Clinical, educational, and epidemiological value of autopsy

doi:10.1016/S0140-6736(07)60376-6

The Lancet

Volume 369, Issue 9571, 28 April–4 May 2007, Pages 1471-1480

https://doi.org/10.1016/S0140-6736(07)60376-6 Get rights and content

Summary

The autopsy is now often regarded as of marginal use in modern clinical practice. In this Review we contend that the autopsy remains an important procedure with substantial, if largely underused, potential to advance medical knowledge and improve clinical practice. Many doctors lack familiarity with autopsy practices, and are insufficiently aware of the benefits for not only bereaved families but also present and future patients. In this Review, which has an international perspective, we consider the ascent and decline of the autopsy, the legal frameworks that govern its use, the value and potential pitfalls of alternatives to the conventional method, and the autopsy's role in undergraduate medical education. We also draw attention to the continuing ability of autopsies to improve the completeness and reliability of death certification, which is important for public-health strategies and for some bereaved families.

Section snippets

Trends in autopsy rates

Until the 1960s, the autopsy was regarded as central to medical research, education, and professional development.¹ However, many studies2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 have shown the decline of autopsy in adults in most developed countries in the latter half of the 20th century and beyond (table 1).

The fall in autopsy rates is not universal and can be reversed.¹⁰ In Nova Scotia, Canada, although the clinically indicated autopsy rate fell in the 13 years before

Attitudes to autopsy

The reasons for the fall in autopsy rates are multifactorial and complex. The general public, medical professionals, and pathologists all have a vested interest in the autopsy, and knowledge of the attitudes of these interested parties is essential to understand the present status of the procedure.

Legal aspects

Autopsies can be undertaken only with appropriate consent or other authorisation, which defines the limits of the procedure. In most cases nowadays, authorisation comes from the relevant medicolegal officer, and is restricted to an examination that allows that officer to establish the cause and circumstances of death.

Authorisation for tissue retention at autopsy

Tissue is retained from autopsies most often for histological confirmation or refinement of the macroscopic findings. Such is the value of histology that routine sampling of major organs and lesions is regarded as an integral part of the autopsy in protocols issued by many professional pathology organisations. The subsequently archived tissue can be re-examined for clinical reasons to reinterpret the findings and perhaps revise the cause of death in view of new information. Archived tissue is

Minimally invasive autopsies

Minimally invasive and non-invasive autopsies are considered when there are strong emotional, cultural, or religious objections to a complete autopsy, or where there are serious risks to the health and safety of the pathologist and mortuary staff. Minimally invasive autopsies include those in which only blind or targeted percutaneous needle biopsies are taken (needle autopsies), and examinations that use an endoscope or laparoscope (endoscopic autopsies). Non-invasive autopsies, also referred

Verbal autopsy

The so-called verbal autopsy has emerged as an indirect retrospective method to identify the probable cause of death. This approach has largely been confined to developing countries where resources are restricted and to countries where there are strong religious objections to human dissection.⁷⁶ No examination of the body is undertaken in this method. Indeed, we contend that the term verbal autopsy is an oxymoron, and suggest that post-mortem clinical case review is more appropriate. The

Role of autopsies in medical education

Autopsy epitomises problem-based learning for students. Despite curricular reform, a decline in autopsy rates, and adverse media attention to autopsy, medical educators regard this technique as valuable but underused in medical education.42, 43 Provided that adequate consent has been obtained,⁵¹ students can either be invited to the mortuary to witness autopsies, from external examination to reconstruction of the body, or they can be called once the examination has been completed to discuss the

Conclusions

We cannot support the assertion, published in The Lancet, that “the autopsy has lost much of its authority and now has a marginal role in contemporary medical practice”.⁹⁸ Despite intensive modern clinical investigations, autopsies continue to reveal major ante mortem diagnostic errors in around 30% of cases;⁹⁹ thus, autopsies improve the completeness and reliability of national mortality data on which health-care strategies are based. Autopsy is also a decisive factor in the discovery of

Search strategy and selection criteria

We searched Medline (January, 1966–January, 2006). We used the search terms “autopsy”, “necropsy”, and “post-mortem examination”, in combination with the terms “attitudes”, “consent”, “education”, “endoscopic autopsy”, “histology”, “history”, “needle autopsy”, “pathologist”, “rates”, “regulation”, “training”, “trends”, “undergraduate”, and “verbal autopsy”. The search was limited to articles relating to work in people. We concentrated on publications in the past 5 years, but did not exclude

