Connected to the cloud at time of death: a case report
In the digital age our experience of health and illness is no longer constrained to the boundaries of our physicality. Through cloud-based healthcare platforms, implanted biomedical devices, and interconnected consumer technologies, we have opened up our bodies to the internet, streaming our physiological data to servers around the world, embedding digital imprints of ourselves into space and time . In the UK, one in twenty-five people has an implanted medical device, and increasingly these technologies integrate digital components, with advanced software functions (for example, Artificial Intelligence) and telemonitoring capabilities . The benefits of such technology have been reported in the lives of many patients, yet the role of these tools in death is a topic that remains relatively unexplored . Yet now that younger generations are progressively adopting biohacking practices, digital natives are ageing, and we are approaching the 50th anniversary of the internet, we must begin to question how we should respond to the growing number of deaths that are mediated by, and manifesting through, the medium of technology . In the bioinformatics field researchers have adopted the term ‘everyday cyborgs’ to refer to the expanding population of patients that rely on medical devices and biomedical accessories to manage their health and wellbeing—cyborg being short for cybernetic organism . The landscape of available devices continues to grow, encompassing technologies as varied as cloud-connected hearing aids, embedded pacemakers, cloud-loop insulin pumps, and consumer technology such as subcutaneous Radio Frequency Identification (RFID) chips and smart implants . In addition to the rise of digital devices, we are witnessing a mass expansion of the ‘Internet of Medical Things’ (IoMT)—the construct that describes the interconnected nature of healthcare technologies. The development of the IoMT has facilitated the growth of remote platforms for healthcare devices, including cloud-based platforms that monitor patient’s cardiac devices, hearing aids, cochlear implants, and renal dialysis systems . By linking patient devices to the cloud, we have created a virtual environment of patient vital signs, to which thousands of bytes of physiological data are streamed from patient’s homes around the globe. The challenges presented by the integration of biological persons with synthetic and connected parts has been explored in the legal domain and by bioethicists, but less so in the clinical context . Through a medical lens there are novel clinical challenges that emerge with these new hybrid ways of being. When biological cells interface with digital mediums, the internal process of living tissues come to interact with the forces central to digital devices, such as electrical simulation, interconnectivity and electromagnetism (EM) . New pathways emerge, where software malfunctions or battery failures can affect biological mechanisms and cellular architecture, manifesting as novel symptoms experienced by the patient . These novel physiological pathways herald a new form of ‘cyborg’ medicine, in which clinicians currently receive little to no training . Cyborg technologies also introduce new ways of dying. For patients with internet-connected medical devices (for example. pacemakers), in the moments of their death their physiological demise may be streamed live to cloud platforms, to be received by algorithmic systems responsible for alerting the relevant services . Shifting death to the virtual domain in this manner introduces new questions about oversight, responsibility and cybersecurity, for attacks on these platforms could hold cohorts of remotely monitored patients to ransom. In addition to changing the manner by which deaths gain medical attention, cyborg technologies directly potentiate new pathways to death through digitally mediated illness and injury (for example. software bugs in pacemakers, malicious hacks on insulin pumps) . Digital injuries and deaths have been described by first-responders in healthcare settings and in policing . The technology that mediates a death may be relatively upstream and disconnected from a patient, such as in the death of a woman in Dusseldorf that was attributed to a hospital cyberattack . A recent review of cyberattacks on healthcare services described the range of possible attacks and highlighted an infant death during a ransomware attack, that compromised vital equipment used for monitoring fetal heart rates . Technologies that directly interface with the body may have immediate lethal effects for example. injury associated with the failure or manipulation of implanted medical technologies . Cybersecurity researchers have demonstrated extensive vulnerabilities that exist within implanted medical devices and the UK media has reported cases of domestic abuse enacted via Bluetooth-enabled personal medical technologies . Outside of autopsy practices, research in cardiology has examined the differing clinical needs for digitally dependent patients during life and the roles of data streams in anticipating death . The first implantable pacemaker was introduced in 1958, since which time the design of these devices has advanced significantly . Walsh et al. give a comprehensive overview of the wireless technologies entering that market that stream physiological data to the Cloud . In 2023 Tarakji et al. described the first pacemaker to use Bluetooth to communicate with a smart device (phone or tablet) to facilitate remote