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0855-713X102/56-60$03.00/0 AMERICAN JOURNAL OF MEPICAL QUALITY Copyright 0 2002 by American College of Medical Quality .,t.

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Voll7, No 2 Mar/Apr 2002

The 'Autopsy: A Professional Responsibility in Assuring Quality of Care
Elizabeth C. Burton, MD

Forly years ago, the value of autopsies was widely reoognized as new diseases were discovered or clarified andscientific technology advanced greatly. Despite the autopsy's strong foundation, its value is not currently being properly conveyed to physicians or patients. Although autopsy-related policy exists, these policies have had little effect on. increasing or even maintaining adequate autopsy rates, More recently, the autopsy has fallen on hard times, with US hospital rates now below 5%,The reasons for the decline in rates are multffaceted and include a lack of direct reimbursement for the procedure, lack of defined minimum rate standards, overconfidence in diagnostic ' technology, and the fear of litigation. Regardless of the reasons for the declining rates, the ethical and professional reasons for increasing the number of autopsies are far more important. Key words: Autopsy, autopsy rates, ethics, health care policy, health care quality assessment, health care quality assurance, quality of health care, '.'
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that technological advances have replaced the need for autopsies. Regardless of the reasons for the decline in autopsy rates, the ethical and professional reasons for increasing the number of autopsies are.far more important. The American Medical Association (AMA) has adopted and reaffirmed a policy that states "performance of autopsies constitutes the practice of medicine" (2). That being said, there are 5 (of the 7) principles of medical ethics of the AMA (3) that are directly applicable to autopsies: 'I. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity. II. A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or"competence, or who en. gage in 'fraud 'Ordeception. III. A physician~hall respect the law and recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. V. A physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients; colleagues, and the public, obtain consultation, and use the talent of other health professionals when indicated. VII. A physician shall recognize a responsibility to . participate in activities contributing to an improved community. . Like most of health care, economic constraints have had a huge effect on the autopsy. Many pathologists do not want to do autopsies because they are time-consuming, underappreciated, and not specifically paid for. Most clinicians do not request autopsies because . they believe that everything about the patient's' illness .was already known', the autopsy findings might contradict their clinical findings, and tHey are generally' . uncomfortable: talking with the family about the au.,

US autopsy rates have decreased ckamatically from approximately 50% in the 1960s to a low of about 5% of all patients who die in oUI hospitals under our care. Because no institution currently syste¥1.at,icallycollects autopsy rates for OUInation's hospitals, this 5% rate is an extrapolation 'based on 1995 numbers from the National Center for Health Statistics (1). It is an undisputed fact that the autopsy lias' served us well in the past by advancing medical knowledge, monitoring the quality of care, and establishing the truth. However, for the past 40 years, autopsy rates have continued to decline and autopsies are now near extinction. Reversing this problem deserves serious attention. There 'ire 4 primary reasons for the decrease in autopSies: lack .of direct reimbursemen t, lack of defined minim urn ra te standards, fear 01 malpractice litigation, and the belief
Dr Burton was with the Louisiana State University Health Sciences Center, Department ofPatbology, New Orleans, LA She is now with the Baylor Health Care System, Dallas, Tex. I , Corresponding author: Elizabeth C. Burton, MD, Clinical Scholar, Pathology and Laboraooty Medicine, Baylor Health Care System, Baylor University Medical Center, Department of Pathology, 350Q Gaston Ave, Dallas, TX 75246.

