The decision to do a postmortem examination of human remains often involves tension among several compelling interests: the goals of the physician (medicolegal, scientific, educational, or clinical), the wishes of surviving friends and family (informed by prevailing religious and societal norms), and the interests of society (as articulated by the law). All 3 will factor into each autopsy request. All 3 will contribute to the climate within which the request is made. Before discussing the mechanics of requesting an autopsy, it is worthwhile to take a closer look at some of these interests. Physicians Physicians may feel that the entire uncomfortable situation can be avoided in their hospitalized patients, because so much clinical, laboratory, and radiographic information has already been gathered. In short, they may feel that the diagnoses are already well established and the autopsy is unnecessary. This belief is not supported by the published data (see below). In cases in which the diagnoses are less certain, the medical staff may be concerned about litigation, and they may worry that the results of an autopsy may actually hurt them. Surprisingly, perhaps, many pathologists are no more interested in autopsies than their clinical colleagues. Autopsies are unpleasant to perform. The procedure itself, the selection of tissue for histology, the review of the slides, and the report writing involve a substantial investment in time (see The Autopsy Report). And, unlike surgical pathology specimens or cytology specimens, most hospital pathologists are not directly reimbursed for their work on autopsies. In short, there is any number of compelling reasons for a physician not to request permission for an autopsy. Surviving friends and family The topic of autopsy may be equally awkward for the family of the deceased. It can seem like a rude and insensitive request, and it comes, of necessity, at an extremely difficult time. Family members often have questions about the autopsy procedure and its effects on funeral arrangements. What does the procedure entail? Will the remains be treated with dignity? Will the body be rendered unsuitable for viewing? Will the autopsy delay the funeral arrangements? How useful will the results of the autopsy be? When will the results be available? How much will the autopsy cost? Studies have shown that the requesting physicians, many of whom have received no training in obtaining consent for an autopsy, may not be prepared to answer such questions. For many bereaved families, religion can be a source of answers and solace. Although very few religions completely ban all autopsies, some religious traditions place a strong emphasis on the inviolability of human remains and view anything much more than ritual cleaning of the body as a desecration (see Religions and the Autopsy). In some strict interpretations of Judaism and Islam, for example, sacrilegious practices include embalming, cremation, organ harvest for transplant, and the use of cadavers for anatomic demonstrations. Not surprisingly, some of these orthodox branches specifically prohibit autopsies except under extraordinary circumstances, usually in criminal cases.2 Extremely well-organized Jewish philanthropic groups (such as Zaka in Israel and Misaska in the United States) are devoted to all matters surrounding death, and one of their stated purposes is to assist families who are opposed to an autopsy.3 In summary, without some guidance from the medical staff, the family may not see any good reason to grant permission for an autopsy. Society Apart from the benefits to the family and physicians, autopsies offer several concrete benefits to society (eg, medical quality assurance and accurate mortality statistics; see Quality Control Metrics). In a few countries these societal benefits are seen as crucial, and the law reflects this. For example, in Austria (where autopsy enjoyed its apotheosis in the 1800s) the law permits nonforensic autopsies to be done without the consent of next of kin in cases in which there is a clear medical, educational, or scientific interest.4 Some Scandinavian societies have also promoted the practice of autopsy pathology. Societal support for the autopsy in the US has waxed and waned over the years. At the end of the 1800s, academic medical schools in the US were staffed by physicians who had received part of their training in Europe and borrowed from the Austrian model of medical education. Autopsy pathology in the US was further bolstered in 1910 by the release of the Flexner Report. The report was harshly critical of the state of US schools in general, but it singled out as notable exceptions schools such as the Johns Hopkins Medical School, where the autopsy and the clinicopathologic correlation were a crucial component of training. Against this backdrop, this article will present an overview of the elements involved in obtaining consent for a postmortem examination in the US. The discussion will, of necessity, be general, because the applicable laws can vary significantly from one state to the next. When in doubt, the reader is advised to consult their hospital's legal counsel or another attorney who is familiar with local statutes. One constant aspect of the law regarding autopsy is the distinction between 2 classes of autopsy -- medicolegal or forensic autopsies and medical autopsies. Medicolegal autopsies will be considered first. Every state has some government apparatus (coroner's office or medical examiner's office) that is charged with the investigation of "unnatural" deaths. This is generally felt to include the death of any person not under a doctor's care. It always includes cases of death by homicide, suicide, or accident. Society, and therefore the state government, is felt to have a compelling interest in such cases. Consequently, although coroners and medical examiners make every reasonable effort to respect the wishes of family members, no permission from next of kin is required for the performance of medicolegal autopsies. If families do have religious objections, they may argue their case in court, but the interests of society are usually given priority. In 2009, the United Kingdom approved the use of so-called radiographic autopsies as an option in some such cases.7 Laws governing consent for autopsy in the US vary somewhat from state to state, but all address the same crucial issues, as follows8 : Cabot, in his landmark paper of 1912, demonstrated what he characterized as a humbling rate of discrepancy between premortem diagnoses and anatomic diagnoses found at autopsy.10 These included a significant rate of major diagnostic discrepancies. Subsequent studies have shown surprisingly little change in these rates with time,11,12,13 although at least some authors have questioned the methodology of those studies.14 Autopsy Request Process
Background
Physicians are generally comfortable asking for permission to perform all types of invasive, uncomfortable, and sometimes risky diagnostic and therapeutic procedures on their patients. It is part of their everyday work. Such procedures fit neatly into a physician's mission of improving and prolonging the lives of patients. Many physicians, however, are much less comfortable approaching a grieving family after a patient's life has ended to ask for permission for an autopsy. There is, obviously, no benefit to the patient. And the benefits to the family, the medical community, and the community at large (although very real) may not be immediately apparent.
