as well as the relative lack of ticks and summer humidity prevalent in Missouri. Another benefit of working in this capacity in Utah is the Office of the Medical Examiner’s (OME) statewide structure. Much of the U.S. is a patchwork of death investigation systems; most jurisdictions are county-based, and many are led by elected coroners with varying levels of training. In some places, the qualifications to be a coroner amount to age, residency and winning an election. Autopsies may be performed by “any willing physician” in many jurisdictions. Utah, by contrast, runs a statewide medical examiner system within the DHHS, which establishes uniform standards and ensures consistent data collection. It also, crucially, provides a direct link between death investigation and public health. “People think a death certificate is just paperwork,” Amaro says. “But the cause and manner we assign are coded into ICD. That becomes mortality data. It’s how we know what’s really killing people — and how we decide what to do about it.” She can point to the benefit of this data for public health, both contemporary and historic. In the present, Utah’s clarity about fentanyl-related deaths through robust and accurate data has underpinned a multi-stakeholder response, including the governor’s Fentanyl Task Force. A historical example involves an autopsy technician on the East Coast who noticed an alarming pattern: infants dying in car crashes at far higher rates than others. Once validated with national mortality data, that observation helped drive a change in car-seat requirements, which led to a decrease in the number of infant deaths in car accidents. Cases like these illustrate the profound impact that the quiet, meticulous work of death investigation and data analysis can have on the lives of the living. For family physicians, the most immediate intersection with Amaro’s office is the death certificate. Most deaths in Utah are natural deaths under physician care and never become ME jurisdiction. That’s where clinicians often feel a pang of uncertainty. The patient died at home over the weekend. Police arrived first. The funeral home is calling. What now? First, Amaro reassures, it is typically unnecessary to complete a certificate outside business hours. While issuing the death certificate promptly is critical for the family of the deceased, it’s normal for physicians to take time, gather the information they need to complete the certificate and ask for help from the ME if needed. “There are several steps that happen before your signature is needed,” she says. Law enforcement often makes the initial scene assessment in unattended deaths; the funeral home usually coordinates the next steps and outreach to the treating physician. If the scene investigation has ruled out trauma, overdose or suspicious circumstances, and the patient’s clinical history supports a natural process, it may be reasonable to certify a natural death even without an autopsy. “Uncertainty is part of medicine,” she notes. “An autopsy isn’t a magic box that always yields a single, definitive answer. We make clinical judgments in life; we also make them at the end of life.” If families ask about an autopsy outside the ME jurisdiction, the pathway is a hospital or private autopsy. Both require consent from the legal next of kin. Utah has an additional safeguard that clinicians should be aware of and explain to families: The ME’s office reviews every case slated for cremation or removal from the state. Most reviews are straightforward, but they occasionally surface concerns that warrant a deeper look. “Sometimes the body is the evidence,” Amaro says. When that evidence would otherwise be destroyed or leave the state, the office may intervene — a necessary step, though it may be inconvenient for families. Behind these processes lies Amaro’s larger appeal to family physicians: collaboration. Physicians receive little formal training in death certification. It can be stressful when a patient dies and the “final diagnosis” falls to a clinician who wasn’t present at the time of death and, in some cases, has not seen the patient in some time. Her message is simple: Call us. “If one of your patients dies and it’s not our jurisdiction, but you have questions about how to structure the certificate, we’re happy to help. We know how important this is for the family, and for understanding the health of our community.” That collaboration begins with a shared ethos. To Amaro, signing a death certificate is an act of care, not a bureaucratic chore. It honors the patient’s story with a clear, defensible conclusion that reflects what we know about their health and the circumstances of death. When uncertainty creeps in, consider the information you, as the physician, Dr. Deirdre Amaro 21
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