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978.. the autopsy suites in many_ decline in rates. . the Health Within health care organizations. Hospital administrators do not want autopsies done because they cost money.. .. had defined standards for a nance.. most benefits cease upon 'the patient's death.969.reimbursable exFrom a policy standpoint.tem. they have in fact restricted care. industry and accrediting agencies-no Ion:'. of these changes have ra:i:_sedoncerns that a physi-: . Further fueling:·. paymany organizations act to rejuvenate the autopsy efers do not have specific autopsy policies and because. Although these institutions have no hospitals have been converted into space for other acnew requirements for performing autopsies at a. find. Moreover. . in the past. . Currently. H~85.be performed in hostopsies. Physicians should not. HCFA states in its current hospital regulations. to families about the benefits of autopsies. the folOne reason for the restructuring of.977. Although coverage is reaffirmed a number of excelIentpolicies pertaining to "built into Medicare Part A for autopsy-related activiautopsies (AMA policies H~85. This is especially alarming because ual. and this action has certainly added to the high cost of health cafe and are therefore viewed as dispensable . " . ". nent for autopsies is covered asa:·. in the event there is no specific reimbursement figure provided in that the f~y requests that an autopsy be done. it is not assurance. H-85. when there are no facilities or provisions for autopsy performance.' hoes.973. the AMA has adopted and pense under Medicare Part A. in the plan may provide to their patients. and the Aceconomic pressures to tighten the bottom line and inereditation Council on Graduate Medical Education vest revenue up-front for prevention. When managed care plans place restrictions on the care that physicians Sles. autopsies assess the quality of care they provide if they ings from autopsies are used as a source. . only the nonprofe'!lsional composomething to hide. tutions such a~ the Joint Commission on Accreditation of Health Care Organizations (JCAHO). payment was to decrease the cost and ·overutilization (!:!). set rate. an autopsy should be performed . Additionally.13) of the AMA 'states.. they do have some standards that address autoptivities and many new hospitals are now built without sies.. and underuse all potentially threaten the quality of provisions for autopsies. fee schedule (RBRV8) for direct compensation to patholothey are denied this service or told that they will have to pay -for the autopsy. many hospitals choose not 85.989. the decline. "The medical staff should attempt to secure autopsies in all cases of The expansion of managed care has brought a verieunusual deaths and of medical-legal and educational ty of changes to: medicine. . .. veloped to provide physicians with general guide. ·.I interests of patients firat.ent~on.' .. In the Medical Staff Cha pter of the Hospi tal Manautopsy facilities.. the following points were dehealth maintenance. surprising that physicians are reluctant to talk. Whether this has been accomplished is questionable.. In response.. assessment and improvement" activities" (8).. '. the health care lowing principles apply.980.8I!ddifferr topsy. the medical staff. the JCAHO states. they become distrustful and gists for the professional c01I!po~nt of ~utopsy performay believe that the physician and/or hospital has mance (4).993) and the House of Delegates has asked that to use this money for autopsiesIfi). H-S5. Overuse. . In fact.. attempts to secure How does a hospital with no facilities or provisions for autopsies in all deaths that met the criteria. Despite the fact that the autopsy is the ultimate care and are encouraging care below minimum profesoutcome measure and the "gold standard" for quality sional standards. H-~5. may pose financial risk .to the hospital.. invest money up-front for prev.. in quality do not look at why their patients die? The Code of Ethics (E8. H-85. there exist strong Care Financing Administration (HCFA). autopsies fort. dethe new focus is supposed to be in assessing and imvelops and uses criteria that identify deaths in which proving quality within all health care delivery systems. little progress has occurred (7).s¥!!temafor physicians. but to date.. Instiare not recognized as a coverable benefit (6).. As a result. of care. . Some..964. are nonrevenue producj~g! and ~ost versely affected by the modification of the syswould rather. health mainte(ACGME). The numerical targets for autopsies were later enue producing and believe that they contribute to the eliminated. And. participate 'in al1:Y plan that enceurages or requires payment system from fee-far-service to prospective care at or below minimum professional standards.9S5. Physicians must continue to place the ' ger hold hospitals accountable for performing autop. .. misuse. and primary care. . including new .. ties (as part of the hospital's general operating exH-S5. what may have resulted is the unWhen a hospital (managed care or not) makes no derutilization of medical services.AMERIGAN JOURNAL OF MEDICAL QUALITY Autopsy: Assuring Quality of Care 57 ent reimbursement . c I eian's ability to practice ethical medicine will be ad. H~ penses in providing care). and primary care rather than to invest in auminimum number of autopsies to . Some administrators see autopsies as nonrevpitals. Instead. H-85. when the Medicare resource-based relative value scale. this shift in payment structuring has led to a definite underutilization of the autopsy.

