Autopsy of Adult Patients Deceased in an Academic Hospital: Considerations of Doctors and Next-of-Kin in the Consent Process

Efficacy of postmortem CT and tissue sampling in establishing the cause of death in clinical practice: a prospective observational study

AIMS

The aim of this study is to evaluate whether agreement with autopsy-determined cause of death (COD) increases by use of postmortem CT (PMCT) or PMCT in combination with postmortem sampling (PMS), when compared with clinical assessment only.

METHODS

This prospective observational study included deceased patients from the intensive care unit and internal medicine wards between October 2013 and August 2017. The primary outcome was percentage agreement on COD between the reference standard (autopsy) and the alternative postmortem examinations (clinical assessment vs PMCT or PMCT+PMS). In addition, the COD of patient groups with and without conventional autopsy were compared with respect to involved organ systems and pathologies.

RESULTS

Of 730 eligible cases, 144 could be included for analysis: 63 underwent PCMT without autopsy and 81 underwent both PMCT and autopsy. Agreement with autopsy-determined COD was significantly higher for both PMCT with PMS (42/57, 74%), and PMCT alone (53/81, 65%) than for clinical assessment (40/81, 51%; p=0.007 and p=0.03, respectively). The difference in agreement between PMCT with PMS and PMCT alone was not significant (p=0.13). The group with autopsy had a significantly higher prevalence of circulatory system involvement and perfusion disorders, and a lower prevalence of pulmonary system involvement.

CONCLUSION

PMCT and PMS confer additional diagnostic value in establishing the COD. Shortcomings in detecting vascular occlusions and perfusion disorders and susceptibility to pulmonary postmortem changes could in future be improved by additional techniques. Both PMCT and PMS are feasible in clinical practice and an alternative when autopsy cannot be performed.

Concordance between MITS and conventional autopsies for pathological and virological diagnoses

In pandemics or to further study highly contagious infectious diseases, new strategies are needed for the collection of post-mortem tissue samples to identify the pathogen as well as its morphological impact. In this study, an ultrasound-guided minimally invasive tissue sampling (MITS) protocol was developed and validated for post-mortem use. The histological and microbiological qualities of post-mortem specimens were evaluated and compared between MITS and conventional autopsy (CA) in a series of COVID-19 deaths. Thirty-six ultrasound-guided MITS were performed. In five cases more, specimens for histological and virological examination were also obtained and compared during the subsequently performed CA. Summary statistics and qualitative interpretations (positive, negative) were calculated for each organ tissue sample from MITS and CA, and target genes were determined for both human cell count (beta-globin) and virus (SARS-CoV-2 specific E gene). There are no significant differences between MITS and CA with respect to the detectability of viral load in individual organs, which is why MITS can be of utmost importance and an useful alternative, especially during outbreaks of infectious diseases.

Cause of death and the autopsy rate in an elderly population

Autopsy rates are declining, while major discrepancies between autopsies and clinical diagnoses remain. Still, little is known about the impact of suspected underlying diseases, for example, a diagnosis of cancer, on the autopsy rate. The aim of this study was to investigate the relation between the clinical cause of death, a history of cancer, and the medical autopsy rate using data from the Netherlands Cohort Study on Diet and Cancer (NLCS), a large prospective cohort study with a long follow-up. The NLCS is a prospective study initiated in 1986 and includes 120,852 persons (58,279 males and 62,573 females), 55-69 years of age at the time of enrollment. The NLCS was linked with the Dutch Nationwide Pathology Databank (PALGA), the Dutch Population Register (GBA), the Netherlands Cancer Registry, and the causes of death registry (Statistics Netherlands). If applicable, the 95% confidence intervals were calculated. During the follow-up of the NLCS, 59,760 deaths were recorded by linkage with the GBA from 1991 until 2009. Of these, a medical autopsy was performed on 3736 deceased according to linkage with PALGA, resulting in an overall autopsy rate of 6.3%. Major variations in the autopsy rate were observed according to the cause of death. The autopsy rate increased according to the number of contributing causes of death. Lastly, a diagnosis of cancer affected the autopsy rate. The clinical cause of death and a history of cancer both influenced the medical autopsy rate in a large national cohort. The insight this study provides may help clinicians and pathologists counteracting the further downfall of the medical autopsy.

