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Rapid Responses: Rapid Responses published:
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Obtaining consent for autopsy
- Christopher Womack (4 October 2003)
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Histopathologists should not obtain consent for autopsy.
- Simon Rose (7 October 2003)
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Autopsy Performance at a Cuban Teaching Hospital
- Alfredo Espinosa-Brito, Julian Viera-Yaniz, Osmel Chavez-Troya, Raul Nieto-Cabrera (20 October 2003)
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Personal Decision
- Michael M. Besser (19 May 2005)
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Christopher Womack, Consultant Histopathologist Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA
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This paper describes the dedicated and exemplary work of a single- handed pathologist providing parents with a pre-autopsy consultation and performing almost half of the examinations presumably in his spare time, at weekends. As the author indicates, this may not be practical in other centres for a variety of reasons not withstanding the fact that there are currently 200 consultant histopathologist vacancies in England and Wales. Whilst my colleagues and I at Peterborough might be able to provide such a consultation service for the dwindling number of adult only consent post mortems [dismal total 8 in 2002] this would create an “elite” service that we could not provide for the 500+ coroners’ cases we perform per annum, within current resource. An additional complication is that coroners’ cases fall outside the existing and proposed new NHS consultant contracts. The forthcoming October 2003 edition of the Bulletin of the Royal College of Pathologists [at www.rcpath.org] describes the successful experience of and rationale for, trained pathology specialist or liaison nurses employed in Nottingham and Peterborough. However, the posts in both centres were established with external funding. In common with many other NHS hospitals, the consultant pathologists at Peterborough provide an “on demand” service to discuss autopsy results with bereaved families. This is arguably a better use of consultant time and clinician liaison will be required in some cases. I am somewhat disturbed by the photograph chosen to accompany this paper. It is not clear whether it is a picture of a real bereaved mother or an actor. In either case I feel it does not support the positive message of the text though it does grab attention. Finally, despite the autopsy featuring in several papers and the prominence given on the front cover of this BMJ edition, the Times newspaper chose to give front page and column space to the article on hysterectomy and sexual health. I am disappointed but not surprised. Competing interests: I am paid to perform autopsies at the request of HM Coroners. Other interests are declared in BMJ 327:781-2 |
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Simon Rose, consultant histopathologist NHS, BA1 3NG
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Editor, Michael McDermott is, he accepts, in conflict with his professional bodies when he champions the idea of the consultant histopathologist being responsible for obtaining consent for autopsy (1). He describes a series of pre-autopsy meetings. These “often difficult negotiations” with families covered a high proportion of the 83 autopsies he performed in the 32 months under study. He describes these pre-autopsy meetings as usually including input from a member of clinical medical staff, a consultant pathologist, a social worker, nursing staff, +/- a chaplain. A disproportionate 46% of meetings or autopsy-related work occurred during a weekend or public holiday. He states that this work had to take precedence over other work – presumably diagnostic work for living children, and one assumes also over his family life. His enthusiasm is laudable, but he is living in a completely different and rarefied world from the rest of us. 83 autopsies in 32 months is equivalent to 31 per year. In my department we each do about 140 a year in addition to an individual diagnostic adult cytology, biopsy and resection specimen workload that is several multiples of the paediatric pathologist’s annual quota. He gives a brief nod to the fact that, at a time of an acute national shortage of adult, as well as paediatric pathologists, his suggestions are completely untenable. A cost-per-case analysis of his autopsy practice, including the costs of ancillary staff, would be informative. Even the inclusion of litigation costs over the organ retention issue could be questioned, as no amount of explanation or pre-procedure counselling will prevent a tiny proportion of relatives, whipped up by Milburn & the media, from recourse to grievance or litigation procedures, or even to making death threats to pathologists who, in good faith and with the best of motives, carried out an autopsy on their child. Many pathologists did not, and many trainees will not, enter the specialty with a desire or ability to embark on negotiations with grieving relatives and social workers. Other areas of medicine provide ample opportunity to use such skills. The clinican, who already has a relationship with the family and who can explain the clinical benefits to be derived from the results of the autopsy should request the examination if they feel that it will be of benefit to the family or future siblings. Of course the pathologist must support the clinician with training and explanation of what the procedure will entail. Simon Rose 1) McDermott MB. Obtaining consent for autopsy. BMJ.2003;327:804-6. (4 October). Competing interests: None declared |
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Alfredo Espinosa-Brito, Internal Medicine Department Hospital Dr. Gustavo Aldereguia Lima, Ave. 5 de Septiembre and Calle 51A, Cienfuegos 55 100, Cuba, Julian Viera-Yaniz, Osmel Chavez-Troya, Raul Nieto-Cabrera