a report shall be filed with the-Medireimplement payment for autopsies. Although the peer-redards continue to be ineffective in maintaining or inview process is generally protected from discovery. There has been a push to incompetence.and posed. Autopsy reInterestingly. replaces conjecture with facts and hard evidence in deresidents should review . these current stanview process within hospitals.. and Pensions Committee regarding monetary support does not necessarily have to be a reduction in medical errors and creation of a national. . and establishing the truth.. or documented sy rates for hospital deaths are inappropriate" (11). . the latter position seems overwhelmof a . our profeseional.. that the patient's death was a iresult of an en-or or autopsies. line-item reimbursement on a per-case basis but should be broad-and autopsy specific. Also. howWhen a coroner receives infonnation that is based ever. or medical excould have some negative consequences. soon after autopsies are performed on their patients and should review the autopsy reports" (10). ity of care. No . plaintiffs 'malpractice attorney could not only allege Ir~espective "fthese economic and legal concerna about . economically based. 1. aminer. and accountability.physician's or podiatrist's gross negligence or ingly. rate standards (Medicare . In the event of a patient's death. . Recommendations to enact direct line-item reimbursement for autopsy perfor. if reimbursement on an autopsy-specific per-case basis were to occur with a Experts in the field of quality of care have proposed concomitant increase in autopsy numbers.58 Burton AMERICAN JOURNAL OF MEDICAL QUALITY interest . Although organized pathology recognizes the value of autopsies. on a fee-for-service cal Board of California or the California Board of basis or as abillable procedure under the RBRVS. Economic reaboard-certified or board-eligible pathologist.2743) that have been referred to the Senate Health.. in quality assessment but have not supported policy California is the only state with a statute currently in changes for minimum rate standards as a condition of place that specifically addresses protection from legal participation fQT' Medicare or by the JCAHO for hosliability when disclosing gross negligence for the public pital accreditation. autopsy report in some instances is not. Passage gal standpoint. This Podiatric Medicine.. there are 2 Senate bills (8. without a defined minimum rate. " (9). the CAP BOiUd of Govgood. ''Numerical standards or minimum autopon findings that were reached by. gross . pathologists are firmly divided on the ports generated by coroners or medical examiners can be publicly accessed under state freedom-of-informaautopsy issue. physician and surgeon. For decades. In this regard.f: . nor any autPorized agent. the autopsy has been a part of and should remain an essential component of the peer-rerelated standards. assessing the qualher acting in compliance with this section. The autopsy viewed and autopsies performed whenever possible . shall be liable for autopsies have traditionally been viewed as a means the damages in any ~vil action as a result of his or for advancing scientific knowledge. shall be liable for damages in any 'reasons for doing autopsies when the qu~ity of care civil action as a result of his or her providing information.. No coroner. the motithat error reporting for improving systems of care will vation for doing autopsies could be publicly scrutinot likely occur until confidentiality and reporting pronized. '1 ernor's affirmed its position that autopsies are important in quality assessment and improvement but. termining the cause of death and could allow for . ical errors and improve'patient safety (19 20). Alprompt dismissal of the case or a quick and fair settlethough these institutions continue to include autopsyment. Both the American Society of dictions recognize the exception that autopsy reports Clinical Pathologists (ASCP) and the College of Amerare considered medical records and thus can be exican Pathologists (CAP) support the use of the autopsy cluded under the freedom-of-information acts (14-16). (17) we provide is at stake.2738 and JcAHO) would not only force the autopsy numbers up but' could force monetary support for this service. the creasing autopsy rates. monitoring. perhaps a different strategy is in order.he .'of these bills could likely impact autopsy performance. The fact that 'an autopsy was not of patients who received care by residents must be reoffered or performed could be detrimental. legislation extending peer-review protections related to mance to date. Some juristo change/autopsy policy. Labor. The Residency Review Committee of negligence but could also allege that the death might the ACGME for Internal Medicine states. . The 8. stated. nor any sqns should not override the professionaljand ethical authorized agent. Currently. as physicians. "All deaths have been hastened or caused by economic incentives to undertreat (12). and histological.. not much effort is expended "tion acts' unless an exception applies (13). Recently. and approved by a board-certified or board-eligible pathologist indjcating th~t a death may be a result Unfortunately. Because there has been no progress in achieving tections are in place (18). Education.and ethical I' J . The report shall be confidential. patient safety and health care quality have been proRedefining minimum. voluntary reporting systerp to continually reduce medAutopsy issues present a real conundrum from a le.

