Autopsy (cont.)
What other special studies may be done as part of the autopsy?
Pictures of findings may be taken for future reference.
Special studies may include cultures to identify infectious agents, chemical
analysis for the
measurement of drug levels or metabolic abnormalities, or genetic studies. Tissue
may be frozen for future diagnostic or research purposes. Organs may be
preserved and stored in formalin for later examination, sampling for microscopy,
presentation at conferences, or archiving for the training of medical students.
What is the autopsy report?
After all studies are completed, a detailed report is prepared that describes
the autopsy procedure and microscopic findings,
gives a list of medical diagnoses, and a summary of the case. The report
emphasizes the relationship or correlation between clinical findings (the
doctor's examination, laboratory
tests, radiology findings, etc.) and pathologic findings (those made from the
autopsy).
Why is the autopsy rate declining?
Beginning in the 1950s, hospital autopsy rates started
falling from an average of around 50% of all deaths to 10% in the late 1990s.
Currently, the rates are even lower at non-academic hospitals. In 1970, the
Joint Commission
for Accreditation of Hospitals dropped the requirement that a hospital needed an
autopsy rate of 20% to be accredited. To some, this decline represents a crisis
in medical education, research, and practice, and deprives decedents' families,
physicians, and society of the many benefits of an autopsy.
Multiple factors are believed to contribute to the declining autopsy rate.
Family factors: Certainly the relationship between patients and their doctors
has changed dramatically over the past 50 years due to factors such as
specialization, managed care, and the disappearance of the "house call."
Physicians no longer are "family doctors" and do not have the same rapport with
patients and their families as in past years. This change in the basic
doctor-patient relationship would seem to make it increasingly difficult to
obtain consent for an autopsy, as issues of trust are most certainly involved.
Concerns over disfigurement of the remains or delays in funeral arrangements
may prevent a vast majority of families from consenting to an autopsy. In
reality, however, the visual examination of the body and the removal of tissues
and/or organs for microscopic examination can be completed in a few hours.
Furthermore, there are no visible external changes that would preclude an
open-casket funeral service.
In the majority of cases and certainly at academic medical centers, there is
currently no charge to the family. More recently, though, some institutions have
started to charge and private autopsies at the request of family members that
are performed outside of the hospital may cost several thousand dollars.
Clinician factors: The perceived and experienced hostility of patients'
families towards medical providers may also have an impact on the physician's
practice regarding the autopsy. Most physicians are generally uncomfortable
requesting an autopsy because it is not an easy or pleasant task. If, in
addition, a physician feels that a given family questions the care that their
relative was given, the physician may be further dissuaded from requesting an
autopsy that might prove that the care that was given was indeed incorrect.
During the first half of the century, physicians requested autopsies with the
hope of uncovering errors or missed diagnoses that would serve to improve future
patient care. This practice may still occur, but sometimes at the price of a
lawsuit.
Many individuals in medicine feel that modern technology has made the autopsy
outdated or obsolete. With modern imaging studies and laboratory tests, it is
thought that the autopsy is unlikely to reveal any conditions that were not
detected clinically. The accuracy of the clinical diagnosis has been the subject
of numerous research studies. These studies have consistently shown that in 20%
to 40% of autopsied patients, there were important, treatable conditions that
were detected at autopsy that were not diagnosed clinically. This consistent and
significant discrepancy between clinical and pathologic diagnoses is probably
the most compelling argument for continued efforts to revive the autopsy as the
"gold standard" in evaluating the quality of medical care.
Pathologist factors: Some doctors express dissatisfaction with the quality of
an autopsy if the pathologist does not provide answers regarding the case.
Unfortunately, an autopsy does not guarantee that the cause of death, for
example a heart arrhythmia, will be identified.
Autopsy pathology is a vanishing subspecialty, which, for the most part, has
been relegated to a secondary position. At the turn of the century, most of the
pathologist's activities revolved around the autopsy. Since that time,
laboratory medicine and surgical pathology (examining tissue biopsies from
living patients) have become the major activities of practicing pathologists.
In addition, the autopsy is not one of the favorite activities among the
majority of pathologists. For many pathologists, an autopsy is an extra burden
with no compensation during a busy day.
Next: What are the benefits of autopsies? »
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