Autopsies may not be infallible when it comes to diagnosing causes of death, but they are still widely regarded as the most accurate method available by many medical professionals.
However, there is an alarming decline in autopsies being carried out, according to a study by Angus Turnbull of Imperial College School of Medicine in London. According to Turnbull, the number of autopsies performed on people who died while in hospital has fallen from approximately 40% in 1960 to less than 1% today. Similar declines in the number of autopsies being performed can be observed in the US and Australia.
Decline in Autopsies Could Lead to Missed Opportunities
Turnbull and his team believe the consequences of a decline in autopsies could potentially result in more people passing away with a misdiagnosed cause of death, misallocation of resources due to incorrect death statistics and missed opportunities for medical students, doctors and medical researchers to investigate the causes of new diseases, such as Severe Acute Respiratory Syndrome (SARS), and frequently misunderstood but increasingly common medical conditions such as Alzheimer’s disease. The drop in the number of autopsies being performed could also result in the families of victims of medical misdiagnosis failing to receive the compensation they are entitled to.
“At this rate, all autopsies will disappear within 20 years,” Turnbull said. “Now, at medical school, you can go through six years of training without seeing one”.
Autopsies Performed in Just 0.69% of Deaths
Turnbull’s report – ‘Hospital Autopsy: Endangered or Extinct?‘ – is based on autopsy data from 2013, collected from 184 of the 186 National Health Service trusts in the UK. They found that on average, autopsies were performed in just 0.69% of patient deaths that occurred in hospital. Autopsy rates were lowest in Northern Ireland, with only 0.46% of deaths investigated with an autopsy. The highest rates were found in Scotland, with autopsies carried out on 2.13% of deaths. The team found that in a quarter of trusts, the practice of performing autopsies had already disappeared completely.
Possibilities for Error
One of the main reasons for the decline in autopsies is that doctors often believe that modern MRI and CT scanning techniques mean their diagnoses are more accurate than ever before, rendering autopsies unnecessary. However, this confidence in their understanding of a patient’s cause of death can be misplaced, says Sebastian Lucas, professor of histopathology at St Thomas’ Hospital in London. “The impression that all is known through pre-mortem imaging and diagnostic tests is pervasive, but wrong.”
Instances of medical misdiagnosis still occur more frequently than they should. For example, one US study on the autopsies of 86 people who had succumbed to cancer found that a quarter of them had major missed diagnoses, and half of those would likely have received a different course of treatment had their medical condition been correctly diagnosed in the first place. And cases of cancer misdiagnosis are just the tip of the iceberg: a 2012 review of 31 studies involving intensive care units found that at least one instance of medical misdiagnosis occurred in 28% of the autopsies carried out.
“The proportion of misdiagnosis is shockingly high for conditions that, had they been recognised while the patient was alive, very likely would have altered care and perhaps improved outcome,” says Bradford Winters of Johns Hopkins University School of Medicine in Baltimore, Maryland, who conducted the 2012 review. “Without a reference measure such as autopsy to determine our misdiagnosis rate, efforts to prevent misdiagnosis will not be able to generate sufficiently valid data so that we can tell the public that we are making strides,” he says. “We will essentially be ‘guessing’ whether the situation is improving or not.”
Permission to Conduct Autopsies
Another possible reason for the dramatic decline is that doctors may believe that relatives of deceased patients will feel uncomfortable about being asked for permission to conduct autopsies – especially in the wake of the organ theft scandals at Alder Hey and Bristol Royal Infirmary hospitals, where literally thousands of children’s organs were retained without the knowledge or consent of their parents. “Since Alder Hey, many doctors have assumed people won’t give consent for autopsies,” says Turnbull, but this is simply not the case. In many cases where cause of death is not immediately obvious, an autopsy would provide the relatives of the deceased with a sense of closure.
This is backed up by a recent study at London’s St Bartholomew’s Hospital, where 18 of 23 groups of bereaved families consented to an autopsy on their dead relative. And despite the fact that the organ scandal of the 1990s is still fresh in the minds of many, Alder Hey Hospital itself has the highest autopsy rate in the country at 21%.
Turnbull is of the opinion that it will be hard to reverse the decline, but not impossible. If doctors had an obligation to refer at least one uncertain death per year for autopsy, that could help to turn around the decline, as would making the process of obtaining consent easier, he says.
Jason Brady, clinical negligence solicitor at Blackwater Law and specialist in medical misdiagnosis compensation claims, said: “There is an argument that resources should be directed towards identifying mistakes in diagnosing or treating patients since it facilitates continuous learning within the NHS, otherwise there is a risk that the same medical errors and misdiagnoses may continue to happen, potentially leadinging to deaths and injuries which may have been avoided.”
Autopsies performed using high resolution MRI scanners immediately after death – or virtual autopsies – have their place, but many believe they are no substitute for a physical autopsy, as the false positive and false negative rates virtual autopsies provide are still unknown. Although virtual autopsies have their benefits, such scans can miss vital clues such as blood clots, says Turnbull. “Also, who would do them, as there’s no training for it.”
While an autopsy may not always prove beyond doubt the cause of death, it is still the “gold” standard when it comes to determining how a person died. If the decline in autopsies is not arrested, more cases of medical misdiagnosis may slip under the radar.