. This code does not exclude full disclosure to the patient's family or . Fla Stat §415. C4P Trxlay. we have no idea about the magthe facts necessary to ensure understanding of what nitude of our 'undertaking. 2001. despite this overconfi-. 2. Residency Review Committee. TheArchives ot Pathology and Laboratory Medicine 'and the autopsy.. 512. 'Institutional and economic influences on autopsy performance. we science (21-27). Although the cited reasons for the decline in autopsy rates are true. occur solely through the accumulation of objective evidence.·in 10-15% of the cases. do autopsies? In my opinion. Autopsy: Assuring Quality of Care 59 obligations should prevail! Technologica. 5. 42 CFR Cb. Without it. f •• . Furthermore. 17. and then by law. 1b Err Is Human: Building a and the AMA Code (EB. Modified: Res. then this is morally reprehensible. 28: E51. 533 NE2d 1359. Q & A. Oakbrook Terrace. Accreditation Council 00 Graduate Medical Education. negligence/malpractice litigation) should not override our moral and ethical principles. 1996. documented premortem diagnostic errors occur I formation for shared decision making. How can we fulfill these obligations if we do not might uncover mistakes. Available at: http:// www. Donaldson M. provide compasin -approximately 40% of all patients autopsied. Nemetz PN.12) of the AMA states. Nemetz PN. of which the most fundamental obligation is trust. also have an obligation to society in exchange for the if the premortem diagnosis had been correct.. H-85. 1~. most physicians dislike medical uncertainty sick. Lundberg GO. arid critically assess the porting the fact that clinical diagnosis' is not an exact 'care that we provide. to expand. 19911.. we have a fiduciary duty to our patients. Nonetheless. In these sttl. Being J. the treatpublic investment incurred for' our training as physiment and outcome could have changed (2B-30).orgll'eq/140pr700. inquiry leads to knowledge.acgme. and\ learn from our mistakes. And. Lundberg GD. Burton EC. Code of Medical Ethics Current Opinions and Annotaticns. The emotional needs of the family and the integrity of the physician-patient relationship must at all times be given foremost consideratioh" (3). sup-:' sionate and competent care.978. 7. 6. Furthermore. 1988. Accrediuuion. Unforcians to use our skills and knowledge to benefit the tunately.. personal fear of the consequences.l advances that we will act in his or her best interest. provide anything new. 8. "Disclosing the death of a patient to the patient's' family is a duty which goes to the very heart of the physician-patient relationship . 9. First and foremost.18) states.surrogate in such cases where the physician has erred and death has occurred as a result. 18.' 11. Corrigan J. IV at section 482. A potpourri of legal issues relating to the autopsy. Internal Medicine. and each patient trusts . Carey K. includes the ability to recognize. 14'. Additionally. Low-tech autopsies in the era of high-tech medicine: continued value for quality assurance and patient safety. 2001. HeraJil Co v Murray. Healthcare Finance Administration. the interests of the individual physician or health care organization (eg. A-OO. Scientific and the potential for inciting malpractice litigation. ~e"must bring back the mistake or judgment. fallibility is an inevitable of autopsies because of concerns of personal discredit and necessary feature of intellectual growth. A·90.8:150. Powers J. sician should at aU times deal honestly and openly admit. Vol §802. " has occurred.280:1273-1274. AB physihave contributed to the illusion of clinical omniscience cians. and to apply this sense of failure. 