References (101)

T Waldhoer et al.
Rates of postmortem examination in Austria. The effect of distance between location of death and site of examination
J Clin Epidemiol
(2003)
RA Lahti et al.
Exploitation of autopsy in determining natural cause of death: trends in Finland with special reference to the diagnostics of ischemic heart diseases and cerebrovascular diseases in middle-aged males, 1974–1993
Forensic Sci Int
(1998)
A Lugli et al.
Effect of simple interventions on necropsy rate when active informed consent is required
Lancet
(1999)
EC Burton et al.
The relation of autopsy rate to physicians' beliefs and recommendations regarding autopsy
Am J Med
(2004)
C Jackowski et al.
Virtopsy: postmortem imaging of the human heart in situ using MSCT and MRI
Forensic Sci Int
(2005)
TAGM Huisman
Magnetic resonance imaging: an alternative to autopsy in neonatal death?
Semin Neonatol
(2004)
PD Griffiths et al.
Post-mortem MRI as an adjunct to fetal or neonatal autopsy
Lancet
(2005)
MJ Thali et al.
Is ‘virtual histology’ the next step after ‘virtual autopsy’? Magnetic resonance microscopy in forensic medicine
Magn Reson Imaging
(2004)
EL Korenromp et al.
Measurement of trends in childhood malaria mortality in Africa: an assessment of progress toward targets based on verbal autopsy
Lancet Infect Dis
(2003)
MJ Clark
Autopsy
Lancet
(2005)

J Roulson et al.

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review

Histopathology

(2005)

JL Burton et al.

Necropsy practice after the “organ retention scandal”: requests, performance, and tissue retention

J Clin Pathol

(2003)

RD Start et al.

Clinical autopsy rates during the 1980s: the continued decline

J Pathol

(1993)

KG Shojania et al.

The autopsy as an outcome and performance measure

Evid Rep Technol Assess

(2002)

K Khunti

Referral for autopsies: analysis of 651 consecutive deaths in one general practice

Postgrad Med J

(2000)

TN Gibson et al.

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

J Clin Pathol

(2002)

KA Szalma et al.

Comparison of clinical data of two autopsy series, 1938–1951 and 1990–2002, at the Debrecen University Department of Neurology [Hungarian]

Orv Hetil

(2004)

PJ Bradley et al.

A head and neck cancer patient dies! Why perform an autopsy: for the relatives, for the clinicians, or for the pathologists?

Acta Otolaryngol

(2003)

P Lindström et al.

Declining autopsy rate in Sweden: a study of causes and consequences in Malmö, Sweden

J Int Med

(1997)

MB Loughrey et al.

The declining autopsy rate and clinicians' attitudes

Ulster Med J

(2000)

P Chariot et al.

Declining autopsy rate in a French hospital: physicians' attitudes to the autopsy and use of autopsy material in research publications

Arch Pathol Lab Med

(2000)

The decline of the hospital autopsy: a safety and quality issue for healthcare in Australia

Med J Aust

(2004)

KQ Zhu et al.

[Analysis of autopsy cases in 50 years][Chinese]

Zhonghua Nei Ke Za Zhi

(2004)

J Sperhake et al.

[The autopsy law of Hamburg from February 9, 2000—changing autopsy rates in departments of pathology in Hamburg][German]

Pathologe

(2003)

JH Lardenoye et al.

[Evaluation of the rate of autopsy and rate of disparity between autopsy results and clinical cause of death in a surgical ward, with emphasis on necrological review][Dutch]

Ned Tijdschr Geneeskd

(2005)

A Leibovitz et al.

Postmortem examinations in patients of a geriatric hospital

Aging Clin Exp Res

(2001)

MJ Wood et al.

Declining clinical autopsy rates versus increasing medicolegal autopsy rates in Halifax, Nova Scotia

Arch Pathol Lab Med

(2001)

DS Allan et al.

