The role of autopsy in the medical profession is difficult to overestimate. Western medicine takes its roots from comparative studies between patient’s symptoms and the findings on autopsy.
Participation in an autopsy was one of the most valuable lessons from medical school and residency. If you participated in the patient’s care, there is no greater educational tool than witnessing the postmortem exam. It is especially true if the cause of death was unclear. And even when you are sure what the patient died from, getting insight into how things look inside our bodies is still useful.
The rate of performing autopsies in the United States and worldwide has been declining for decades. There are multiple factors, both on the patient’s family and the healthcare provider sides, which contribute to this decline.
Some argue that with the improvement of the imaging technology the diagnosis and the cause of death are more certain in most cases. Yet, the studies find that there is disagreement between pre and post-mortem diagnoses in almost 30% of cases.
Unless the autopsy is mandated by the coroner — typical for homicides, suicides and cases with unclear cause of death, the attending physician has to obtain consent for the autopsy from the family. A study conducted in Ireland shows increasing physician’s reluctance to obtain consent.
Some of the physicians are concerned about the legal aspect of an autopsy and are afraid of being subjected to a lawsuit if the autopsy is conducted. Once again, research shows that there are, actually, fewer lawsuits filed after the deceased had an autopsy. It was shown that even in the cases of disagreement with the pre-mortem diagnosis, the family is less likely to file a lawsuit. It seems to provide the family with closure after the death of their loved one.
Many physicians cite family’s refusal to provide consent for an autopsy as one of the biggest obstacles. Several studies focused on the patients families’ attitudes toward an autopsy.
Many families do have concerns for the body integrity after an autopsy. Some families are afraid that an open casket burial is simply not possible after an autopsy. The families should be educated in these cases that autopsy performed in a respectful manner with no disfigurement to the body and that an open casket funeral is still possible. The concerns that the funeral is going to be delayed are generally not true as well.
Interestingly enough, it was found that the patients from more affluent and educated families are more likely to undergo autopsy than the patients from less fortunate families. Some researchers, though, suggested that the difference could be explained by a higher rate of possession of automobile and life insurance among affluent patients. Some insurance policies require an autopsy before the payment is made.
In terms of the relationship between race, ethnic background and the rate of autopsy, the data is somewhat contradictory. Some studies state that the patients of African-American and Hispanic origins receive autopsies more often. Same studies suggest that the difference could be explained by a higher rate of homicides and violent crimes among these groups, which leads to coroner mandated autopsies. Some researches also suggested that a general mistrust to the medical profession among African-American and Hispanic families leads to a higher rate of requests for an autopsy.
Other studies found the exact opposite connection between race and the rate of autopsy.
There are, obviously, religious concerns as well. Most religions, though, do allow autopsies one way or another.
Simply practical concerns and the refusal of the major insurance companies to cover autopsy contributes to the decline as well. If the patient dies in the hospital, the autopsy is often free to the family and the hospital pays the bill. If the patient dies at home or at a nursing home, the autopsy can cost the family as much as $2000.
There are many other factors that contribute to the decline in the rate of autopsy. It is simply beyond the scope of this post to cover them all. Autopsy is a valuable education and research tool and the training of the future generation of doctors might simply not be complete without it.
Ralph Gordon is a critical care physician who blogs at realICU.
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