Does it matter who requests necropsies? Prospective study of effect of clinical audit on rate of requests

Introduction

Despite the potential benefits of postmortem examination, rates are declining throughout the world.1 Reasons for this decline include the reluctance among doctors to request,2 relatives to give permission for,3 and pathologists to perform necropsies. This trend might be reversed by using medical education to change doctors' attitudes; delegating the task of requesting necropsies to other staff4; and increasing public awareness as to the potential benefits of necropsies. We prospectively studied the effect of clinical audit on necropsy rate and the subsequent effect of a patient affairs officer assuming responsibility for requesting necropsies.

Methods and results

Since March 1991 we have audited the necropsy rate in a 112 bed department of acute medicine for the elderly. The results of an initial six month audit and the potential benefits of and possible barriers to achieving a high necropsy rate were discussed with members of the department, and the departmental policy of obtaining the highest possible necropsy rate was reinforced. The impact of our audit programme on the rate of necropsies obtained by medical staff was then observed over six months, during which we recorded request and refusal rates. On completion of this audit cycle, the patient affairs officer (JRJ) accepted responsibility for requesting necropsies as she believed that she could achieve a higher necropsy rate than the medical staff. Subsequent audit compared her performance with that previously achieved by medical staff. Over three successive years we audited the annual performance of the patient affairs officer and looked at the effect of relatives' refusal to give permission for necropsy.

Clinical audit had a marginal effect on the rate of necropsies obtained by doctors, which increased from 22.3% to 28.0%. There was a more substantial increase to 46.2% when the patient affairs officer requested necropsies (table 1), due mainly to an increased rate of requests (refusal rates for medical staff and the patient affairs officer are comparable (38.8% v 36.8%)). The rate of requests by the patient affairs officer showed a consistent annual increase, rising from 64.3% to 79.6%, but the necropsy rate plateaued at around 51%, apparently because of a stable refusal rate of about one third.

Comment

The marginal effects of audit on the necropsy rate obtained by junior doctors suggest that they are reluctant to request necropsies. Many hospitals in the United States, but few in Britain, delegate the task of requesting necropsies to non-medical staff; we are not aware of reports of their performance or of comparisons with medical staff. Our patient affairs officer's approach to requesting necropsies has proved satisfactory to the recently bereaved relatives and has gained the confidence and support of the medical staff. It is likely that she is more effective than medical staff in requesting necropsies because of her enthusiasm; there is no conflict of interest as she has not had contact with the deceased patients or their relatives; she may have better communication skills; and there are fewer demands on her time.

Our study also shows that relatives' refusal to give permission for necropsy is an important limiting factor in achieving a high necropsy rate. This is independent of the process of requesting the examination.

A minimum necropsy rate of 35% has been recommended for clinical audit.5 To achieve this, necropsies must be requested on more than half of deaths as about a third of requests are likely to be refused. Our results show that a high necropsy request rate is more likely to be achieved by non-medical staff. A further increase in this rate is unlikely unless public attitudes to necropsy are changed.