monitoring . In 2019, the first clinical application of real-time remote programming of cardiac devices was shown to be feasible, safe and clinically useful . Tong et al. describe such a platform, detailing a 5G-cloud follow up platform from which a device specialist can test and program cardiac devices from a remote location via an internet connection or mobile wireless network . Monkhouse et al. reported a series of twenty-eight deaths caught on a remote cardiac monitoring, identifying the challenges inherent within these cases, stating that despite the integration of triage alert systems, “there is no specific alert for a potentially deceased patient”  . Their case series from London describes a centralised cloud-based system for cardiac patients, that oversees 7000 patients on remote monitoring at home, receiving over 100 transmissions per day  . Further research from the USA has highlighted the lack of death aftercare, with electrophysiologists and morticians advocating for universal post-mortem device analysis . Logani et al. discuss the challenge of distinguishing device malfunctions from progression of underlying disease, which may not be possible to ascertain without autopsy . Of note, the authors state that while autopsy may facilitate the inspection of devices, this often does not lead to device interrogation or bench testing, and as a result issues relating to cybersecurity or software malfunctions may remain undetected . Studies of patients with implanted cardiac devices that have died from sudden cardiac death, have identified device concerns in half of the cases, due to causes such as battery depletion, drop in pacing output, and lead fractures . At present the siloed nature of clinical medicine, pathology, computer science and cybersecurity means that the pathways from a cybersecurity exploit to a clinical manifestation are rarely mapped out . With these pathways currently not being taught in medical education, it is essential that pathologists have access to appropriate guidance for ensuring digital deaths are effectively captured and documented. Such documentation plays an important epidemiological role, as death certification facilitates a post-mortem surveillance system for mapping causes of death, without which we cannot quantify prevalence and enact changes that protect the living. For example, population-level digital health threats could include an outbreak of speech disturbance due to a software failure in cochlear implants, or motor impairment induced by interference with deep brain stimulators (DBS) . In our article, we explore these issues, examining the applicability of current autopsy guidelines to the novel forms of death and disease that have emerged with digital technologies. The systematic evaluation of the deceased can be traced back to Babylonian practices 3500 years ago . In traditional autopsy the pathologist carefully examines the body and organ tissues, noting relevant information/data that can provide valuable clinical knowledge, reveal pathological processes, and provide information on individual and population-level threats to health . The insights gained from autopsy practice can be useful to the family of the deceased, the treating physicians, and the population as a whole. For the families, autopsy information may assist in the bereavement process through the provision of answers and alleviation of guilt or confusion . For medical scholars and clinicians, the process of autopsy has been validated as a tool for improving diagnostic skill, knowledge and experience . The foundational practice of autopsy has adapted over time in response to the changing landscape of health threats, most recently in the COVID19 pandemic . As threats to life change, as with the emergence of new infectious diseases and bioterrorism agents, autopsy practices have been updated to detect and evaluate these dangers . Historically, autopsy guidance that discusses implanted devices focused on static implants, such as intrauterine contraceptive devices, metal prostheses and artificial cardiac valves, evaluating issues such as allergy, infection, and toxic materials . These are very different to electronic and digital devices that we now see, which interact with the body through electric stimulation, vary in voltage and current, may be subject to cyberattacks and electromagnetic (EM) interference, and require very different pathological and forensic considerations . While the latest guidance from the Royal College of Pathologists (RCPath) does mention electronic failures in devices, cybersecurity is not mentioned throughout the document . Furthermore, for internet-connected patients, autopsy guidelines may not capture key information streamed externally to cloud-servers and remote platforms that store a patient’s physical readings. At present, these externalised digital forms of physiology are not captured by the autopsy process. Previous research has described that pathologists and morticians often treat implanted devices as medical waste as a default, and research from Kirkpatrick et al. in Chicago highlighted that only 4% of morticians reported returning devices to manufacturers for analysis and amongst patients 87% of subjects did not know how devices were handled after a patient dies . The absence of integrated communication pathways between the clinicians treating living patients, those involved in death aftercare, and the device manufacturers, means that digital deaths may fall through the gaps. Schaer et al. described the case of a 53-year-old man with an implanted ICD