Defining, exploring the sources and expressing post-mortem diagnostic uncertainty

Diagnostic uncertainty is a well-recognized concept in clinical practice, encompassing both technical perspectives and the subjective perceptions of physicians. Post-mortem diagnostics (PMD), which involves all post-mortem investigations to assess diseases and injuries and determine the cause of death, shares this inherent uncertainty due to the complexity and multidisciplinary nature of autopsies.

A comprehensive literature review was conducted to uncover relevant publications focusing on diagnostic uncertainty in PMD. An expert panel evaluated expressions and sources of diagnostic uncertainty to identify factors influencing PMD uncertainty.

 Literature specifically addressing PMD uncertainty is sparse, though implicit and explicit references exist. This article illustrates the presence of uncertainty in PMD by drawing upon both literature and pathology practice. We introduce the definition of PMD uncertainty as “the inability to determine the exact cause of death and/or the precise significance of certain autopsy findings”. PMD uncertainty can stem from a pathologist's subjective perception, but often results from several objective factors. Six factors inherent to the PMD setting were identified as contributing to this uncertainty. To systematically express the certainty of cause-of-death determinations, we developed a new Post-Mortem Diagnostic Certainty Scale (PMDCS) featuring eight categories, distinguishing between assignable and non-assignable causes of death.

Understanding and applying the concept of PMD uncertainty will enhance comprehension of the importance of certain post-mortem findings and improve the accuracy of autopsy result interpretation. While eliminating PMD uncertainty entirely is not feasible, standardizing investigations can reduce uncertainty, and using the PMDCS can improve the clarity of autopsy reports.