Despite the benefits of autopsy - including better information on cause of death, efficacy of treatment and undiagnosed disease - the U.S. autopsy rate has dropped from nearly 50 percent during the post World War II years to an estimated fewer than 10 percent today. According to Stephen A. Geller, M.D., Chair of the Cedars-Sinai Medical Center Department of Pathology and Laboratory, autopsy can serve as an important tool for quality assurance as well as function as a measure of the appropriateness of therapies and their subsequent effect on the patient.
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Stephen A. Geller, M.D., Chairman, Department of Pathology and Laboratory, Cedars-Sinai Medical Center
LOS ANGELES (December 2, 1998) - Despite the potential benefits of autopsy, the number performed in the U.S. has declined from a rate of nearly 50 percent during the years following World War II to an estimated fewer than 10 percent today. This dramatic decrease in the autopsy rate is limiting both the quality and effectiveness of health care, according to Stephen A. Geller, M.D., Chairman of the Department of Pathology and Laboratory Medicine at Cedars-Sinai Medical Center.
"The autopsy is the 'gold standard' in the medical field in terms of diagnosis," said Dr. Geller, citing a 15 percent to 20 percent discrepancy rate in diagnoses determined before and after death. "Autopsy provides more than information on the cause of death; it also offers valuable insight into unrecognized disease and the efficacy of treatment."
These "discrepancies" are not a reflection on the medical profession's aptitude or ability, Dr. Geller points out, but the result of the limitations, uncertainties and imperfections inherent in even the most technically advanced society. Autopsy can serve as an important tool for quality assurance as well as function as a measure of the appropriateness of therapies and their subsequent effect on the patient.
"The autopsy is an excellent means of gauging the effectiveness of medications and, equally important, their relative toxicity, particularly for the many drugs employed in treating cancer," said Dr. Geller. "For example, the tendency for Adriamycin, a potent anticancer agent, to cause heart failure became understood in this way, and the dosage was modified to minimize the likelihood of fatal injury."
In addition, Dr. Geller believes that autopsy results can be valuable in compiling national statistics on disease. Because autopsy findings are not included in the national statistics, and also because so few autopsies are performed, there is no accurate information about causes of death. Such information could potentially aid in health planning efforts, he said.
"Autopsy is vital to research," said Dr. Geller, whose experience in the field spans more than 30 years. "Many important changes in medical care are based on autopsy findings, which translate into improved patient care."
According to Dr. Geller, one of the most beneficial aspects of autopsy is its ability to help families understand and cope with the death of a loved one. Studies indicate that the grieving period is reduced when the results of an autopsy, particularly in the case of a child's death, are communicated to family members. One such study looked at parents who had experienced the death of an infant. Those informed about autopsy results by their pediatrician and the pathologist within two weeks had a lower divorce rate and shorter period prior to their next pregnancy.
"Knowing and understanding the cause of death allowed these couples to wrap up a painful chapter in their lives," Dr. Geller explained. "Autopsy helps to remove the doubts and guilt that many families face, often wondering if there was something they could have or should have done." This is as true if an adult dies as it is when a child dies.
The very nature of autopsy -- and its advantages -- are misunderstood by the public and clinicians alike, according to Dr. Geller. Autopsy, derived from a Greek word meaning "seeing for oneself," allows for three kinds of "insight" -- examination of the exterior of the body, dissection and examination of the major organs and microscopic study of tissues.
Misconceptions about autopsy have led to the decline in the procedure, said Dr. Geller. For families, there is often a concern that the procedure will delay transfer of the body to the funeral home; in reality, the autopsy is performed in just two to four hours. There is also a fear that the body will be "mutilated" during the course of an autopsy, another erroneous assumption. Despite the benefits in both personal understanding and medical knowledge, families are often unaware that they can request an autopsy.
"In some cases, families deal with a number of physicians and may not feel close enough to any one doctor to ask for an autopsy, which is an option for anyone who requests it," explained Dr. Geller. "For other patients, religious objections can also be a factor, though few faiths actually prohibit autopsy."
Because autopsy is increasingly rare in medical schools, fewer physicians are exposed to the practice, which may influence their requests for the procedure, Dr. Geller stated. Another factor in the decline of autopsy is a sometimes misplaced faith in the infallibility of newer technology, though even the most sophisticated diagnostic equipment is imperfect. Perhaps most importantly, death is a difficult and sensitive issue for both physician and family to confront -- making autopsy a seemingly painful step in an already unpleasant process.
Another impediment to autopsy is the fact that it is not covered by health insurance except in Medicare cases. The cost for a typical autopsy is approximately $1,500 to $2,000.
"Many health care advocates, including myself, feel autopsies should be performed on a routine basis," stated Dr. Geller. "The autopsy is just another component in the continuum of care that ensures the best medical treatment for our patients."
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