Student nurses' end-of-life and post mortem care self-efficacy: A descriptive study

BACKGROUND

Student nurses providing end-of-life care reported that caring for a person dying created anxiety, fear, and increased stress and reflected low self-efficacy. New nurses felt unprepared academically and emotionally. High self-efficacy is necessary to handle adverse emotional reactions. However, the literature lacks an instrument to evaluate nursing students' self-efficacy in caring for someone who is dying.

OBJECTIVE

The study aims to investigate the reliability and validity of the "End-of-Life and Postmortem Self-Efficacy Scale" and explore nursing students' self-efficacy associated with the nursing duties and responsibilities of caring for individuals during the active phase of dying and immediately after death.

DESIGN

The study was a quantitative descriptive, cross-sectional design.

PARTICIPANTS

National Student Nurses' Association members enrolled in undergraduate registered nurse associate's, bachelor's degree programs, or a nursing diploma program.

METHOD

National Student Nurses' Association members responded to an electronic survey containing 18 items related to end-of-life and post mortem nursing responsibilities.

RESULTS

A total of 498 responses were analyzed. Cronbach's alpha (α = 0.938) showed high reliability of the 18 items on the instrument. The Kaiser-Meyer-Olkin was 0.925 and indicated sampling adequacy. Bartlett's test of sphericity was highly significant (p = .001). The nursing students' mean end-of-life and post mortem self-efficacy score was 62 (scale of 0-100).

CONCLUSION

The "End-of-Life and Postmortem Self-Efficacy Scale" showed high reliability in evaluating the latent concept of end-of-life and post mortem self-efficacy. The low mean self-efficacy score indicated that nursing students might be underprepared to provide EOL and post mortem care as new graduates. Faculty can use the "End-of-Life and Postmortem Self-Efficacy Scale" to assess student readiness and identify gaps in knowledge in the care of someone who is dying. Future research is needed to determine how increasing nursing students' end-of-life and post mortem self-efficacy influences the perception of end-of-life preparedness.

SOX-1 antibodies in a patient with Crohn's disease: a case report

BACKGROUND

The anti-SOX-1 antibodies have been mainly associated with Lambert-Eaton Myasthenic Syndrome (LETMS) and Small-Cell Lung Cancer (SCLC). In this report, we describe the interesting case of a patient with serum anti-SOX-1 antibodies and Crohn's Disease (CD) with ensuing neurological symptoms.

CASE PRESENTATION

A Caucasian 67-year-old female was admitted to the Emergency Department with seizures, vertigo, emesis, nausea, postural instability and recurrent falls, over a period of 10 days. She had been affected by Crohn's Disease since 1991. A CT scan failed to detect any ischemic or haemorrhagic lesion. A brain MRI revealed signs of leukoencephalopathy. Western blot analysis of her serum revealed a high titre of the onconeural antibody anti-SOX1, consistent with a neurological, cerebellar type, paraneoplastic syndrome. In spite of multiple efforts to unmask a possible underlying malignancy, no neoplastic lesion cropped up during hospitalization. Her clinical conditions progressively deteriorated, up to respiratory failure; a few days later she died, due to ensuing septic shock and Multiple Organ Failure.

CONCLUSIONS

Our experience may usher and reveal a new role of anti-neural antibodies, so far reckoned an early indicator of associated malignancy, suggesting that neurological syndromes associated with such antibodies may complicate also chronic Gastrointestinal (GI) diseases. As of now, testing for anti-neuronal antibodies appeared unnecessary within the diagnostic assessment of gastroenterological disorders, which may lead to overlooking incident neurologic autoimmune diseases. Further exploration of such research hypothesis in clinical grounds appears intriguing.

