Monday, May 16, 2011
The tragedy of losing a loved one can be compounded by not knowing why they died. The uncertainty leaves people wondering how the death might have been prevented and often prevents closure to allow the grieving to end. This is especially true when a young person dies unexpectedly. Luke Killian was only 16 years old when he collapsed and died at a football practice. Derek Boogaard was an NHL hockey player who was found dead at his home at age 28. When the cause of death is uncertain, the medical examiner or coroner may order an autopsy be performed to help with the investigation. While autopsies are glamorized by television detective dramas, they are perhaps more useful when performed on people who haven’t died from a crime.
The value of autopsies is well established. It helps the physician confirm diagnosis and can also help families understand how and why their relative died. The family can be reassured (or become upset) that the treatment provided was appropriate. I may also help predict whether any hereditary diseases might be present. For example, dementia is a common diagnosis but it is the result of an illness. It may make a difference to future generations if that illness was Alzheimer’s, Parkinsonism, Huntington’s or many other potential illnesses so that early recognition and treatment can be considered.
Unfortunately, the rate of autopsies that are performed is decreasing due to a variety of reasons. Medical staff are hesitant to approach grieving family members to ask permission to perform an autopsy. Doctors and nurses may be unaware of the logistics of the procedure or may have personal fears that prevent their asking effectively. Families may be fearful that the body will be mutilated and the dignity of their loved one will be lost. There may be religious issues or concern that funeral will be delayed. However, the most compelling reason that the autopsy rate has fallen is money. An autopsy is not cheap and may cost more than $2000. If a patient dies in the hospital, it is the hospital’s responsibility to cover the cost and the hospital administration may not be an advocate for the procedure. If a person dies at home or at a nursing home, the cost of the autopsy is borne by the family and is an expense that many cannot afford and one that insurance, including Medicare, does not cover.
40 years ago, hospitals were mandated to do autopsies as part of their accreditation and to improve quality. Only by looking inside could one know what had happened. Technology has progressed and with CT, MRI and PET scans looking inside has never been easier if it is used. Unfortunately, many diagnoses are missed and 20-30% of autopsies uncover and unexpected finding. The ability to learn from the patient, even after death, is perhaps the greatest gift that the family can give to the physician but the family has to be asked for that gift.
The first act that a family physician performs for a patient is signing a birth certificate. The death certificate is the final act. It notes the cause of death and lists contributing factors. Words on a form are harsh and cold and lack the compassion of explanation. The autopsy may help shed some light o nteh sadness of death.