whose death was suspected to relate to an electrode problem, yet the ICD was neither interrogated nor explanted . In addition to missing the processes of death, neglecting the digital elements of a case may lead to missed opportunities in death aftercare, for previous research has demonstrated that digital data can be used to establish the circumstances of a death . Novel digital technologies bring the promise of improved disease monitoring and personalised care, yet researchers have also raised concerns regarding the confidentiality and cybersecurity implications of these devices . Existing papers that have focused on remote care platforms and digitally-dependant devices have not examined the role of pathologists and autopsy practice. Our report focuses on an internet-connected patient death, communicated to the cloud via an embedded cardiac device. We explore the digital additives that may be needed in autopsy practices through the case of a patient who died while streaming to the cloud.   Daniel, a white British man in his 50s, was assumed to be at home when the data streaming from his implanted cardiac defibrillator (ICD) began to transmit an abnormal cardiac rhythm at 1430 hours. An alert on the remote care system notified the secondary care team that his heart rate had dropped significantly, at which point they attempted to contact the patient but were unsuccessful. The cardiology department contacted the ambulance team to explain that the patient’s heart rate had dropped to around 30 beats per minute (bpm) and then entered asystole. The ambulance arrived at Daniel’s address after 3 hours, at which point he was found deceased in his bed with a CPAP (continuous positive airway pressure) machine on, with mask in situ for obstructive sleep apnoea. During this time the cardiology doctors had separately reached out to Daniel’s Next of Kin (NOK) to explain that they could see remotely that his device had become more active, however the implications were unclear, and they were unable to inform the family with certainty whether he had died or not at the time. Daniel had been implanted with an ICD two years earlier due to a Ventricular Fibrillation (VF) arrest, occurring on a background of congenital heart disease and pulmonary stenosis. His full past medical history included (1) Pulmonary stenosis with previous valvotomy, (2) Previous VF arrest leading to pulmonary valve replacement and ICD Implantation, (3) Atrial Fibrillation, (4) Type 2 Diabetes Mellitus, (5) Hypercholesterolemia and (6) Gout, and his regular medications are listed in Table The last device transmissions demonstrated a heart rate of 24 beats per minute (BPM). The Electrogram (EGM) showed the device delivering multiple shocks which coincided with the ventricular electrical activity observed and the corresponding alert of “Right ventricular intrinsic amplitude out of range” . The electrograms from the preceding months demonstrated a falling night heart rate to 37 bpm, visualised in the trend graph in Fig. . The gradual downward trend in the patient’s heart rate is in keeping with existing research that has identified a deteriorating bradycardia as a preceding indication of death on cloud platforms. Whilst collating the medical notes of the case, it was found that a remote clinic appointment had been carried out and documented two days after Daniel’s death. On being unable to contact Daniel, the clinician reviewed the last device check four months earlier and determined a good battery life and stable lead parameters with no arrhythmias, booking Daniel for another appointment in six months’ time. It appears that at this point the system was not updated, providing the detailed information regarding Daniel’s death. We now turn to the death aftercare of Daniel’s case, focusing on the autopsy process in evaluating the deceased.   Hardware evaluation Existing guidelines advise the careful dissection and extraction of implanted devices such as pacemakers, keeping the leads and generator unit intact for potential device evaluation in the clinic. Previous research has described the importance of extracting cardiac device leads, as lead malfunction remains a dominant cause of system dysfunction . In practice, the process of autopsy requires physical force and breaking of tissues which may disturb hardware placement from the initial opening of the chest. Furthermore, by the time of autopsy the hardware has often become embedded within the tissue with regenerative epithelial changes and scarring. In the case of Daniel, the scarring of the heart and pathological changes associated with the disease process, meant that delicate extraction of component parts was not possible, and the leads were pulled out early in the process. Lastly, on discussing with the pathologist how the ICD could be evaluated for its contribution to the death, it was felt that this was a diagnosis to be made by the clinical team during life, not by the autopsy professionals who are trained in the histopathology of biological tissues as opposed to digital components. Interconnectivity and data evaluation In our experience of this case and discussions with the wider clinical team, it does not appear to be standard practice for the historic transmitted data preceding death to be interrogated or downloaded for retrospective analysis. It would be interesting to know whether the cloud-based data from the preceding six months indicated any issue with the device settings or battery, however this retrospective evaluation of device information is not mainstream practice. It has