Lack of Early Etiologic Investigations in Young Sudden Cardiac Death

BACKGROUND

Since majority of sudden cardiac arrest (SCA) victims die in the intensive care unit (ICU), early etiologic investigations may improve understanding of SCA and targeted prevention.

METHODS

In this prospective, population-based registry all SCA admitted alive across the 48 hospitals of the Paris area were enrolled. We investigated the extent of early etiologic work-up among young SCD cases (<45 years) eventually dying within the ICU.

RESULTS

From May 2011 to May 2018, 4,314 SCA patients were admitted alive. Among them, 3,044 died in ICU, including 484 (15.9%) young patients. SCA etiology was established in 233 (48.1%) and remained unexplained in 251 (51.9%). Among unexplained (compared to explained) cases, coronary angiography (17.9 vs. 49.4%, P<0.001), computed tomography scan (24.7 vs. 46.8%, P<0.001) and trans-thoracic echocardiography (31.1 vs. 56.7%, P<0.001) were less frequently performed. Only 22 (8.8%) patients with unexplained SCD underwent all three investigations. SCDs with unexplained status decreased significantly over the 7 years of the study period (from 62.9 to 35.2%, P=0.005). While specialized TTE and CT scan performances have increased significantly, performance of early coronary angiography did not change. Autopsy, genetic analysis and family screening were performed in only 48 (9.9%), 5 (1.0%) and 14 cases (2.9%) respectively.

CONCLUSIONS

More than half of young SCD dying in ICU remained etiologically unexplained; this was associated with a lack of early investigations. Improving early diagnosis may enhance both SCA understanding and prevention, including for relatives. Failure to identify familial conditions may result in other preventable deaths within these families.

Autopsies and quality of cause of death diagnoses

Objective:

The consequences of a low autopsy rate are not considered in determining the cause of death.

Method:

We have analyzed the Cause of Death Register of the Swedish National Board of Health and Welfare since it started 1969 to and including 2016 to visualize the decline in the frequency of clinical autopsies over time and evaluated the effect on the quality of the cause of death diagnoses.

Results:

Over the five decades studied, the frequency of clinical autopsies declined from almost 40% to less than 5%. The rate of decline was not even. Political decisions and changes of healthcare organization in Sweden affected the slope of decline of autopsies superimposed on a linear decline over time reflecting changes in clinical routines. A request of clinical autopsies was highly dependent on the level of care at the time of death, with the lowest number of requests for persons who died in nursing homes. The age at the time of death was a major factor affecting the number of autopsies, resulting in an autopsy rate of less than 1% in the ages where most persons die. Although men were autopsied more often than women, a gender-specific difference was not seen after correction for the age of death. We also found a higher rate of unspecific and irrelevant diagnosis in the cases not autopsied and we know from earlier studies by us and other authors that the cause of death diagnoses were missed in between 30% and 50% of the cases not autopsied.

Conclusion:

The decline in the clinical autopsy rate reduced the value of the death certificate register. An increase in the number of autopsies performed will improve the understanding of disease and cause of death, as well as to better inform next of kin.

At the limits of patient autonomy: an ethical re-evaluation of coroner's postmortems

