U.S. autopsy rates continue to decline
Is this a concern for ethics committees?
How often are post-mortem examinations performed on patients who die at your hospital? Chances are, very rarely. If you’re at an academic teaching center, experts estimate that approximately 10% of medical deaths at your facility undergo autopsy.1,2 If you are at a nonteaching hospital, the rate is more likely to be 9% or lower.2
That’s a far cry from the late 1960s and early ’70s when autopsies were performed on approximately 50% of medical deaths at most U.S. hospitals, says Jan Marc Orenstein, PhD, MD, professor of pathology at George Washington University in Washington, DC.
And, he and other experts claim, the low rate of autopsy is ensuring that many medical mistakes, problems in health care delivery, and public health issues continue to go undetected.
"It used to be the standard of care," Orenstein states. "Before there were pathologists, clinicians would go do their own autopsies. Then, when it became too much of a burden, the speciality of pathology developed."
Traditionally, performing a post-mortem examination was deemed necessary for the following to:
• officially establish the cause of death;
• assist in determining the manner of death (such as homicide or suicide);
• compare the premortem and post-mortem findings;
• produce accurate vital statistics;
• monitor public health;
• assess the quality of medical practice at a particular institution;
• instruct medical students and physicians;
• identify new and changing diseases in a population;
• evaluate the effectiveness of therapies such as drugs, surgical techniques, and prostheses.2
However, with the advent of new, high-tech diagnostic techniques and therapies, use of the autopsy came to be seen as an unnecessary expense and burden on families. New techniques were thought to ensure the accuracy of diagnoses, so the conventional wisdom held that autopsy was no longer as useful.
In the mid ’70s, the Joint Commission on Accreditation of Healthcare Organizations removed its requirement that hospitals main-tain an autopsy rate for medical deaths no lower than 25%, Orenstein says.
Still a necessary clinical tool
But many medical experts have long feared that the low rate of autopsy was in fact having a significant negative impact on the U.S. health care system.
Several clinical studies in the 1990s indicate that the discordance rate between premortem and post-mortem diagnosis (the frequency with which autopsy reveals that the cause of death was different than what the treating physician found) has hovered around 40%, since the late 1930s.2 This would indicate that new high-tech diagnostic tests are not working as well as they should in allowing physicians to make accurate diagnoses.
In particular, a 1998 study by researchers at the New Orleans-based Medical Center of Louisiana, revealed that the discordance rate between clinical and autopsy diagnoses of malignant neoplasms over a 10-year period at their institution was 44%.3
"There are numerous other studies showing that death certificates are up to 50% wrong," adds Orenstein. "With all of these less invasive techniques, we have a clearer picture of what is wrong with the patient. But, clearly when you do an autopsy and find that the patient died of a malignancy that was unsuspected or had a pulmonary embolism that was not suspected, it is quite clear that all of those CAT scans and MRIs are not foolproof and do not reveal everything."
In 1983, the Journal of the American Medical Association declared a "war on the nonautopsy," and the AMA House of Delegates passed numerous resolutions between 1986 and 1997 aimed at increasing the rate of post-mortem examinations.2
However, the use of the autopsy has continued to decline for a number of complex reasons.
Lack of resources
Third-party payers, including the Baltimore-based Health Care Financing Administration which administers the Medicare program, do not cover autopsy, except in rare situations, says Orenstein. "It is a cost almost always completely absorbed by the hospital," he explains. "And, a lot of hospitals are not teaching institutions. At a teaching hospital, you have pathology residents who need to do autopsies in order to get their qualifications for the boards. In a lot of nonacademic settings, the autopsy rate is zero; they simply won’t do them."
Adding to the problem is that many physicians are uncomfortable asking a patient’s family for permission. Also, adds Orenstein, there is a certain level of fear that the examination will reveal an error in diagnosis or a mistake in treatment.
"It is always a question of medical-legal issues," he believes. "Nobody really talks about it. Many may believe that something is going to be found at autopsy that is going to be detrimental to them, or show that they did not treat the patient properly."