been suggested that it is up to the pathologist’s discretion regarding which devices to send for interrogation, however these judgements require an understanding of the clinical manifestation of device errors of which there is little clinical training . Software evaluation Similarly, to the cases found in our background research, Daniel’s device was treated as medical waste and was taken away by the funeral team, precluding any digital forensic analysis. Without this sort of analysis, software bugs or malicious hacks cannot be considered or investigated. In the case presentation we also mentioned the patient’s sleep apnoea mask, for previous research has described interactions between CPAP masks and cardiac devices . Evaluating any possible interaction and contribution to death would have required an awareness from the frontline responders to collect the sleep mask technology, and additional resources for device interrogation that would evaluate issues stemming from electromagnetic (EM) interference . In conclusion, Daniel’s cause of death was assigned to his underlying heart failure and the digital components of the death were not considered in the autopsy process. The device was treated as medical waste, the cloud data was not retrospectively analysed, sources of potential digital harm were not collected from the scene of death, and there was no forensic hardware or software evaluation. As this case report was focused on examining current clinical practice as guided by existing standards, we did not attempt to introduce new steps to the autopsy process. We have however identified areas where there may be missed opportunities and missed harms, and we now turn to these and a series of recommendations.   Existing guidelines advise the careful dissection and extraction of implanted devices such as pacemakers, keeping the leads and generator unit intact for potential device evaluation in the clinic. Previous research has described the importance of extracting cardiac device leads, as lead malfunction remains a dominant cause of system dysfunction . In practice, the process of autopsy requires physical force and breaking of tissues which may disturb hardware placement from the initial opening of the chest. Furthermore, by the time of autopsy the hardware has often become embedded within the tissue with regenerative epithelial changes and scarring. In the case of Daniel, the scarring of the heart and pathological changes associated with the disease process, meant that delicate extraction of component parts was not possible, and the leads were pulled out early in the process. Lastly, on discussing with the pathologist how the ICD could be evaluated for its contribution to the death, it was felt that this was a diagnosis to be made by the clinical team during life, not by the autopsy professionals who are trained in the histopathology of biological tissues as opposed to digital components.   In our experience of this case and discussions with the wider clinical team, it does not appear to be standard practice for the historic transmitted data preceding death to be interrogated or downloaded for retrospective analysis. It would be interesting to know whether the cloud-based data from the preceding six months indicated any issue with the device settings or battery, however this retrospective evaluation of device information is not mainstream practice. It has been suggested that it is up to the pathologist’s discretion regarding which devices to send for interrogation, however these judgements require an understanding of the clinical manifestation of device errors of which there is little clinical training .   Similarly, to the cases found in our background research, Daniel’s device was treated as medical waste and was taken away by the funeral team, precluding any digital forensic analysis. Without this sort of analysis, software bugs or malicious hacks cannot be considered or investigated. In the case presentation we also mentioned the patient’s sleep apnoea mask, for previous research has described interactions between CPAP masks and cardiac devices . Evaluating any possible interaction and contribution to death would have required an awareness from the frontline responders to collect the sleep mask technology, and additional resources for device interrogation that would evaluate issues stemming from electromagnetic (EM) interference . In conclusion, Daniel’s cause of death was assigned to his underlying heart failure and the digital components of the death were not considered in the autopsy process. The device was treated as medical waste, the cloud data was not retrospectively analysed, sources of potential digital harm were not collected from the scene of death, and there was no forensic hardware or software evaluation. As this case report was focused on examining current clinical practice as guided by existing standards, we did not attempt to introduce new steps to the autopsy process. We have however identified areas where there may be missed opportunities and missed harms, and we now turn to these and a series of recommendations.   