Patient autonomy is one of the four pillars of modern medical ethics. In some cases, however, its value is not absolute and autonomy may be overridden by sufficiently important matters of public interest. Coroner's autopsies represent an example of when the wishes of the deceased and their family may come in conflict with the benefits of knowledge gained from understanding the cause of death. Current legislation governing coroner's autopsies relies on the assumption of their obvious public benefit, hence consent for them need not be sought. This interpretation has attracted controversy, as exemplified by the case of Rotsztein vs HM Senior Coroner and a recent study questioning the prevalent use of invasive autopsy. However, this issue has received little recent attention in ethical literature. In this essay, the ethical nature of coroner's autopsies in cases of natural deaths with unexplained causes is examined as a balance between patient autonomy and the value of knowledge gained from them. This is done by analysing a case which under current legislation warrants coroner's autopsy, however, its ethical justification remains contentious. This discussion is expanded by discussion of non-invasive alternatives and comparison to another situation which balances individual autonomy with public benefits-organ donation. The conclusion of this analysis is a moral middle ground in which objection to invasive autopsy could be respected once issues of overriding public interest are excluded, or at least non-invasive alternatives should be considered, with coroners left responsible for demonstrating specific public needs that could override objection.

Introduction of postmortem CT increases the postmortem examination rate without negatively impacting the rate of traditional autopsy in daily practice: an implementation study

AIM

The aim of this implementation study was to assess the effect of postmortem CT (PMCT) and postmortem sampling (PMS) on (traditional) autopsy and postmortem examination rates. Additionally, the feasibility of PMCT and PMS in daily practice was assessed.

METHODS

For a period of 23 months, PMCT and PMS were used as additional modalities to the autopsy at the Department of Internal Medicine. The next of kin provided consent for 123 postmortem examinations. Autopsy rates were derived from the Dutch Pathology Registry, and postmortem examination rates were calculated for the period before, during and after the study period, and the exclusion rate, table time, time interval to informing the referring clinicians with results and the time interval to the Multidisciplinary Mortality Review Board (MMRB) meeting were objectified to assess the feasibility.

RESULTS

The postmortem examination rate increased (from 18.8% to 32.5%, p<0.001) without a decline in the autopsy rate. The autopsy rate did not change substantially after implementation (0.2% decrease). The exclusion rate was 2%, the table time was 23 min, and a median time interval of 4.1 hours between PMCT and discussing its results with the referring clinicians was observed. Additionally, more than 80% of the MMRB meetings were held within 8 weeks after the death of the patient.

CONCLUSIONS

Our study shows that the implementation of a multidisciplinary postmortem examination is feasible in daily practice and does not adversely affect the autopsy rate, while increasing the postmortem examination rate.

Effect of minimally invasive autopsy and ethnic background on acceptance of clinical postmortem investigation in adults

OBJECTIVES

Autopsy rates worldwide have dropped significantly over the last five decades. Imaging based autopsies are increasingly used as alternatives to conventional autopsy (CA). The aim of this study was to investigate the effect of the introduction of minimally invasive autopsy, consisting of CT, MRI and tissue biopsies on the overall autopsy rate (of CA and minimally invasive autopsy) and the autopsy rate among different ethnicities.

METHODS

We performed a prospective single center before-after study. The intervention was the introduction of minimally invasive autopsy as an alternative to CA. Minimally invasive autopsy consisted of MRI, CT, and CT-guided tissue biopsies. Autopsy rates over time and the effect of introducing minimally invasive autopsy were analyzed with a linear regression model. We performed a subgroup analysis comparing the autopsy rates of two groups: a group of western-European ethnicity versus a group of other ethnicities.

RESULTS

Autopsy rates declined from 14.0% in 2010 to 8.3% in 2019. The linear regression model showed a significant effect of both time and availability of minimally invasive autopsy on the overall autopsy rate. The predicted autopsy rate in the model started at 15.1% in 2010 and dropped approximately 0.1% per month (β = -0.001, p < 0.001). Availability of minimally invasive autopsy increased the overall autopsy rate by 2.4% (β = 0.024, p < 0.001). The overall autopsy rate of people with an ethnic background other than western-European was significantly higher in years when minimally invasive autopsy was available compared to when it was not (22/176 = 12.5% vs. 81/1014 (8.0%), p = 0.049).

CONCLUSIONS

The introduction of the minimally invasive autopsy had a small, but significant effect on the overall autopsy rate. Furthermore, the minimally invasive autopsy appears to be more acceptable than CA among people with an ethnicity other than western-European.