The process of approaching a family for an autopsy can feel awkward and is something that many physicians feel ill-prepared for.1 Thus, like many other tasks that are perceived as less desirable, the task of asking for permission for an autopsy often rolls downhill to the most junior members of the medical staff (see Autopsy Rate and Physician Attitudes Toward Autopsy).
The payment generally comes as part of an annual lump fee for the pathologists' performance of administrative services (laboratory management, educational activities, committee meetings, etc) for the hospital. Under such an arrangement, a group of pathologists receives the same reimbursement whether they do autopsies daily or once a year. This lack of enthusiasm for performing autopsies combined with the more immediate demands of signing out surgical pathology and cytology specimens often translates into delayed autopsy reports.
Interestingly, although the rate of hospital autopsies has fallen in most Italian hospitals, the University Hospital in Trieste has an autopsy rate of about 80%. This may be due to the fact that before the unification of Italy, the city of Trieste was part of the Austro-Hungarian Empire and subject to Austrian law.5 At the opposite end of the spectrum are societies like the Maldives, a country in which civil law adheres closely to Islam. There, the first autopsy was not performed until 1997, and it required the importation of a foreign pathologist.6 Most countries fall somewhere between these 2 extremes.
The Joint Commission on Hospital Accreditation was founded in 1951 and, as part of an effort to improve the quality of care, set a minimum hospital autopsy rate of 20% for hospitals. For a time autopsies enjoyed the support of medical educators, hospital administrators, and regulators, and in the years after the Second World War the autopsy rate in the US rose to almost 50%. But what began as a gradual decline in the 1960s turned into a drastic plunge in 1970 when the Joint Commission did away with the 20% minimum hospital autopsy rate. Most estimates place the current autopsy rate at about 10% in academic hospitals and at 5% or less in community hospitals.Consent for Medicolegal Autopsies
All medical autopsies in the US require the permission of the next of kin. The elements that go into a proper legal consent for autopsy will be discussed in the next section of this article.Consent for Medical Autopsies
Although all valid autopsy permits will address these questions, individual institutions are given some latitude in how they accomplish this. Some autopsy permits consist of a single page or less. (An example can be found on the Website for the College of American Pathologists at
http://www.cap.org/apps/docs/committees/autopsy/sample_autopsy_consent_form.pdf)
Notice that the questions surrounding tissue disposition are addressed generally. Specific questions about which tissues are retained, how long they are retained, and how they are eventually disposed of are not addressed in detail; rather, they are left to the discretion of the pathologist. Likewise, the issue of autopsy limitations is addressed in a general fashion, and a space is provided if the next of kin wants to list any specific limitations. Other permission forms are much more elaborate and deal with the above issues in much greater detail. The consent autopsy permit used in New Mexico, for example, runs 8 pages in length. Although consent for organ donation or use of tissue for research purposes must be obtained separately from consent for an autopsy, some permission forms will provide space for all 3 on the same page.
The permission form must be completed by the deceased's legal next of kin, signed, and witnessed. In some states, if written permission cannot be obtained in a timely manner, then the next of kin can grant permission by phone or fax, again, with an appropriate witness.
Next of kin
The next of kin is usually the individual who is legally responsible for the disposition of the remains of the deceased. Below is a widely accepted list of family members, in order of priority, who are legally authorized to grant permission for an autopsy:
The person highest on the list is considered the legal next of kin and is the person from whom permission must be obtained. This list may vary slightly from state to state. When there is more than one adult child, some states require consent from only one, whereas other states require permission from all the siblings. If in doubt, it is best to consult your state's statutes or your hospital's risk management department.
