Things to know about autopsy
An autopsy (also known as a post-mortem examination or necropsy) is the examination of the body of a dead person and is performed primarily to determine the cause of death,
- An autopsy is the examination of the body of a dead person.
- An autopsy may be restricted to a specific organ or region of the body.
- Autopsies are performed to determine the cause of death, for legal purposes, and for education and research.
- The body is opened in a manner that does not interfere with an open casket service.
- The autopsy rate has dropped from 50% to less than 10% over the past fifty years.
What is an autopsy?
An autopsy (also known as a post-mortem examination or necropsy) is the examination of the body of a dead person and is performed primarily to determine the cause of death, to identify or characterize the extent of disease states that the person may have had, or to determine whether a particular medical or surgical treatment has been effective. Autopsies are performed by pathologists and medical doctors who have received specialty training in the diagnosis of diseases by the examination of body fluids and tissues. In academic institutions, autopsies sometimes are also requested for teaching and research purposes. Forensic autopsies have legal implications and are performed to determine if death was an accident, homicide, suicide, or a natural event. The word autopsy is derived from the Greek word autopsia: "to see with one's own eyes."
Who determines whether an autopsy is performed?
A medical examiner can order an autopsy without the consent of the next-of-kin. Deaths that are investigated by the medical examiner or coroner include all suspicious deaths, and, depending upon the jurisdiction, may include deaths of persons not being treated by a physician for a known medical condition, deaths of those who have been under medical care for less than 24 hours, or deaths that occurred during operations or other medical procedures.
In all other cases, consent must be obtained from the next-of-kin before an autopsy is performed, even at academic institutions or hospitals. The next-of-kin also has the right to limit the scope of the autopsy (for example, excluding the brain from evaluation or limiting the procedure to the examination of the abdomen).
Who Has Access to Autopsy Information
Medical Author: Melissa Conrad Stöppler, MD
Medical Editor: Jay W. Marks, MD
Viewer Question: Who has access to the information obtained from an autopsy? Can this information (e.g. about hereditary diseases or conditions that may run in our family) be obtained by third parties?
Doctor’s Response: The same rules of doctor-patient confidentiality apply to autopsy examinations as to medical records of living patients. This means that doctors are not allowed to reveal the results of an autopsy examination to third parties without the permission of the next-of-kin of the deceased.
In many medical centers, the autopsy report is first submitted to the physician who treated the patient; the treating physician then shares the findings with the family. The family (next-of-kin) is always entitled to receive a copy of the autopsy report. The hospital is not allowed to give out any information about an autopsy or to respond to inquiries about an autopsy from any third parties. Of course, the family may choose to share the information with anyone they wish, but they must give written permission for the hospital to release autopsy records, just as with any medical records.
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What are the benefits of autopsies?
Benefits for families: For families, the autopsy has both tangible and psychological benefits. Uncertainty regarding the cause of an individual’s death can delay payment of insurance benefits. The autopsy can also uncover genetic or environmental (for example, a bacterium or fungus) causes of disease that could affect other family members. Psychologically, the autopsy provides closure by identifying or confirming the cause of death. The autopsy can demonstrate to the family that the care provided was appropriate, thereby alleviating guilt among family members and offering reassurance regarding the quality of medical care. Lastly, the autopsy is a mechanism that enables the family to participate in medical education and research.
Benefits for the clinician and hospital: The procedure can confirm the accuracy of the clinical diagnoses and the appropriateness of medical care. The autopsy findings can be utilized to educate physicians, nurses, residents, and students, thereby contributing to an improved quality of care.
Benefits to society: Many of the benefits of the autopsy are experienced by society as a whole. The autopsy aids in the evaluation of new diagnostic tests, the assessment of new therapeutic interventions (drugs, devices, surgical techniques), and the investigation of environmental and occupational diseases. Autopsy data are useful in establishing valid mortality statistics. Data derived from death certificates in the absence of autopsy data have repeatedly been shown to be inaccurate. New medical knowledge on existing diseases that is derived from autopsy-based research is clearly important for everyone. Remarkably, new diseases continue to emerge which can only be fully investigated by autopsy.
Who pays for autopsies?
Presently, there is no direct funding to hospitals or doctors for autopsies. As part of the federal government's Medicare funding to hospitals, reimbursement for autopsies is theoretically included in fixed payments that hospitals receive. Thus, the federal government contends that it is paying for autopsies. Since these funds are not specifically earmarked for autopsies, they may not reach the pathology department or pathologist. Managed care organizations consider the autopsy to be built into their hospital contracts. However, these organizations have stated that they are willing to reimburse for autopsies if and when they are convinced of their value. Sometimes in hospital autopsies are performed at the request of physicians, the autopsy is not billed to the patient's family, but they should check with the hospital performing the service. This is different from autopsies the family requests from private pathologists, which may lead to charges billed to the deceased's next-of-kin.
In our litigation-oriented society, a growing proportion of private-pay autopsies are motivated by distrust, anger, and a desire to sue the potentially responsible physician(s) and hospital. Several groups of pathologists and business persons throughout the country are marketing their autopsy services through direct mail, newspapers, funeral homes, and online. Whether the quality and objectivity of these private autopsies will match those of general hospitals and academic medical centers remains to be determined.
