Saturday, February 17, 2007

Organs and autopsies

A while ago I talked about the latest Royal College of Pathologists Bulletin, and mentioned two things in that were particularly interesting. One was training and the second was coronial autopsies (page 13 if you can get hold of a copy). This article by Dr Peter Cowling, discusses the latest NCEPOD report (and its launch at the RCPath) which I’ve also talked about before.

One of the main points made both in the report and in the article is that the function of the coronial autopsy is not well defined. I think part of the problem is that as medics we see the autopsy as a medical procedure, whilst the majority of coroners are not medically qualified and to them is it the legal aspects that are important. At its most basic the legal function of a coronial autopsy is to exclude an unnatural cause of death and this (in combination with the new Human Tissue Act and coroners’ rules) leads to the situation where, as soon as a plausible cause of death is identified, the autopsy is stopped and no histology, toxicology or microbiology etc is usually done. This occurs in the jurisdiction of some (the minority I think), but luckily not all, coroners. No toxicology? Remember Harold Shipman? As a medical procedure this practice is unacceptable. The RCPath position as stated in the article is:

post-mortem examinations should be performed to the highest standards possible, to answer the needs of relatives and to serve the public health through improved national mortality statistics’

After reading a paper referenced by this article (Discrepancies between clinical and postmortem diagnoses in critically ill patients: an observational study. Full text available free) I would add ‘providing feedback to the clinicians treating the patient’ to these functions. Historically this was one of the main functions of the autopsy – in the past the autopsy room would have been full of doctors seeking to learn and improve their practice. Now it is almost deserted and this function has been sidelined. The rate of consented (non-coronial) autopsies has declined dramatically recently.

The paper above looks at patients dying in an intensive care unit. They reviewed 38 cases which is not a huge number but considering the low and declining number of autopsies is not surprising. 39% of the cases had a major diagnosis missed before death, although the missed diagnosis may not have had an impact on the patient’s survival.

I’m sure all of us trainee pathologists have heard consultants say that a third of death certificates are wrong, something also mentioned in the NCEPOD report, hardly a good thing for mortality statistics. If finding a plausible cause of death and then stopping the autopsy is also occurring then this is likely to reduce the accuracy of the cause of death in some autopsied cases. So falling autopsy rates and the poor standard of some autopsies is likely to have a negative impact on mortality statistics.

As for answering the needs of relatives, as the RCPath article says, we don’t know what the relatives or the public want from autopsies. Maybe they don’t care at all about autopsies, is this the reason for the results of the NCEPOD study sinking without trace in the media? I don’t think is entirely true; autopsies were never out of the news during the organ retention scandal. So what do the public think of autopsies now? Do they know why autopsies are important, what the uses of the autopsy are and the potential consequences of badly done autopsies? Do they understand how the Human Tissue Act and coroners’ attitudes to autopsy histology (partly in reaction to the organ retention scandal) make medical investigation of deaths difficult and the implications of this? I doubt it. A browse through the RCPath guidelines on autopsy practice shows why histology is so important as a component of the autopsy, including in relation to cardiac deaths, where the heart may need to be retained for specialist examination to assess any genetic problems that might affect other family members.

During the NCEPOD report launch, Professor Peter Furness talked about some of these problems and wondered if the next ‘organ retention scandal’ would be failure to retain important organs for further examination. In the past we had headlines like ‘Doctors stole my son’s heart’. Will we have ‘Doctors threw away my son’s heart’ in the future?


At 13:54, Blogger The Angry Medic said...

Whoa. I had no idea the government's messy finger-dipping had extended to even the autopsy. Enough that they're messing with how we treat the living, now they want to mess with how we treat the dead?

Congrats on the BritMeds mention again! Oh, and thank you so very much for your comment on my post. I really needed to hear that. Sometimes when my friends (invariably from professions that will make them richer faster than mine will) ask me why I chose to do medicine in the first place, I find myself increasingly being unable to provide them with an honest answer.

Thanks again.

At 14:27, Blogger Dr K said...

Thanks for the comment. Yes, everyone wants to tell us how to do autopsies (or to stop doing them). The first draft of the new Human Tissue Act appeared to have been written by people with no understanding of what human tissue is, what happens to it, what it's used for, and why. Luckily the RCPath sorted out some of the problems with it.

Just wait till Patricia Hewitt 'reconfigures' your med school curriculum! (I hope that stays a joke and doesn't become a reality)

At 18:03, Anonymous Anonymous said...

Dr K,

Another very interesting post highlighting some very important and underpublicised issues.

At the medical school I attend, the local coroner will not let coronial autopsies be used for the teaching of medics.

This only leaves approximately six per year we could attend and many are announced at such a short notice that we don't find out about them until after the event.

Having spent a bit of time in the DR looking at livers today as well as in the histopath lab being lectured on the same, I rather lament the difficulty of obtaining more exposure to pathology from the slide upwards since it brings the pathology a patient comes in with sharply into focus ...

The fact that justice is in effect being thwarted by some coroners by not having tests performed is in effect invalidating the whole process and deeply disturbing...


At 15:01, Blogger Dr K said...

Hi Bee

Seeing an autopsy as a medical student is probably very useful (I never saw one when I was a student) and most of the deaths are natural causes and don't need an inquest so I don't really understand why students aren't allowed to see this type of case. It's not really justice being thwarted in these cases, more medicine. In deaths where there are suspicious circumstances the police and forensic pathologists are involved and they don't have the same restrictions that we can be put under. Some coroners don't mind students watching autopsies so if you get an attachment to another hospital during your course (which might be in the jurisdiction of a different coroner) it's worth going and talking to the pathologists about whether you could go and see an autopsy. In some busy departments there will be autopsies most days but in others it can be difficult to predict as they won't know when a body is likely to come in.


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