Factors which influence necropsy requests: a psychological approach

Reversing the slow death of the clinical necropsy: developing the post of the Pathology Liaison Nurse

The adult clinical necropsy has been declining for many years and is nearing extinction in many hospitals. In Norwich, to prevent this from occurring, a Pathology Liaison Nurse (PLN) was appointed, resulting in a modest reversal of the trend. In 2005, the number of adult clinical necropsies increased to 58 (clinical necropsy rate = 2.4%) from its nadir of 34 (clinical necropsy rate = 1.4%) in 2003. Moreover, consent is now much more likely to be full and to allow histopathological and other studies. The PLN ensures that consent is properly and fully obtained, in line with current legislation. She also plays an important role in arranging for feedback to be given by clinicians to the families after the examination, and in teaching and training Trust staff about death, bereavement, and related matters. This paper describes how the role of PLN was established and evaluated, and gives details of the current state of the adult clinical necropsy in Norwich.

Perinatal pathology in the context of a clinical trial: a review of the literature

Perinatal postmortem rates are declining world wide. In the United Kingdom, perinatal pathology has recently been seriously undermined by controversy. There are important consequences for perinatal trials that include pathology studies. This review looks at the reasons for the decline in perinatal postmortem examinations and the effects on research.

Who to report to the coroner? A survey of intensive care unit directors and Her Majesty's Coroners in England and Wales

We performed a postal survey to assess the ability of intensive care unit directors and Her Majesty's Coroners to recognise deaths that should be reported to the local coroner. The survey questionnaire consisted of 12 hypothetical case scenarios. Coroners were significantly better at identifying reportable deaths than intensive care unit directors (median correct recognition scores of 11 (interquartile range 9.25-11) vs. 8 (interquartile range 7-10), respectively, p < 0.01). Deaths associated with an accident, medical treatments, industrial disease, neglect and substance abuse were significantly under-reported by intensive care unit directors (p < 0.01). Results show that significant numbers of deaths on intensive care units in England and Wales may not be being referred for further investigation, and that wide variation in local coroners' practices exists. Improvements in postgraduate medicolegal education about deaths reportable to a coroner are required. National regulations need to be more detailed and standardised so that regional variation is eliminated.

Concordance between premortem and postmortem diagnosis in the autopsy: results of a 10-year study in a tertiary care center

We describe the concordance between clinical diagnoses and autopsy findings in a tertiary care center. Clinical autopsy is a useful tool for the evaluation of accuracy of the clinical diagnoses. However, autopsy rates have declined around the world recently. We randomly evaluated 500 of 2,211 autopsies performed in the department of pathology of a tertiary care hospital during a 10-year period. We computed the sensitivity, specificity, predictive values, and concordance scores between premortem and postmortem diagnoses. The autopsy diagnoses were used as the "gold standard." Four-hundred twenty-two (84.4%) of the autopsies met inclusion criteria. Diseases of the respiratory tract were diagnosed in 44.1% (186) of all autopsy reports reviewed. The higher sensitivity for diagnosis was observed in congenital anomalies (87.5%), while the higher specificity was observed in diagnosis of complications of pregnancy, childbirth, and the puerperium (98.98%). The higher concordance between premortem and postmortem diagnosis was observed with the diagnoses of neoplasms (kappa = 0.76), and for the group of complications of pregnancy, childbirth, and the puerperium (kappa = 0.76). A clinical diagnosis successfully addressed the cause of death in 40% of the cases Low values for concordance between autopsy reports and clinical diagnoses were present in most of the autopsies reports reviewed. We encourage physicians to continue considering the autopsy as an important tool that extends our understanding of diseases.

Declining autopsy rates in stillbirths and infant deaths: results from Funen County, Denmark, 1986-96

OBJECTIVE

The aim of this study was to describe the development of the autopsy rate in stillbirths and infant deaths in an 11-year period and evaluate the information gained by performing an autopsy.

METHODS

Included in the study were all stillbirths and infant deaths in Funen County, Denmark, in 1986-96. Data sources were death certificates and autopsy reports.

