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As deaths attributed to the COVID-19 pandemic soar above 200,000, physicians and medical examiners have to decide whether decedents with positive SARS-CoV-2 tests died from COVID-19 or merely "with" it -- with autopsies providing the only sure answer.

At a press conference at the 2020 , specialists noted that while autopsies – the gold standard for cause of death – can't be performed on everyone, national totals for COVID-19 deaths probably come close to an accurate count.

"Whether we are overestimating or underestimating COVID-19 deaths often depends on how carefully we look," said Harold Sanchez, MD, assistant professor of pathology at the Yale School of Medicine/Bridgeport Hospital in Connecticut.

"Obviously with more than 200,000 deaths we aren't going to be doing autopsies on all the cases," he told MedPage Today. "So it depends on whether we are getting an accurate sample. The harder you look, the more cases you will find. In states that do have vigorous forensic pathology and do have the equipment and facilities to do autopsies, you are going to get a more accurate count. In my personal opinion, just based on local experiences, we are somewhere in the ballpark, but it is hard to know."

Alex K. Williamson, MD, chief of autopsy pathology and director of regional autopsy service and associate professor of pathology at Hofstra/Northwell Health in New Hyde Park, New York, added, "We have people who test positive for COVID-19 in life, but when they come to autopsy we try to figure out what role COVID-19 played."

"Most of them will have lung disease caused by COVID-19," he told MedPage Today, "but in a significant proportion of people who have positive COVID-19 testing in life, they will die of another pathology. I had a person with type 2 diabetes who was unable to get his insulin and he basically died from diabetes ketoacidosis. Even though he had tested positive for COVID-19, his death was deemed to be a diabetic death, not a COVID-19 death."

In Iowa, Jonathan Thompson, MD, the state's deputy medical examiner, told MedPage Today, "What is a COVID-19 related death is something that can be debated. Last week I had an older gentleman with COVID-19 who was under a lot of restrictions and he couldn't take those restrictions and ended up taking his own life. Is that a COVID-19 related death? Maybe. Without COVID-19 he probably would still be alive," Thompson said.

"We are not coding that on the death certificate as a COVID-19-related death but some people could argue that it is a COVID-19-related death. Statistics show that there are increases in drug-related deaths among people who may be concerned about COVID-19, but none of those deaths are being certified as COVID-19 related," he said.

"On the other hand, a lot of physicians are listing broncho-pneumonia on the death certificate and are not putting the underlying cause of death which would be COVID-19. In some cases, if a person tests positive for COVID-19 they are getting COVID-19 as the cause of death even though they may be completely asymptomatic for the disease. I think that these cases kind of cancel each other out," Thompson said.

"Sometimes it is quite challenging from the medical examiner perspective to determine if a person is dying with COVID-19 or from COVID-19. I recently had a gentleman in his 30s who was healthy – or at least didn't have any past medical history that we knew of. His family all stated that he was healthy. He tested positive for COVID-19 about 8 days prior to his death. He had been living in a friend's basement. He was found to have rip-roaring lung disease."

There was "another man who lived at home with several [pre-existing] conditions. When we did the autopsy, other than some sequelae from alcohol abuse, everything looked normal, so in him the COVID-19 was just an incidental finding. So he died with COVID-19 as opposed to the 30-year old man who died from COVID-19," Thompson said.

"Autopsy has played an important role in the COVID-19 pandemic almost from the very start of the pandemic," Williamson said. "Autopsy informs our understanding of disease, ensures that the therapies that we are employing medically and surgically are effective in targeting and dealing with the diseases. Autopsies provide important information for families so they can understand what happened to their loved ones and proceed through the grieving process and hopefully come to closure. Autopsy also plays a vital role in quality assurance of medical care, and autopsy plays a very important role in assuring accurate public health data in terms of death certification."

And Sanchez added, "If you are going to be making intelligent decisions about public policy and if you are going to make decisions about treatment, etc., we need the best information about disease and cause of death and that is something that autopsy can provide and there really is no other way to do it."

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