Maintaining high autopsy rates in a Canadian blood and marrow transplant program: preserving a diagnostic and research tool

Bone Marrow Transplant

(2005)

SA Geller

Religious attitudes and the autopsy

Arch Pathol Lab Med

(1984)

AD Renteln

The rights of the dead: autopsies and corpse mismanagement in multicultural societies

South Atl Q

(2002)

A Sheikh

Death and dying—a Muslim perspective

J R Soc Med

(1998)

V Risper-Chaim

The ethics of postmortem examinations in contemporary Islam

J Med Ethics

(1993)

J Green et al.

Dealing with death: a handbook of practices, procedures and law

(2006)

JE Rutty

Religious attitudes to death: what every pathologist needs to know

JE Rutty

Religious attitudes to death: what every pathologist needs to know. Part 2

K Lishimpi et al.

Necropsies in African children: consent dilemmas for parents and guardians

Arch Dis Child

(2001)

HE McHaffie et al.

Consent to autopsy for neonates

Arch Dis Child Fetal Neonatal Ed

(2001)

R Rankin et al.

Cross-sectional survey of parents' experiences and views of the postmortem examination

BMJ

(2002)

F Oppelwal et al.

Family members' experience of autopsy

Fam Pract

(2001)

P Vanezis et al.

Next of kin clinics: a new role for the pathologist

J Clin Pathol

(1999)

J Midelfart et al.

The value of the autopsy from a clinical point of view: a survey of 250 general practitioners and hospital clinicians in the county of Sor-Trondelag, Norway

APMIS

(1998)

NJ Carr et al.

The autopsy: lessons from the National Confidential Enquiry into Perioperative Deaths

J R Soc Med

(2002)

KE Bove et al.

The role of the autopsy in medical malpractice cases, II: Controversy related to autopsy performance and reporting

Arch Pathol Lab Med

(2002)

IB Bayer-Garner et al.

Pathologists in a teaching institution assess the value of the autopsy

Arch Pathol Lab Med

(2002)

RD Start et al.

Attitudes of senior pathologists towards the autopsy

J Pathol

(1994)

F Stubbs et al.

The attitudes of junior pathologists towards the autopsy

J Pathol

(1992)

GE Rosenbaum et al.

Autopsy consent practice at US teaching hospitals: result of a national survey

Arch Intern Med

(2000)

JL Burton

The autopsy in modern undergraduate medical education: a qualitative study of uses and curriculum considerations

Med Educ

(2003)

JL Burton

Medical educators' personal attitudes towards the necropsy

J Clin Pathol

(2003)

CN Petri

Decrease in the frequency of autopsies in Denmark after the introduction of a new autopsy act

Qual Assur Health Care

(1993)