RESULTS

The study included 273 stillbirths and 351 deaths in infancy. The rates of stillbirth and infant death did not change significantly during the period. The overall autopsy rate for stillbirths was 70% and for infant deaths 57%. There was a significant decline in autopsy rate during the years 1991-96 as compared with 1986-90 for stillbirths, infant deaths and infant deaths excluding sudden infant death syndrome. In stillbirth, the autopsy changed the diagnosis in 9% of the cases. In 22%, the clinical diagnosis was maintained, but additional information was obtained. In infant death, the numbers were 10% and 40%, respectively.

CONCLUSION

In 10% of the autopsies the diagnosis was changed completely, with an impact on genetic counseling as well as on statistical records of causes of death in fetuses and infants. With additional information in 22-40% of the autopsies, the study emphasizes autopsy as a useful investigation.

Necropsy request practices in Jamaica: a study from the University Hospital of the West Indies

AIM

To investigate necropsy request practices at the University Hospital of the West Indies, Jamaica, to determine the extent to which these might influence the declining necropsy rates. This is the first such study from a developing country.

METHODS

The necropsy service was audited prospectively over a six month period, and data relating to non-coroner's (hospital) necropsy requests, including the clinical service and post of the clinician involved, were documented. The reasons for non-request were recorded for deaths in which a necropsy was not requested, in addition to the reasons given by pathologists for not performing necropsies in cases that were requested but not done. The overall, non-coroner's, and coroner's necropsy rates in addition to the non-coroner's necropsy request and success rates were calculated.

RESULTS

There were 364 deaths comprising 323 non-coroner's and 41 coroner's cases. The overall, non-coroner's, and coroner's necropsy rates were 29.2%, 20.2%, and 38.7%, respectively. The non-coroner's necropsy request rate was 35.3% with a success rate of 65%. Seventy five per cent of the requests were made by non-consultant clinicians and on the internal medicine service, which accounted for most of the non-coroner's deaths; necropsy requests were biased towards younger patients (p < 0.0001). Confident clinical diagnosis was the main reason for not requesting a necropsy, and the primary reason for refusing to perform a necropsy was that the request had been made too long after death.

CONCLUSIONS

These findings show a relatively high necropsy success rate in the face of a comparatively low necropsy request rate, and indicate that necropsy rates can be increased if clinicians make more necropsy requests in a timely manner in patients of all ages.

The declining autopsy rate and clinicians' attitudes

The autopsy rate has been declining worldwide for decades. This study determined the overall and differential autopsy rates for the Royal Victoria Hospital, Belfast for the years 1997-1999 inclusive. Trends were examined by comparison with previously collected data for the years 1990, 1991 and 1993. Reasons for the decline in autopsy rates as perceived by hospital clinicians were assessed by means of a questionnaire. Over the last decade, there has been a steady decline in the overall autopsy rate from 30.4% in 1990 to 18.4% in 1999. This is due to a decrease in the hospital autopsy rate from 21.6% in 1990 to 7.9% in 1999. The coroner's autopsy rate has remained comparatively unchanged at around 11%. The decline in the overall and hospital autopsy rates involves all of the principal bedholding directorates, but is most dramatic in medicine, surgery and intensive care, where hospital autopsy rates are currently 7% or less. The main reasons for this decline as perceived by clinicians are difficulty in obtaining consent from relatives and advances in modern diagnostic techniques. The findings of this enquiry are in keeping with trends elsewhere, despite repeated studies which clearly demonstrate the continuing value of the autopsy in clinical practice. Recent publicity concerning the retention of organs can only have an adverse affect. Pathologists and clinicians who value the autopsy must become actively engaged in both public and medical education. Renewed emphasis must be placed on the importance of the autopsy in teaching, training and clinically relevant research, and as a means of medical audit.

Clinician beliefs underlying autopsy requests

The aim of the study was to use psychological theory to identify and evaluate factors influencing clinical autopsy requests. A series of pilot interviews were conducted with 20 clinicians to identify beliefs about the benefits and drawbacks, social groups and circumstances influential in the decision to make an autopsy request. The most common beliefs, together with measures of intention to request autopsies, were incorporated into a questionnaire which was distributed among all appropriate clinicians in four hospitals. Statistical analyses identified which beliefs had the most influence on clinicians' intentions to request autopsies. A total of 145 clinicians returned the questionnaire, a response rate of 42%. Clinicians were significantly more likely to request autopsy the more they thought that the outcome of requesting would be of educational value, would confirm clinical diagnoses, would not distress relatives, would not be time-consuming and that the request itself would receive support from their consultant. An autopsy request was unlikely in circumstances where clinicians felt uncomfortable when requesting relatives' permission and when the patients were elderly. The fear of causing distress to relatives and the degree of support from the clinician's consultant were found to be the strongest predictors of intention to request autopsies. These are two areas in which intervention could help to increase autopsy request rates.