The effective evaluation of a death with a digital component would cover both the traditional autopsy techniques of examination and histopathology, integrated with digital methods such as retrospective data analysis, device evaluation (both hardware and software) and digital forensics of the device. In doing so, deaths mediated by digital technology may be captured and prevented in the future, and new opportunities created by digital systems may be leveraged to improve current care. Digital data may provide essential information to health and security services in cases of malicious harm, such as the time of death and recent geospatial movements of a patient . Research from Lacour et al. demonstrated that the interrogation of cardiac devices was able to inform the time of death in 70% of cases that presented over a five year period to a Berlin hospital . In addition, Monkhouse et al. described the specific diagnostic feature that may indicate death on streamed electrograms from cardiac devices and Stroobandt et al. identify the predictive potential of pacing lead impedances for identifying time of death . Their findings raise the question around the utility of digital data from other streamed devices that may be helpful in determining a cause of a death, and whether equivalent ‘digital death markers’ may be uncovered from data from other healthcare technologies (for example. spinal simulators, cochlear implants, or the data from continuous blood glucose monitoring systems etc.). Unfortunately, unless devices and their respective data are treated in an informed manner, with mortuary protocols written with digital input, vital forensic information may be lost. For example, it has been demonstrated that cold temperatures can disrupt device integrity, precluding forensic analysis, and hence the mortuary practices of negative temperatures may need to be adapted for device-dependent patients . In our research we have not found a study reporting the impact of mortuary temperatures (refrigeration and freezing) on digital devices. Furthermore, digital analytics are dependent on device memory hardware, which differs between models and manufacturers. In addition, the rise in post-mortem radiological imaging has been proposed as a powerful way to improve current autopsy practice, however the EM interference such imaging entails may prevent the evaluation of digital deaths due to the EM disruption of device settings . A lack of awareness amongst frontline practitioners may also preclude the identification of digital harms . In the case of Daniel, the law enforcement report detailed standard practices for excluding harmful intent, by exploring for any suspicious items at the scene and ensuring the premises were locked when the body was identified. These measures however would not account for deaths mediated by digital components, where remote hacks of devices can be performed over a distance and sources of interference may derive from unsuspecting household items . Additional research has demonstrated that in instances of domestic violence, forms of technology-facilitated abuse are often not suspected by frontline health workers, and in one case a domestic murder enacted by an insulin pump was almost missed due to the initial disposal of the device by the responding team . Educational initiatives focused on the digital pathways to death would benefit both first responders and pathologists carrying out autopsies. The end-of-life care of patients with digital devices remains an unexplored topic that is not integrated into medical curricula. While clinical trainees learn the best practices for ‘breaking bad news’ (for example. communicating deaths on a hospital ward), they are not trained to communicate uncertain deaths that are occurring online. Breaking bad news’ is a key tenant of medical education, and refers to training in delivering upsetting or difficult news to patients and their family, such as a death or terminal diagnosis . Buckman previously identified the challenges that clinicians face when navigating these scenarios, including (i) fear of the unknown and untaught, (ii) fear of expressing emotion, (iii) fear of not knowing all the answers and (iv) personal fear of illness and death . Clinical situations involving breaking bad news related to life-threatening events manifesting online, present novel challenges that fall under these previously identified headers. Clinicians tasked with communicating the online deterioration may not understand the digital information provided; they may not be able to answer how likely a patient is to have died; and they may have their own emotional reactions to witnessing deaths occurring online that they cannot intervene in. Responding to a death in the digital world, where you cannot directly intervene with clinical skills and interventions, presents a new form of psychological and emotional challenge to healthcare staff. For cases like Daniel, where there is a ‘potential’ death occurring on an internet platform, clear research and guidance is needed to ensure families are prepared for this call in advance, and receive informed, appropriate communication when an event happens. The question of responsibility and liability over device related issues has been explored in the medical regulation domain, and is relevant here given there is no clear system for the oversight of potential digital deaths . The story we have told reflects the trend described in existing research, which states that despite patients, practitioners, and funeral directors being willing to participate in post-mortem device retrieval, devices are often thrown away or kept in the funeral home. In fact, following a series of pacemaker and ICD failures and recalls, the Heart Rhythm Society recommended that physicians return all explanted devices to the manufacturer for analysis in order to improve the reporting of device malfunctions and failures . The guidance that suggests returning devices to manufacturers for evaluation has been challenged by the research