Added value of post-mortem computed tomography (PMCT) to clinical findings for cause of death determination in adult "natural deaths"

Purpose

The aim of this study was to investigate whether post-mortem computed tomography (PMCT) provides additional information regarding the cause of death and underlying diseases in a general practitioners’ (GP), out-of-hospital population.

Methods and materials

Bodies donated to our anatomy department between January 2014 and January 2018, who consecutively underwent a total body PMCT and had given permission for retrieval of their medical records during life, were included. PMCT scans were assessed by a radiologist and compared with the cause of death as stated in the medical records. Discrepancies were analyzed with an adjusted Goldman classification.

Results

Ninety-three out of the 274 scanned donors during the inclusion period had given consent for the retrieval of their medical records, of which 79 GP’s responded to the request thereof (31 men, 48 women, average age 72.8 years, range 36–99). PMCT identified 49 (62%) cases of cancer, 10 (12.7%) cardiovascular diseases, 8 (10.1%) severe organ failures, 5 (6.3%) cases with signs of pneumonia, 2 (2.5%) other causes, and 7 (8.9%) cases without an (underlying) definitive cause of death. Eleven major discrepancies on the Goldman classification scale, with possible relevance to survival between PMCT and GP records, were identified.

Conclusion

PMCT can have added value for the detection of additional findings regarding the cause of death in an out-of-hospital, GP’s population, especially to identify or exclude major (previously non-diagnosed) underlying diseases.

The Importance of the Autopsy in Medicine: Perspectives of Pathology Colleagues

This article presents a perspective on the importance of the autopsy in medical practice and science based on experiences of the authors as physician-scientists involved in autopsy practice. Our perspectives are presented on the seminal contributions of the autopsy in the areas of cardiovascular disease, including congenital heart disease, atherosclerosis, coronary artery disease, and myocardial infarction, and infectious disease, including tuberculosis and viral infections. On the positive side of the future of the autopsy, we discuss the tremendous opportunities for important research to be done by application of advanced molecular biological techniques to formalin-fixed, paraffin-embedded tissue blocks obtained at autopsy. We also note with concern the countervailing forces impacting the influence of pathology in education and clinical practice at our academic medical centers, which also present impediments to increasing autopsy rates. Our challenge as academic pathologists, whose careers have been molded by involvement in the autopsy, is to counter these trends. The challenges are great but the benefits for medicine and society are enormous.

Conventional Autopsy versus Minimally Invasive Autopsy with Postmortem MRI, CT, and CT-guided Biopsy: Comparison of Diagnostic Performance

Purpose To compare the diagnostic performance of minimally invasive autopsy with that of conventional autopsy. Materials and Methods For this prospective, single-center, cross-sectional study in an academic hospital, 295 of 2197 adult cadavers (mean age: 65 years [range, 18-99 years]; age range of male cadavers: 18-99 years; age range of female cadavers: 18-98 years) who died from 2012 through 2014 underwent conventional autopsy. Family consent for minimally invasive autopsy was obtained for 139 of the 295 cadavers; 99 of those 139 cadavers were included in this study. Those involved in minimally invasive autopsy and conventional autopsy were blinded to each other's findings. The minimally invasive autopsy procedure combined postmortem MRI, CT, and CT-guided biopsy of main organs and pathologic lesions. The primary outcome measure was performance of minimally invasive autopsy and conventional autopsy in establishing immediate cause of death, as compared with consensus cause of death. The secondary outcome measures were diagnostic yield of minimally invasive autopsy and conventional autopsy for all, major, and grouped major diagnoses; frequency of clinically unsuspected findings; and percentage of answered clinical questions. Results Cause of death determined with minimally invasive autopsy and conventional autopsy agreed in 91 of the 99 cadavers (92%). Agreement with consensus cause of death occurred in 96 of 99 cadavers (97%) with minimally invasive autopsy and in 94 of 99 cadavers (95%) with conventional autopsy (P = .73). All 288 grouped major diagnoses were related to consensus cause of death. Minimally invasive autopsy enabled diagnosis of 259 of them (90%) and conventional autopsy 224 (78%); 200 (69%) were found with both methods. At clinical examination, the cause of death was not suspected in 17 of the 99 cadavers (17%), and 124 of 288 grouped major diagnoses (43%) were not established. There were 219 additional clinical questions; 189 (86%) were answered with minimally invasive autopsy and 182 (83%) were answered with conventional autopsy (P = .35). Conclusion The performance of minimally invasive autopsy in the detection of cause of death was similar to that of conventional autopsy; however, minimally invasive autopsy has a higher yield of diagnoses. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Krombach in this issue.

