I have a confession to make. I don't do autopsies as often as I'd like. I work in a community hospital, an environment where few autopsies are performed. Some smaller hospitals don't do them at all. Academic medical centers with pathology residency programs have higher autopsy rates, but their numbers have also decreased. This isn't just localized, it's nationwide. The United States isn't the only place this has occurred-this is a global phenomenon.
A study published in National Center for Health Statistics Data Brief No. 67, August 2011, notes that the percentage of deaths for which autopsies in the United States were performed declined from 19.3% in 1972 to 8.5% in 2007, a drop of more than 50%. The decline was partly due to the Joint Commission on Hospital Accreditation's(the hospital regulatory body in the US) decision to abolish a requirement that hospitals maintain a 20% autopsy rate. Advances in medical imaging may have also played a role.
Why are autopsies so important? Despite the public's false belief that hospitals use them to cover up their mistakes, it's actually a form of quality assurance. From personal observation, there is no collusion between the attending physician and pathologist-they usually don't even know one another. From a financial standpoint, it makes more sense NOT to do an autopsy because hospitals don't typically charge for them.
But autopsies remain a necessity. Hospitals don't always diagnose patients correctly, and medical errors unfortunately do happen sometimes. In a 2004 study published by JAMA Internal Medicine, autopsies were performed on 167 patients who died in an ICU. Major diagnostic errors were identified for 31.7% of the autopsied patients, and the correct diagnosis would have changed management and possibly resulted in a cure or prolonged survival for up to 10% of the patients. The hospital can use this data to change procedures and protocols in order to provide better patient care.
A 2011 ProPublica article examined this issue, stating that due to low autopsy rates "experts say diagnostic errors are missed, opportunities to improve medical treatment are lost, and health-care statistics are skewed." The author of the article interviewed Dr. Elizabeth Burton, the deputy director of the pathology department at Johns Hopkins University School of Medicine, who said "performing autopsies on patients who have died of hospital-acquired infections helps save others. Infection clusters “go in waves” in hospitals, she said. Physicians have used her findings to change antibiotic regimens, snuffing out the bacterium."
The article also mentions, "A 2002 review of academic studies by the federal Agency for Healthcare Research and Quality which found that when patients were autopsied, major errors related to the principle diagnosis or underlying cause of death were found in one of four cases. In one of 10 cases, the error appeared severe enough to have led to the patient’s death.“Clinicians have compelling reasons to request autopsies far more often than currently occurs,” the agency concluded."
I had an autopsy recently which provides an example of a finding that a hospital would want to know about.
A patient in their 70s came to the hospital with a change in mental status and suddenly died after a brief stay. The hospital contacted the medical examiner about the death, as is required by state law. The patient had extensive medical history, including two different types of cancer, so the medical examiner felt their death was due to natural causes, and declined to do an autopsy. The hospital didn't know why the patient died, although they suspected it may have had something to do with the cancer history. The attending physician ordered an autopsy and gained authorization from the patient's family.
When I did my external examination, the patient looked a little emaciated and there were a few CPR related abrasions on the center of the chest, but nothing particularly notable externally.
When the tech opened up the body for me, we saw extensive rib fractures and hemorrhage throughout the chest from vigorous CPR chest compression. At first I wondered if this was the cause of death, but realized that everything was postmortem. This is actually not an uncommon finding in autopsies. There's an EMT saying which advises those giving CPR ,"if you haven't broken any ribs, you're not doing it right."
We examined the body for recurrent cancer, but found none. The organs looked fairly normal for someone this age. No infection, no emboli. Some scarring from a surgical procedure, a small kidney stone, and an equally small gallstone, but nothing that would have killed the patient. The brain was slightly pale, but we didn't see any obvious infection. Usually meningitis shows up as a thickened, pale tan to greenish gooey membrane on the outside of the brain.
I showed my findings to the pathologist. He looked at me, puzzled, and asked, "Why on earth did this patient die?"
Two weeks later, I cut in the brain. We soak brains in a formaldehyde solution in order to firm up the tissue. A "fresh" brain has the consistency of Jello, making it difficult to section.
For some strange reason, this brain had the soft consistency of a fresh brain. Several slices actually fell apart. I was kicking myself. Why was this happening? Surely I had properly soaked the brain for the appropriate of time, it was even on my Google calendar!
As I took a closer look at my sections, I noticed there were some areas on the outer surface of the brain that had a slightly membranous appearance. This was why the brain had initially looked pale and could potentially explain the softness of the tissue. I showed this to the pathologist, and we took some samples of these areas.
When he examined the tissue under the microscope, he found the cause of death: bacterial meningitis.
An example of a similar, slightly more obvious case of bacterial meningitis. Arrows point to exudate, or pus caused by the infection. © Copyright UAB and the UAB Research Foundation, 1999-2013. All rights reserved.
Bacterial meningitis is an important finding to report for both hospital safety and healthcare statistical reasons. Without an autopsy, the hospital and the family would have never known what killed this patient. This is just one instance of a situation that calls for an autopsy. There have been others, and there will be more to come.