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Autopsy is the gold standard method for determining cause of death. Young sudden death (SD) is a prototype condition in which autopsy is universally recommended. The aim of this review was to quantify real-world global rates of autopsy in either all-cause death or young SD. A systematic review was conducted. Rates of autopsy in all-cause death and in young SD were determined in each country using scientific and commercial search engines. In total, 59 of 195 countries (30.3%) reported autopsy rates in all-cause death, with rates varying from 0.01%–83.9%. Almost all of these figures derived from academic publications rather than governmental statistics. Only 16 of 195 countries (8.2%) reported autopsy rates in the context of young SD, with reported rates ranging from 5%–100%. The definition of “young” was heterogeneous. No governmental statistics reported autopsy rates in young SD. Risks of bias included inability to verify reported figures, heterogeneity in reporting of clinical vs medicolegal autopsies, and the small number of studies identified overall, resulting in the consistent exclusion of low- and middle-income countries. In conclusion, most countries globally do not report autopsy rates in either all-cause death (69.7%) or in SD (92.8%). Without transparent reporting of autopsy rates, global burdens of disease and rates of sudden cardiac death cannot be reliably calculated.
Comparing the diagnostic accuracy of post-mortem CT with invasive autopsy in fire-related deaths: a systematic review
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The value of post-mortem computed tomography (PMCT) in trauma victims is well established. In this review the diagnostic accuracy and value of PMCT will be investigated specifically for fire related deaths, which has yet to be fully investigated.
PRISMA guidelines informed this systematic review. A total of ten databases were searched in December 2020. All articles exploring the use of PMCT and autopsy to investigate fire related deaths in adults were deemed eligible for inclusion, and were reviewed by two independent researchers. The QUADAS-2 tool was used to assess the quality of these papers.
Seven studies were selected, containing a total of 110 burns victims. PMCT was superior in identifying fractures, and is particularly accurate with regards to fractures and injuries of the skull, facial bones, neck and extremities. However, PMCT fared poorly in identifying signs of vitality during a fire compared to autopsy. Toxicological examinations to assess carbon monoxide levels were often still required to make a conclusive diagnosis of fire as the cause of death.
Despite the heterogeneity of the methodologies’ reviewed, it is clear that PMCT is an extremely powerful visualisation tool with great potential for documentation and examination in forensic cases. The limitations of PMCT mean that it can not fully replace autopsy in these cases, but if autopsy is not available PMCT, in combination with a toxicology and histology examination, can identify the cause of death to a high degree of certainty.
The need for integrated research autopsies in the era of precision oral medicine
2023, Journal of the American Dental Association
Autopsy has benefited the practice of medicine for centuries; however, its use to advance the practice of oral health care is relatively limited. In the era of precision oral medicine, the research autopsy is poised to play an important role in understanding oral–systemic health, including infectious disease, autoimmunity, craniofacial genetics, and cancer.
The authors reviewed relevant articles that used medical and dental research autopsies to summarize the advantages of minimally invasive autopsies of dental, oral, and craniofacial tissues and to outline practices for supporting research autopsies of the oral and craniofacial complex.
The authors provide a historical summary of research autopsy in dentistry and provide a perspective on the value of autopsies for high-resolution multiomic studies to benefit precision oral medicine. As the promise of high-resolution multiomics is being realized, there is a need to integrate the oral and craniofacial complex into the practice of autopsy in medicine. Furthermore, the collaboration of autopsy centers with researchers will accelerate the understanding of dental, oral, and craniofacial tissues as part of the whole body.
Autopsies must integrate oral and craniofacial tissues as part of biobanking procedures. As new technologies allow for high-resolution, multimodal phenotyping of human samples, using optimized sampling procedures will allow for unprecedented understanding of common and rare dental, oral, and craniofacial diseases in the future.
The COVID-19 pandemic highlighted the oral cavity as a site for viral infection and transmission potential; this was only discovered via clinical autopsies. The realization of the integrated autopsy’s value in full body health initiatives will benefit patients across the globe.
Is Chronic Pain a Disease?
2022, Journal of Pain
It was not until the twentieth century that pain was considered a disease. Before that it was managed medically as a symptom. The motivations for declaring chronic pain a disease, whether of the body or of the brain, include increasing its legitimacy as clinical problem and research focus worthy of attention from healthcare and research organizations alike. But 1 problem with disease concepts is that having a disease favors medical solutions and tends to reduce patient participation. We argue that chronic pain, particularly chronic primary pain (recently designated a first tier pain diagnosis in International Diagnostic Codes 11), is a learned state that is not intransigent even if it has biological correlates. Chronic pain is sometimes a symptom, and may sometimes be its own disease. But here we question the value of a disease focus for much of chronic pain for which patient involvement is essential, and which may need a much broader societal approach than is suggested by the disease designation.
This article examines whether designating chronic pain a disease of the body or brain is helpful or harmful to patients. Can the disease designation help advance treatment, and is it needed to achieve future therapeutic breakthrough? Or does it make patients over-reliant on medical intervention and reduce their engagement in the process of recovery?
Autopsy in a neonatal intensive care unit: do we still need it in 2022?
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Accuracy and clinical utility of standard postmortem radiological imaging after early second trimester termination of pregnancy
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This study aims to assess accuracy and clinical utility of postmortem radiological exams [Magnetic Resonance Imaging (MRI), Computed Tomography (CT) and Radiography (XR)] after termination of pregnancy at <23 weeks’ gestation for congenital fetal malformations in comparison to autopsy.
This a prospective single-center study on fetuses underwent termination of pregnancy for fetal defects. Overall concordance between any radiological exam and autopsy was evaluated. For postmortem MRI only, the following subgroups were analyzed: 1) total agreement; 2) agreement for main findings; 3) agreement for main findings but major relevant additional findings at autopsy; 4) total disagreement.
174 cases were collected. The overall concordance with autopsy for main findings was 71% (115/163) for postmortem MRI and 99% (173/174) for prenatal ultrasound (US). Postmortem MRI detection rate was high for central nervous system (CNS) defects (98%), gastrointestinal, genitourinary and respiratory defects (100%), while it was poor for cardiovascular and musculoskeletal defects (25% and 42%, respectively). For musculoskeletal abnormalities, the performance of postmortem XR and postmortem CT exams improved the detection rate from 42% for postmortem MRI alone to 92%.
Postmortem MRI has a good overall concordance for fetal defects after termination of pregnancy performed at <23 weeks. Along with autopsy, postmortem MRI may be offered for all cases of CNS defects in order to prevent inconclusive exams due to autolysis of the brain tissue, while postmortem CT and postmortem XR are indicated for musculoskeletal defects. In the presence of multiple abnormalities or cardiac defects the couple should be counseled on the poor performance of radiological investigations.