Funeral directors, mortuaries and necropsies: implications for necropsy consent rates and the prevention of infection

AIM

To evaluate the attitudes and experiences of funeral directors in relation to necropsies.

METHODS

All 1631 members of the National Association of Funeral Directors were surveyed by postal questionnaire about the purposes of necropsies, the technical and administrative problems associated with necropsied cases and their relations with relatives, mortuaries and pathology departments.

RESULTS

In total, 123 funeral directors completed the questionnaire (8% response rate). Workload, proportion of cases necropsied and type of mortuary did not influence answers. Necropsies were considered important for the assessment of treatment outcome, identification of inherited disease and junior pathologist training, but not for medical audit. There was strong support for more education about necropsies. The areas of necropsy practice most frequently discussed with relatives related to concerns about funeral delay and the involvement of the coroner or equivalent authority. Funeral directors occasionally counselled relatives for or against giving necropsy consent. The commonest technical problems associated with necropsies were difficulties in embalming, leakage of body fluids and scalpel penetration in visible areas. Few administrative problems were reported; the commonest was inflexibility in body collection times. There was strong support for a national code of practice to cover relations between funeral directors and mortuaries despite general satisfaction with relations with local pathology departments.

CONCLUSIONS

Although the relation among the funeral profession, mortuaries and pathology departments is largely satisfactory, a national code of practice for funeral directors and mortuaries is desirable.

Asking relatives for permission for a post mortem examination

This article discusses the possible aims, benefits, and also the content, format and timing of training in one specific aspect of clinical practice; how to request permission for post mortems.

How do clinicians learn to request permission for autopsies?

A postal survey of 434 clinicians at four local hospitals was undertaken in order to identify the methods by which clinicians learn how to request permission for hospital autopsies and to assess the preferred techniques and timing of relevant communication skills training. The majority of 128 responding clinicians had learnt through personal experience with some assistance from senior colleagues and peers. Few clinicians appeared to have learnt through formal training. The preferred methods for the provision of communication skills training were training in small groups (such as seminars or tutorials) and observation of clinicians at work. The most desirable time for the provision of this training was considered to be between the beginning of the final undergraduate year and the end of the pre-registration house officer year. The communication skills training provided within medical education is in need of improvement. More emphasis should be given to clinical-task- or situation-specific applications such as requesting permission for autopsies.

Diagnosis of malignant tumor: comparison between clinical and autopsy diagnoses

A review was made of the results of 1,036 consecutive autopsies (average patient age, 75 years; 617 male and 419 female patients; autopsy rate, 40.2%) done at the Hospital of Monfalcone from January 1986 through December 1991. In 457 autopsies (44%) one or more malignant neoplasms were found (single tumor in 382, dual tumor in 69, and triple tumor in six) for a total of 538 tumors. In the corresponding death certificates the clinical diagnosis of malignancy was found in 302 autopsies for a total of 310 tumors (single in 294 and dual in eight). The number of clinically unrecognized malignancies was 228 (42%) and the number of patients with undiagnosed tumors was 155 (34%). The neoplasms were subdivided into four stages according to their extension at autopsy: stage 0 (85 tumors), microscopic neoplasm; stage I (146 tumors), neoplasm localized at the site of origin; stage II (43 tumors), local advanced neoplasm; and stage III (264 tumors), neoplasm with metastases. The rate of correct clinical diagnoses increased according to the level of stage; (stage 0, 1%; stage I, 40%; stage II, 58%; and stage III, 66%). The greatest numbers of tumors found at autopsy were located in the gastroenteric apparatus (170), the respiratory apparatus (149), and the urogenital apparatus (130). The number of clinically undiagnosed neoplasms was high with respect to the urogenital apparatus (77% overall and 51% excluding stage 0) and the gastroenteric apparatus (41% and 38% excluding stage 0); in contrast, the number was low for the respiratory apparatus (17%). The rate of correct diagnoses was higher in patients younger than 65 years (65%) than in those older than 65 (54%), but the difference was not significant. The duration of hospitalization in the 12 months before death was statistically higher (P < .001) in patients with a correct diagnosis (36 days) than in undiagnosed patients (14 days). Even taking into account the biases that affect selection of patients for autopsy, the notable discrepancy found between clinical and autopsy diagnoses underlines the fact that autopsy, despite improvements in diagnostic techniques, maintains its fundamental importance in assessing the reliability of clinical diagnoses and furthermore shows the underestimation of the incidence of tumors in epidemiological studies based solely on death certificates.