Public health issues
The decline in the use of autopsy has serious implications beyond that of detecting misdiagnoses or problems at individual institutions, says Laura Siminoff, PhD, associate professor of medicine and associate professor of biomedical ethics at the Center for the Study of Biomedical Ethics at Case Western Reserve University in Cleveland.
"There are countries in Europe, like Austria, that automatically do an autopsy in every death," she notes. "There is presumed consent there, in which you would have to opt out in advance, because of the idea that it is for the common good."
On an individual level, the autopsy may reveal a congenital defect that would have an impact on the deceased’s family. And, society as a whole would benefit from learning whether the patient died from something besides what the treating physician thought they died from.
Another issue is the ability of widespread use of post-mortem examinations to detect problems across a whole population of people, she adds.
"This speaks to things like better diagnosis and understanding what the real prevalence of particular diseases are. For example, one of the things that autopsy has shown in this country is the prevalence of multiple sclerosis," she explains. "Many more people have this condition than are diagnosed with it while alive. It has shown that this disease can have a different course, and maybe there are people who have a chronic course and people who have a more sporadic course, and it is just not being diagnosed."
It’s also through the use of autopsy that medical science has much of its information about the progression of such infectious diseases as AIDS and Legionnaire’s disease, says Orenstein. "We consider the autopsy to be the final examination of the patient, the last opportunity to correlate the clinical and pathological entities that the patient was suffering from," he states. "If that opportunity is not taken, you can only believe what you believe, you haven’t any objective data, you only have subjective impression."
Is it a concern for the committee?
Should hospital ethics committees get involved in increasing the rate of autopsy at their institution? Or, is it a matter that must be resolved through public policy and clinical practice?
"It seems to me that ethics committees should get involved," says Siminkoff. "On one hand, you question whether they should, because then is everything an ethical issue? But, certainly asking for organ donation is considered an ethical issue, and I am not sure why this would be different. Both issues bear on the ability of the system to care for future patients."
But, many larger issues must be resolved before the rate of autopsy in the United States can be brought back up to a reasonable standard, says Orenstein. First of all, there are not enough practicing pathologists to perform the autopsies if the rate were to suddenly jump back to even 25% of medical deaths, he says. And, the procedure can be expensive. Short of asking for families to pay for the examination (something few physicians and advocates support), there is no obvious source of funding for this added service.
Last, but not least, is the problem of encouraging physicians to request permission to perform an autopsy from grieving family members.
"I think you should ask [for permission to perform autopsy] in every case," Orenstein says. "But, that is one of the problems, doctors are not asking. Doctors are not trained to ask, and they shy away from it."
Orenstein believes it will take the involvement of the medical leadership at an institution to change physician attitudes.
"The most important person in this — since most autopsies would come from the department of medicine — would [be] the chairman of medicine or the person who runs the program. When [he or she] goes over their mortality and morbidity conferences or the deaths on the service, ask for the results of the autopsy," he says. "If the chairman asks, Well, what did the autopsy say?’ Then, the residents and the house staff know the autopsy was needed and they should have gotten it."
With the concern generated by the recent Institute of Medicine (IOM) report on the frequency of medical errors, use of the autopsy must come back into vogue for the medical community to even know how many mistakes it is making, he concludes.
"There is nobody covering this; no one is looking to see what we are missing," he states. "The IOM report mentions the estimated number of people dying each year from medical mistakes. The autopsy is the perfect way to find out the true number and to start dealing with it."
Sources
• Jan M. Orenstein, George Washington University Hospital, 901 23rd St., N.W., Washington, DC 20037. Telephone: (202) 715-4000.
• Laura Siminoff, Center for Biomedical Ethics, CWRU School of Medicine, 10900 Euclid Ave., Cleveland, Ohio 44106-4976. Telephone: (216)368-6196.
References
1. Marwick C. Pathologists request autopsy revival. JAMA 1995; 273:1,889-1,891.
2. Lundberg G. Low-tech autopsies in the era of high-tech medicine. JAMA 1998; 280:1,273-1,274.
3. Burton E, Troxclair D, Newman W. Autopsy diagnoses of malignant neoplasms: How often are clinical diagnoses incorrect? JAMA 1998; 280:1,245-1,248.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content