community who have suggested a need for independent testing . Logani et al. share the challenge that device company representatives are not incentivised to encourage the return of devices . In the case of potentially malfunctioned devices returned to the manufacturer, return product analysis can be performed to determine whether device has malfunctioned or reached battery depletion, however this incurs financial costs for manufacturers which are not reimbursed . The findings of such interrogation may also not be pleasing to manufacturers, as this analysis would reveal the magnitude of inadvertent device deactivation caused by poor programming or exposure to EM energy sources . With regards to device ownership after death the UK Royal College of Pathologists currently states that “ It is reasonable to accept that, at the point of implantation, any device (property in law) passes from the hospital (or equivalent) to the patient. On death, within UK probate law, such property passes into the deceased’s estate, in the same way as clothing or jewellery”. Thus, the Next of Kin (NOK) technically inherits the device, and there is a question as to whether this also extends to the cloud data. In cases where this may need to be accessed for legal or forensic purposes, what is the process of consent? Furthermore, in Fig. 1.0 we illustrated the gradual decline in the patient’s heart rate, raising the question as to whether this event could have been predicted and if patients should have access to the information on their own potential trajectory. Greater cross-disciplinary research is required to understand the clinical symptoms, signs and deaths of these patients. Understanding deaths mediated by technology require an understanding of the post-mortem changes that may occur at the interface of human tissues and digital parts. It is known that the body undergoes complex and intricate changes after death, mediated by temperature, body morphology, injuries etc., however the role that digital implants play in the death pathway are not understood. Further, the analysis of a device may be hampered by the body’s reaction to the implant before death, such as the scarring and adhesions that occur during life. Lastly, health equity must be considered. The innovative digital systems that may improve care through the internet may also be manipulated by malicious actors, and this needs to be kept in mind for patients at heightened risk of harm and abuse . Scholars in the domestic violence field have described the disproportionate impact of technology-facilitated abuse on women and girls, and the digital risks faced by young people affected by gang violence and knife crime . Furthermore, evolving cloud-based systems that rely on Artificial Intelligence (AI) software may need to be evaluated for the demographic biases that have been demonstrated in other forms of medical AI with implications for racial and gender-based health disparities . The UK Government’s recent review into medical device equity has revealed concerning biases that may lead to a widening of health inequalities if differential digital performance is note addressed . Urban-to-rural health disparities may also be affected by differences in cellular coverage and access to cloud-based platforms. Given that implanted device models differ in the frequency in which they stream to the cloud or deliver data downloads, economic factors may play a role in digital data availability. Lastly, it’s possible that devices may serve to identify the deceased, however in areas of the world where devices are donated and reused (particularly in low-income countries), this may not be possible and may result in harmful errors and misidentification of victims.   Our report has examined the applicability of the latest autopsy guidelines to modern deaths affected by digital components. Despite the fact that research from over a decade ago identified the need for comprehensive device digital forensics, the disconnect between what is needed and what is being done has not year closed . An appropriate pathway for managing digital devices needs to be developed, to ensure that deaths are picked up and are correctly distinguished from non-concerning events, and public health measures can be introduced for concerning risks to health. In particular we recommend: I. Improvements to end of life management affected by technology (for example. through simulation training for practitioners on breaking bad news over internet) II. Integration of digital components within mortuary protocols, such as accounting for the possible impact of cold temperatures on device hardware. Further, it would be beneficial for the device digital record to be extracted prior to removal of the device, so that pathologists can assess the leads for obvious damage. III. Educational initiatives and support for pathologists and morticians regarding digital pathways to disease and death. There should routine provision of the output from the device to the coroner as part of the scene record which can be given to the pathologist prior to post-mortem to allow these disease mechanisms to be considered. IV. Engagement with technical specialists and manufacturers to ascertain forensic capabilities of devices (for example. death related information available from cochlear implants). V. Updates to guidelines from Royal College of Pathologists and mortuaries to encompass cybersecurity risks, the preservation of digital data, and to expand consideration to all forms of implanted technology (for example. subcutaneous RFID chips).   