View all citing articles on Scopus

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ReviewClinical, educational, and epidemiological value of autopsy

Summary

Section snippets

Trends in autopsy rates

Attitudes to autopsy

Legal aspects

Authorisation for tissue retention at autopsy

Minimally invasive autopsies

Verbal autopsy

Role of autopsies in medical education

Conclusions

Search strategy and selection criteria

J Clin Epidemiol

Forensic Sci Int

Lancet

Am J Med

Forensic Sci Int

Semin Neonatol

Lancet

Magn Reson Imaging

Lancet Infect Dis

Lancet

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review

Histopathology

Necropsy practice after the “organ retention scandal”: requests, performance, and tissue retention

J Clin Pathol

Clinical autopsy rates during the 1980s: the continued decline

J Pathol

The autopsy as an outcome and performance measure

Evid Rep Technol Assess

Referral for autopsies: analysis of 651 consecutive deaths in one general practice

Postgrad Med J

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

J Clin Pathol

Comparison of clinical data of two autopsy series, 1938–1951 and 1990–2002, at the Debrecen University Department of Neurology [Hungarian]

Orv Hetil

A head and neck cancer patient dies! Why perform an autopsy: for the relatives, for the clinicians, or for the pathologists?

Acta Otolaryngol

Declining autopsy rate in Sweden: a study of causes and consequences in Malmö, Sweden

J Int Med

The declining autopsy rate and clinicians' attitudes

Ulster Med J

Declining autopsy rate in a French hospital: physicians' attitudes to the autopsy and use of autopsy material in research publications

Arch Pathol Lab Med

The decline of the hospital autopsy: a safety and quality issue for healthcare in Australia

Med J Aust

[Analysis of autopsy cases in 50 years][Chinese]

Zhonghua Nei Ke Za Zhi

[The autopsy law of Hamburg from February 9, 2000—changing autopsy rates in departments of pathology in Hamburg][German]

Pathologe

[Evaluation of the rate of autopsy and rate of disparity between autopsy results and clinical cause of death in a surgical ward, with emphasis on necrological review][Dutch]

Ned Tijdschr Geneeskd

Postmortem examinations in patients of a geriatric hospital

Aging Clin Exp Res

Declining clinical autopsy rates versus increasing medicolegal autopsy rates in Halifax, Nova Scotia

Arch Pathol Lab Med

Maintaining high autopsy rates in a Canadian blood and marrow transplant program: preserving a diagnostic and research tool

Bone Marrow Transplant

Religious attitudes and the autopsy

Arch Pathol Lab Med

The rights of the dead: autopsies and corpse mismanagement in multicultural societies

South Atl Q

Death and dying—a Muslim perspective

J R Soc Med

The ethics of postmortem examinations in contemporary Islam

J Med Ethics

Dealing with death: a handbook of practices, procedures and law

Religious attitudes to death: what every pathologist needs to know

Religious attitudes to death: what every pathologist needs to know. Part 2

Necropsies in African children: consent dilemmas for parents and guardians

Arch Dis Child

Consent to autopsy for neonates

Arch Dis Child Fetal Neonatal Ed

Cross-sectional survey of parents' experiences and views of the postmortem examination

BMJ

Family members' experience of autopsy

Fam Pract

Next of kin clinics: a new role for the pathologist

J Clin Pathol

The value of the autopsy from a clinical point of view: a survey of 250 general practitioners and hospital clinicians in the county of Sor-Trondelag, Norway

Review
Clinical, educational, and epidemiological value of autopsy