A Case for Inclusion of Genetic Counselors in Cardiac Care

Recent advances in genetic testing for heritable cardiac diseases have led to an increasing involvement of the genetic counselor in cardiology practice. We present a series of cases collected from a nationwide query of genetics professionals regarding issues related to cost and utilization of genetic testing. Three themes emerged across cases: (1) choosing the most appropriate genetic test, (2) choosing the best person to test, and (3) interpreting results accurately. These cases demonstrate that involvement of a genetic counselor throughout the evaluation, diagnosis, and continuing management of individuals and families with inherited cardiovascular conditions helps to promote the efficient use of healthcare dollars.

Ethical and Legal Challenges Associated with Public Molecular Autopsies

There is a national movement supporting the retention and use of bio-specimens from deceased individuals for the purpose of genetic testing. This manuscript discusses the significance of postmortem genetic testing in the context of death determination by medical examiners (i.e., public molecular autopsies). We highlight distinctive concerns that are raised in the areas of consent, confidentiality, and return of results when genetic testing is performed as part of a public molecular autopsy. We believe our manuscript will contribute to the development of a robust ethical and legal framework for genetic testing in this context.

Critical Diagnoses in Forensic Pathology: Ethics of Disclosure

A complex set of systems exists in the United States to manage and regulate the practice of medicine, and forensic pathologists (FPs) are bound by the associated ethical guidelines and associated statutory obligations. Individual FPs, for example, are required to have and maintain a state medical license that requires continuing medical education and provides oversight of many aspects of the practice of medicine. The laboratories in which forensic pathology is practiced, however, generally do not have to be accredited. In contrast, the College of American Pathologists (CAP) is the recognized accrediting body that “regulates” the majority of anatomic pathology and laboratory medicine, including hospital (consented) autopsies. Unlike hospital-based pathology practices, few incentives are present that encourage or require forensic pathology practices to pursue accreditation. Since the preponderance of forensic pathology practices do not fall under the purview of CAP, this relatively small subset of pathologists are left to determine their own set of professional and ethical standards. The National Association of Medical Examiners (NAME) laboratory accreditation and published autopsy guidelines provides a foundation for development of a quality management program, but does not specifically address disclosure of test results. Defining “critical diagnoses” in forensic pathology is challenging, and communicating these important findings to the proper individual(s) or organizations may not fall under statutory or accrediting requirements, and thus may become an ethical issue for the medical examiner/coroner.

National Association of Medical Examiners Position Paper: Retaining Postmortem Samples for Genetic Testing

Sudden unexpected death is typically diagnosed in infants, children, teenagers, and young adults following completion of an autopsy that fails to identify a cause of death or when autopsy suggests a potentially genetic cause of death in an individual less than 40, such as cardiomyopathy or aneurysm. Such deaths may be a result of genetic abnormalities that are unable to be diagnosed by gross or microscopic inspection, but may be detectable by molecular studies. Unfortunately, the ability to perform postmortem genetic testing is frequently hindered by lack of an appropriate specimen following completion of an autopsy. This paper provides recommendations developed by the National Association of Medical Examiners with the assistance of genetic counselors. The recommendations establish procedures to facilitate postmortem genetic testing and DNA banking by health care professionals assisting families who have experienced sudden death in young relatives by clarifying proper sample acquisition and storage. Additionally, recommendations for discussion with surviving family members and test planning are provided. The objective of these recommendations is to ensure that postmortem samples suitable for DNA banking are retained, allowing at risk family members improved detection of potentially treatable genetic diseases.