith G.S., et al., PLoS ONE 10(8):e0135296, August 2015.

5. “Variability of undetermined manner of death classification in the U.S.,” Breiding M. J. and Wiersma B., Injury Prevention 12 (suppl II), 2006.
“Confronting Death from Drug Self-Intoxication (DDSI): Prevention through a Better Definition,” Rockett I. R., Smith G. S., Caine E. D., et al., American Journal of Public Health, 104(12), December 2014.
“State Variation in Certifying Manner of Death and Drugs Involved in Drug Intoxication Deaths,” Warner M., Paulozzi L. J., Nolte K.B., Davis G.G., Academic Forensic Pathology, 2013 3(2): 231-237.
Also, supra notes 2, 4.

6. Tenn. Code Ann. §38-7-108(a).

7. Tenn. Code Ann. §38-7-105.

8. “Suicide Determination and the Professional Authority of Medical Examiners,” Timmermans S., American Sociological Review 70(2) April 2005.

9. “A Guide for Manner of Death Classification,” Hanzlick R., Hunsaker J. C., Davis G. J. Marceline (MO): National Association of Medical Examiners; 2002, https://name.memberclicks.net/assets/docs/4bd6187f-d329-4948-84dd-3d6fe6.... Last accessed July 23, 2018.

10. “Mind Your Manners: Part II: General Results from the National
Association of Medical Examiners Manner of Death Questionnaire,” Goodin J., Hanzlick R., 1995, American Journal of Forensic Medicine and Pathology, 18(3), September 1997.

11. Handbook of Forensic Pathology, 2nd Edition 2003, Froede, R. C. (ed), College of American Pathologists, Northfield, Illinois. National Center for Health Statistics, medical examiners’ and coroners’ handbook on death registration and fetal death reporting, Hyattsville, Maryland, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2003, https://www.cdc.gov/nchs/ data/misc/hb_me.pdf. Accessed July 23, 2018.
Also, supra notes 9, 10.

12. Rockett, supra note 5.

13. Supra note 4.

14. “Intent in Manner Determination,” Oliver W. R., Academic Forensic Pathology 2012 2(2), 126-137.

15. Supra note 9.

16. Supra notes 9, 14.

17. Supra note 8.

18. Supra notes 2, 8.

19. Id.

20. “National Association of Medical Examiners and American College of Medical Toxicology Expert Panel on Evaluating and Reporting Opioid Deaths: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid Drugs,” Davis G.G., Academic Forensic Pathology, 2013 3(1): 62-76.
Also, Paulozzi, supra note 5.

21. Supra note 4.

22. Rockett, supra note 5.

23. Davis, supra note 20.

24. Supra note 3.

25. Id.

26. “Principles for Communication with Next of Kin During Medicolegal Death Investigations,” Scientific Working Group for Medicolegal Death Investigation (SWGMDI), published June 2012,  https://www.nist.gov/sites/default/files/documents/2018/04/25/swgmdi_pri... tions.pdf. Last accessed July 23, 2018.

27. Supra note 8.

28. Official Compiliation of the Rules and Regulations of the State of Tennessee, 1200-07-01-.10(2)(a)(5) Tennessee Department of Health, https://publications.tnsosfiles.com/rules/1200/1200-07/1200-07-01.201506....

29. Supra note 1.


Dr. Amy Hawes is an assistant medical examiner at the Regional Forensic Center in Knoxville. She is the former chief medical examiner of the Middle Tennessee Regional Forensic Center in Nashville, and former deputy state medical examiner for Tennessee. She has 18 years’ experience in forensic pathology and is board certified by the American Board of Pathology in Anatomic, Clinical and Forensic Pathology. She serves as the medical examiner liaison to the Knox County Drug Related Death Task Force. Her areas of special focus include drug overdose deaths and sudden infant death investigations.

 
Dr. Darinka Mileusnic-Polchan is chief medical examiner for Anderson and Knox counties, is a clinical associate professor of pathology at the University of Tennessee Graduate School of Medicine, and is medical director of the Knox County Regional Forensic Center. She chairs the State Medical Examiner Advisory Council. She is board certified in anatomic and forensic pathology. Her main areas of interest are forensic toxicology and pediatric forensic pathology, particularly pediatric trauma and sudden unexplained death in infancy and youth.

 

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