People authorized to perform/attend an autopsy
In most cases, medical autopsies are performed in the hospital where the deceased was pronounced dead or where the individual had received care in the past. The autopsy is usually done by a pathologist on that hospital's staff. This arrangement provides the pathologist easy access to pertinent medical records and to the attending physician(s) for consultation before and after the autopsy. Under these circumstances, the autopsy is usually performed without charge to the family.
Occasionally, the family may object to the involvement of the hospital and its pathologists in the autopsy. In such instances they have the right to arrange for their own autopsy. In fact, some states (eg, Connecticut) require that the next of kin be expressly toldof their option to have the autopsy done by an outside pathologist or at a different facility. Such arrangements must be made by the next of kin and usually involve a fee for the transport of the remains (if necessary) and the performance of the autopsy. Some states may also require that the next of kin be informed of their right to have a physician of their choice present as an observer during the performance of the autopsy.
Limitations on the autopsy procedure
Often, restrictions will result from concerns that the autopsy will render the body unsuitable for viewing. The family should be reassured that a properly performed standard autopsy will not leave any visible trace and that funeral arrangements will not be significantly changed. That said, the next of kin has the right to place any restrictions they wish on the autopsy procedure. Such wishes must not only be respected (eg, if an autopsy is limited to the abdomen only, it is not permissible to access the thoracic contents through the abdominal incision) but also clearly documented in writing on the autopsy permission form. In one notable case, a decedent's next of kin successfully sued the hospital and members of its staff for the mental suffering that resulted when a limited autopsy was performed through an incision that was longer than was verbally agreed upon at the time of consent.9
Disposition of tissue
In most cases in which permission for an autopsy is granted, the disposition of the tissues removed and examined is left up to the pathologist. All or some of the tissue may be returned to the body cavity for burial, retained for teaching or research purposes, or disposed of as biohazardous material. However, the next of kin may decide against any of these options, and in some states, they must be specifically told of their right to do so. Although all autopsy permits must address this question, it becomes particularly important when dealing with families whose religious beliefs require the burial of the body in as intact and complete a state as possible (eg, Orthodox Jews, Native Americans).
Breakdowns in communications in such instances have resulted in legal action against the pathologist (eg, Waseta versus the New Mexico Office of the Medical Investigator (OMI). Note: the second link takes a little time to load: http://legis.state.nm.us/Sessions/05%20regular/firs/HB0987.html andhttps://www.aaanativearts.com/article461.html). (Autopsy communications will be discussed in separate article.)Obtaining Consent
It seems clear that despite advances in medical technology and medical imaging, the autopsy still provides diagnostic information that cannot be obtained by any other means. Furthermore, when asked, most physicians agree that the autopsy is still an important diagnostic, educational, and quality-assurance tool.15 And yet the decline in the autopsy rate in the US and across the world has been well documented.16,17
Authors have offered a variety of plausible explanations for this decline in autopsy rates, some of which are outlined above, but it is self-evident that the number of autopsies cannot increase unless the number of requests for autopsies does. Several studies have shown that, if asked for permission, about one third of families agree, another one third flatly refuse, and the remaining one third refuse initially but agree after their questions about the procedure are answered.15,18 With the autopsy rate in the US hovering at around 5%, it seems clear that most families are not being offered the option of an autopsy.
If this trend is to be reversed, the obvious place to start is with the house staff who actually request permission for autopsies. If we are going to delegate this difficult task to our physicians-in-training, then we must convince them that we support them. One of the most important predictors of a resident's willingness to request permission for an autopsy in one study was the perception that the attending staff was genuinely interested in the autopsy and the autopsy rate.18
Ideally, before house staff are sent out to broach this sensitive subject with bereaved family members, they should be properly oriented and armed with information. Residents at one hospital felt that written materials would be a useful reference (eg, the College of American Pathologists' document on requesting permission for an autopsy:http://www.cap.org/apps/docs/committees/autopsy/requesting_consent.doc.15 At another hospital, the institution of formal instruction for the senior residents in requesting autopsies resulted in a 17% increase in the autopsy rate.19
Pathologists should also get involved. Most pathologists agree that autopsies are valuable -- especially if done by someone else. Too often the grudging performance of an autopsy that is viewed as a distasteful obligation translates into a half-hearted, significantly delayed finished product -- the sort of thing that is sure to undo any enthusiasm clinicians may have for requesting an autopsy in the first place.
It is not sufficient for pathologists to be the passive recipients of whatever autopsies come our way. In order for families, the medical profession, and society to realize the considerable potential benefits of a renewed interest in the autopsy, pathologists have to take an active role: by consulting with our clinical colleagues, by providing informative and timely preliminary and final autopsy reports, by participating in collaborative conferences for the attending physicians and house staff, and by supporting efforts by professional organizations to lobby the government for changes that will help reverse decades of neglect.
Sunday, October 17, 2010
Labels: Autopsy Request Process
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