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Dear Editor: We carefully read the very interesting Mc Dermott article about “Obtaining consent for autopsy” (1) and the O'Grady’s one, “Death of the teaching autopsy” (2) There is an evident modern tendency to diminish the importance of autopsy. This has been attributed to various factors: economical, legal, and little motivation among doctors, including pathologists.(2,3) A usually expressed but never proved opinion has been added with especial emphasis to the former factors, which states that the advances in sophisticated ante-mortem diagnostic methods have reduced the autopsy value. (2) In a classical paper, Goldman et al (4) found that the percentage of deaths without clinical-pathological concordance did not decreased in spite of modern diagnostic technologies. On the contrary, in certain cases these “new methods” directly contributed to mislead the diagnosis, in part to doctors’ excessive confidence in them. We briefly communicate here the strategy that we follow obtaining consent for autopsy at the Dr. Gustavo Aldereguía Lima Teaching Hospital in Cienfuegos, Cuba. This is the main center in our province for hospital care of adult patients who suffer clinical and surgical disorders. All the services, including the autopsy performance, are free of charge, as in the whole country are. With 520 beds, each year there are more than 15 000 admissions and about 1100 patients died at this hospital. Since its opening 24 years ago, autopsy was performed in more than 80% of admitted patients who died at this center. When death occurred, the autopsy consent is always voluntary obtained from the relatives, or proxy, after a detailed explanation of all benefits of the postmortem examination by the clinician(s) on charge of the patients. In case of a negative answer, a new intent is done by the Chairman of the Service or by the Chief of the medical staff on duty. Also the families are given the opportunity to ask any questions they may have about the procedure and to know the final report when it will be available. (1) In this teaching hospital, as in all like it in our country, learning from autopsy is one of the most successful activity of the Department of Pathology. Three anatomic-clinical sessions are weekly performed, where more than 50% of died patients are discussed again, few hours after their deaths, now including the first results of the postmortem examinations. Specialists, residents, interns and students from third year on, participate in these fruitful meetings. Monthly a clinical-pathological conference is performed with demonstrative cases for all the medical staff. Furthermore, when the final autopsy reports are available, all the clinical charts of patients who died at the center are reviewed and discussed again every month at the Committee of Mortality Analysis of the hospital. Causes of death in certificates can be rewritten, when errors in clinical diagnosis occurred, in order to improve our vital statistics. This is also a very useful teaching session. Finally, we think that autopsy continues being the gold standard for the diagnosis of the great majority of diseases and injuries which cause death. (3) As O’Grady, (2) we think this procedure still has a vital role in auditing medical care and it maintains an important role in the quality control of medical care, especially in teaching hospitals. 3 Fortunately, Cuban clinicians should feel able to advocate autopsies yet. We welcome all efforts to improve its practice and to disseminate its results. Sincerely, Prof. Alfredo Espinosa-Brito MD, PhD, Internal Medicine Department; Prof. Julian Viera-Yaniz MD, Pathology Department; Osmel Chavez-Troya MD, Internal Medicine Department; Raul Nieto-Cabrera MD, Internal Medicine Department. Teaching Hospital "Dr. Gustavo Aldereguia Lima",
Ave 5 de Septiembre and Calle 51A, Cienfuegos, 55 100, CUBA
References 1. McDermott MB. Obtaining consent for autopsy BMJ 2003;327:804-806 2. O'Grady G. Death of the teaching autopsy. BMJ 2003;327:802-803 3. Rosenbaum GE, Burns J, Johnson J, Mitchell C, Robinson M, Truog RD. Autopsy Consent Practice at US Teaching Hospitals. Results of a National Survey. Arch Intern Med. 2000;160:374-380. 4. Goldman L, Sayson R, Robbins S, Cohn L, Bettmann M, Weishberg M. The value of the autopsy in three medical eras. N Engl J Med 1983; 308: 1000- 1005. Competing interests: None declared |
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Michael M. Besser, Student 01810
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As with many modern day medical dilemnas, the issue of consent for autopsy would best be solved if all adults had the foresight to include provisions relating to their post-mortem wishes in their wills. Family members should not be the ones deciding anything about an autopsy on the deceased. If a person decided to donate his body to science should the family have a say in his decision? The answer is obviously no. While I understand that many cultures place high value on the preservation of the dead (which would prevent the retention of organs for autopsy purposes), these cultural traditions take second place to public health concerns and criminal investigations that may require organ retention and body "mutilation". As far as I'm concerned even when an individual makes his wishes clearly known before death the government has a right to request an autopsy if it makes a case concerning public health and/or a criminal investigation. When you die, you no longer are entitled to the same rights over your body. Although many would view this as disrespectful and controversial, in the end it would be important in fighting disease and crime. Competing interests: None declared |
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