Attitudes of senior pathologists towards the autopsy

The attitudes of 205 consultant British pathologists in four regions were assessed by a postal questionnaire in which they were asked to indicate their level of agreement with 15 statements relating to autopsies. A total of 144 pathologists completed the questionnaire (response rate 70 per cent). Senior pathologists strongly agreed with statements relating to the importance of autopsies within pathology workloads, medical audit, and accreditation for training posts. There was strong support for the attendance of clinicians at autopsy demonstrations and for the suggestion that material from medico-legal autopsies should be made available for teaching and research. There was strong disagreement with the suggestions that advances in diagnostic techniques have diminished the role of autopsies, that performing autopsies does not further pathologists' education, that the cost of autopsies may not be justifiable within a limited budget, and that the autopsy should no longer be part of the MRCPath examination. These results are discussed in the context of the current status of the autopsy in general.

Clinical necropsy rates during the 1980s: the continued decline

The trends in necropsy rates during the 1980s in three groups of British teaching hospitals in Leicester, Manchester, and Sheffield were compared in a retrospective study. The clinical necropsy rates declined in all three cities: in Leicester, from 16 to 10 per cent; in Manchester, from 14 to 8 per cent; and in Sheffield from 18 to 11 per cent. The medico-legal and overall necropsy rates showed variable trends between the cities. Specific events and changes in organization during the review period were correlated with the changing trends. The observed trends emphasize the continued decline in clinical necropsy rates over the last decade and illustrate the importance of monitoring differential necropsy rates.

Clinicians and the coronial system: ability of clinicians to recognise reportable deaths

OBJECTIVE

To assess the ability of clinicians to recognise deaths which require referral to the coroner.

DESIGN

Postal questionnaire consisting of 16 fictitious case histories, 14 of which contained a clear indication for referral to the coroner.

SETTING

Large teaching hospital. Coroner's office.

SUBJECTS

200 clinicians from general medical and surgical firms and senior staff of the local coroner's office (two coroner's officers and the two deputy coroners).

MAIN OUTCOME MEASURES

Number of correct assessments on questionnaire.

RESULTS

The mean recognition score for the clinicians was 9.11 (range 3-14) with no difference between the clinical grades. All of the coroner's senior staff recorded maximum recognition scores of 16.

CONCLUSIONS

The study highlights several features of the coronial system which are poorly understood by clinicians and provides the basis for an initiative to improve the medicolegal education of all clinicians.

Physicians' attitudes to the autopsy

The overall autopsy rate (excluding coroner's autopsies) at a large teaching district general hospital over a four year period was 16.5%, but individual rates for ten general physicians varied from 5% to 35%. During this period, the mean autopsy rate for general medicine (14%) was significantly lower than rates for cardiology (21%), geriatrics (23%) and paediatrics (36%), but similar to general surgery (13%). Autopsies were widely perceived as being of benefit to education and research, but physicians were often unaware of their value for confirming the diagnosis and for clinical audit, and over-estimated their actual autopsy rates on average by 50%. High rates (18-30%) were associated with consultants who had a definite policy regarding autopsies and had made this clear to their junior staff. Low rates (6-10%) obtained where there was no consultant policy on autopsies, and were frequently attributed by the consultant physicians to failure by their junior staff. Physicians should be more aware of the value of autopsies, and should take responsibility for increasing and monitoring autopsy requests to improve clinical audit, quality assurance and medical education.