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What is the history of the autopsy?
The earliest anatomists and pathologists could be considered ancient hunters, butchers, and cooks who had to recognize organs and determine if they were suitably edible. In ancient Babylon, perhaps as early as 3500 BC, autopsies on animals were performed not for the study of disease, but rather for the practice of predicting the future by communicating with divine forces. The intestines and liver were believed to contain messages from divine spirits.
Galen (131-200 A.D.), a disciple of Hippocrates practicing in ancient Greece, performed surgical dismantling (dissection) of animals and humans. He determined that Hippocrates' theory that disease was due to four circulating senses of humor (phlegm, blood, yellow bile, and black bile) was correct. Galen was a highly respected, powerful, and dogmatic individual who dominated the medical thinking of his time and for hundreds of years to follow. It is said that the four humor doctrine paralyzed medical science for about 1400 years.
In general, before 1700 there was a negative attitude regarding the dissection of the human body. Egyptians, Greeks, Romans, and medieval Europeans performed dissections for religious reasons or to learn anatomy, but this was not done in any systematic fashion. There were, however, some notable exceptions. In the late 1200s, the law faculty dominated the University of Bologna and would order autopsies to be performed to help solve legal problems. Thus, some of the earliest autopsies were medicolegal cases. In the late 1400s in Padua and Bologna, Italy, the sites of the world's first medical schools, Pope Sixtus the IV issued an edict permitting dissection of the human body by medical students. Before such edicts from religious leaders, it was considered a crime to dissect the human body, and criminal prosecutions for "body snatching" by students of anatomy date back to the early 1300s.
By the 1500s, the autopsy was generally accepted by the Catholic Church, marking the way for an accepted systematic approach to the study of human pathology. While several "giants" around this time, such as Vesalius (1514-1564), Pare (1510-1590), Lancisi (1654- 1720), and Boerhaave (1668-1738) advanced the autopsy, it is Giovanni Bathista Morgagni (1682-1771) who has been considered the first great autopsist. During his 60 years of observations, Morgagni insisted upon the correlation of pathological findings with clinical symptoms, marking the first time that autopsies made major contributions to the understanding of disease in medical science.
Some historians say that the power of the autopsy in medical education peaked during the 1800s. At the beginning of that century, the Allgemeine Krankenhaus in Vienna was considered the premier medical center of the Western World, in large part because of the stature of its Pathology Institute which was headed by Karl Rokitansky (1804-1878). Almost every patient who died was taken to the Rokitansky Institute, which still exists in Vienna, for autopsy. Rokitansky is said to have supervised 70,000 autopsies and personally performed over 30,000, averaging two a day, seven days a week, for 45 years. Rokitansky stressed a systematic, almost ritualistic, approach to the autopsy with every patient receiving the same detailed examination. For the sake of objectivity, Rokitansky, unlike Morgagni, did not care to know the clinical history of the patients. Because of this style and his disinclination to apply microscopy routinely, many of Rokitansky's theories about diseases proved to be incorrect.
Rudolph Virchow (1821-1902), an eminent German statesman and pathologist, was a younger contemporary and competitor of Rokitansky. Unlike Rokitansky, he grew up with the microscope and was most influential in the systematic application of microscopy to study disease. Virchow advanced the doctrine which held that cellular pathology was the basis of disease, finally laying to rest the humoral theory of Hippocrates and Galen. In many ways, Virchow could be considered the first molecular biologist. Under Virchow, Berlin replaced Vienna as the premier center of medical education.
Many clinicians, upon returning from study in Berlin, became leaders in North American medicine. The most notable of these physicians was the legendary Sir William Osler, who worked in Canada and the US. Osler was arguably the most respected and revered North American physician of his time. He studied with Rokitansky and Virchow and relied heavily on autopsy studies for his education. Osler not only performed autopsies himself and taught others about autopsies, but also left detailed instructions for his autopsy. In speaking of himself, Osler told a friend: "I've been watching this case for 2 months and I'm sorry I shall not see the postmortem." As expected, the autopsy showed that all of Osler's diagnoses were correct.
In 1910, Abraham Flexner reported the sorry state of medical education in the U. S. at that time. The Cabot report issued from the Massachusetts General Hospital in 1920, based on approximately 3000 autopsies performed, revealed astonishing diagnostic inaccuracies on the part of clinicians. The resulting medical reforms included the placement of autopsy pathology as a central, integral component of medical education.
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Should the autopsy be revived?
Government agencies that regulate the accreditation of hospitals and nursing homes are deeply concerned about the decline in autopsy rates. For example, surveys have indicated that less than 1% of nursing home patients who die are autopsied. The U.S. general accounting office, which pays for some nursing home services, recently attempted to prove that particular nursing homes were substandard. Such efforts were thwarted by the lack of hard evidence. The allegations could not be proven because the patients in question were not autopsied and the actual causes of death could not, therefore, be confirmed.
Some information can only be acquired during an autopsy. The information autopsies can provide benefits to society, the medical profession, and families. Many physicians believe that autopsy should be revived. Whether or not it will be revived remains to be seen.
