Intended for healthcare professionals


Requesting necropsies

BMJ 1997; 314 doi: (Published 24 May 1997) Cite this as: BMJ 1997;314:1499

Greater humanity and awareness of suffering will help doctors and patients alike

  1. Jane Turner, Senior lecturera,
  2. Beverley Raphael, Director of mental healthb
  1. a Mental Health Centre, Royal Brisbane Hospital, Queensland 4029, Australia
  2. b Centre of Mental Health, New South Wales Department of Health, Locked Bag 961, Sydney 2060, Australia

    As medicine increasingly acknowledges and even welcomes the active participation of patients and their families in medical care, it is timely to investigate the attitudes of relatives towards necropsies. Any request for a necropsy is necessarily conducted at a time of greatest grief, distress, and uncertainty; and those deaths where a necropsy is required are often those where the bereavement is sudden or otherwise traumatic, and thus likely to be associated with shock, denial, and dissociation. The relatives' mental state is likely to make the request more difficult to deal with and the ultimate outcome of the loss more problematic.1 Thus, requests may be countered with anger, resentment, or rejection.

    Attitudes towards necropsy are shaped by personal and cultural attitudes towards death and medical science and by the context in which a request is made. Studies suggest that a common source of discomfort is the thought of the dead body being cut up, or the fear that the person may “wake up” during the necropsy.2 This is reflected in reasons for refusing necropsy: in one study 83% of relatives felt that “the patient had suffered enough.”3

    In a recent study Start et al suggested that this most complex of tasks is increasingly falling to junior staff.4 In addition to the obvious implications for the relatives in being asked by less experienced clinicians, this must inevitably exacerbate the stress experienced by junior staff in having to convey bad news.5

    Although medical staff may see their main task as “getting the necropsy,” the crucial thing for families is obtaining appropriate feedback about its results. Considerable delay may occur in communicating results to medical staff, let alone families,6 and one study found that only half of those who consented to a necropsy after perinatal death were satisfied with the presentation of the findings.7

    Redressing the problem requires not only a sophisticated approach to the needs of relatives, but also an understanding of doctors' own attitudes towards death, dying, and the postmortem examination. The traditional apocryphal stories about cadavers, disseminated by medical students, probably reflect an attempt to deal with the “decay, death, and dismemberment” that confront students as they embark on anatomical learning.8 A survey of medical students confirms that three quarters of them felt uneasy when they attended a necropsy or when they contemplated one on themselves.9 These reactions are no doubt tempered by the students' own experience of loss, death, and dying and any opportunity they may have had to work through these complex emotions. One under-researched cause of uneasiness among doctors may be that necropsy is seen as “the final audit”–which may not always reflect well on clinical diagnosis and management of patients.

    Clinicians' skills requesting permission for necropsy need to be improved. These skills are usually acquired haphazardly, through personal experience with a smattering of help from senior colleagues.10 Such practices not only undervalue the traumatic impact of such work on junior staff but are a failed opportunity for preventing psychological distress among the patients' family and among staff. They also perpetuate idiosyncratic or insensitive practices. There are recognised techniques for improving doctors' communication skills,11 12 but evidence suggests a need for continuing medical education rather than a one off package;13 the issue should also be addressed at an undergraduate level. Training videos and role playing situations should include messages about the emotional and traumatic impact of many of our interviews with patients. Our medical training must not be allowed to promote sophistication in biological sciences and acquisition of skills at the expense of humanity and awareness of suffering.


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