Incidence of pheochromocytoma and sympathetic paraganglioma in the Netherlands: A nationwide study and systematic review

INTRODUCTION

Recent years have seen major changes in clinical practice which may have affected the incidence rates of pheochromocytoma(PCC)/sympathetic paraganglioma(sPGL). There is, however, a lack of up-to-date information describing trends in these incidence rates.

METHODS

We searched the Dutch pathology registry to identify all histopathologically confirmed cases of PCC/sPGL diagnosed between 1995 and 2015. We calculated incidence rates according to age category as well as age-standardized incidence rates (ASR). We also searched Medline and Embase to find data on nationwide incidence rates of PCC/sPGL.

RESULTS

The nationwide pathology study revealed a total of 1493 patients with either PCC or sPGL. The ASR for PCC increased from 0.29 (95% CI: 0.24-0.33) to 0.46 (95% CI: 0.39-0.53) per 100,000 person-years in the periods 1995-1999 and 2011-2015, respectively. For sPGL the ASR in these same periods were 0.08 (95% CI: 0.06-0.10) and 0.11 (95% CI: 0.09-0.13) per 100,000 person-years, respectively. Concomitantly, PCC size decreased (β -0.17; P < .001) and age at diagnosis increased (β 0.13; P = .001). Our systematic search yielded 3 papers reporting on a total of 530 PCC/sPGL cases, showing a combined annual incidence rate varying from 0.04 to 0.21 per 100,000 person-years.

CONCLUSION

Incidence rates of PCC/sPGL have increased significantly over the past two decades. This trend coincides with a higher age and a smaller tumor size at diagnosis. Most likely these observations are at least in part the result of changes in clinical practice during the study period, with a more intensified use of both imaging studies and biochemical tests for detecting PCC/sPGL.

Autopsy rates in the Netherlands: 35 years of decline

Objective

Although the autopsy still is a valuable tool in health statistics, health care quality control, medical education, and biomedical research, autopsy rates have been declining worldwide. The aim of this study was to examine trends of overall, clinical and forensic autopsy rates among adults in the Netherlands over the last four decades, and trends per sex, age (groups), and hospital type.

Methods

We performed a retrospective study covering 35 years of Dutch national death counts (1977–2011), the number of in-hospital deceased patients, the number of deaths due to external causes, and the proportion of autopsies performed in these populations. The effects of sex, age and hospital category were analysed by linear and logistic regression and differences were evaluated by chi-square tests.

Results

Overall autopsy rates declined by 0.3% per calendar year, clinical autopsy rates by 0.7% per calendar year (from 31.4% to 7.7%), and forensic autopsy rates did not decline. Per calendar year the fraction of in-hospital deceased patients decreased by 0.2%. Autopsy rates were highest among men and younger patients; clinical autopsy rates were highest for patients dying in academic hospitals.

Conclusions

In the Netherlands clinical autopsy rates have rapidly declined while at the same time the fraction of in-hospital deaths decreased, both contributing to the overall reduced absolute number of autopsies performed. It is important to improve awareness among both clinicians and general practitioners of the significance of the clinical autopsy.