524 NYS2d 949. Section TV.. Med Cien Med.504. Board takes stance on autopsy service pay. Res. Knowledge also occurs through self-discovery It is a fundamental ethical requirement that a phyand self-c1ticism and. THe demand to with patients . This may result in avoidance . the physician is ethically required to inforrri-the patient of all autopsy.252:390-392. 3.AMERICAN JOURNAL OF MEDICAL QUALITY . This leads to a through research and publication. Condition of Participation: Medical Staff. F. Arch PallwI Lab Med. followed by the internalized belief that: . tions that may have resulted ffum the physician's and making health care safe. American Medical Association. these reason's are inappropriate for not performing autopsies. Sub. Burton EC. 4. JAMA 1984. Vol. December 1994.!ations. NY County §677.asp#edu. 16. Ill: Joint Cbmmission on Accreditation o(Healthcare Organizations: 1995. Herald Co.22 (d).120:759-762. \ References I. Chicago: American Medical Association. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with the 'patient'! (3) :. 1112. Situations occasionally occur in improve the~quality of health care surrounds us. Medical error and outcomes measures: where have all the autopsies gone? Medscape Gen Med. Manual lor Hospitals. : . as physicians. it is our ethical and professional responsibility and th~ mis'conception that autopsies no longer reveal to deal openly and honestly with our patients. ' Physicians are first bound by ethics(moral culpability) . 2000. 15. Kohn L.5j 1990. JAMA 1998. knowledge in the treatment and care of our patients error~ equate to negligence and the fear that autopsies (31). Cal Bus & Prof Code. 524 NYS2d 94·9:App Div. our patients (and their families) with the necessary indeuce. but knowledge does not The Code of Ethics (EB. 10. Globe Newspaper'Co. C4P 7bday. 2000. Jul 7:E51.14:5. 172. and validate our knowledge and perceive errors as unacceptable. Ifwe which a patient suffers significant medical complicaare truly serious about narrowing the quality chasm. . if the physician suspects thl:\t_ a death is a result of his/her mistake or judgment and chooses to avoid discovery by not requesting an autopsy. advance.

2000. Bayson R.htmll.120:739-742. 1996.Safer Health System. Burton EO. 1991. Diagnostic errors discovered at autopsy. .308:1000-1005. Lee KK. • 31. Forensic Sci Int. Muntwyler J.318:1249-1254. Autopsy diagnoses of malignant neoplasms: how often are clinical diagnoses incorrect? -". 2000. N Eng/ J Med.196:203-210.110:210--2i8. Robbins SL.60 . Schafii C. Troxclair DA. 2000. Medicine (Baltimore). DC: Nationai'Academy Press. 28. An autopsy study of cancer patients.355: 2027-2031. Available at: http:// thomas. 27. Diagnostic yield cif the autopsy in a university hospital and a community hospital.loc.265:885-887. Kirch W. The value of the autopsy in three medical eras. Papadakis MA. Mangione CM. Myers A. LAndefeld CS. Available at: http://thomas. 1988. Diagnostic errors in three medical eras: a necropsy study.2. and society.gov!cgi-binJbdquerylD?d106:338:. 20. A bill to amend the Public Health Service Act to reduce medical mistakes and medication-related errors. 1998. Sonderegger-Iseli K. . Babe C.htmll. I. et al. Comparison of the clinical and post mortem diagnoses of the causes of death. Pellegrino ED. Miediagnoais at a university hospital in 4 medical eras. 1974. Acta Med Scand. A bill to amend the Public Heath Service Act to develop an infrastructure for creating a national voluntary reporting system to continually reduce medical errors and improve patient safety to ensure that individuals receive high quality health care. Treatable abdominal pathologic conditions and unsuspected malignant neoplasms at autopsy in veterans who received mechanical ventilation. 29. et a1. 2000.. Lancet.Itemp/-bdTrL T::V bssldl06query. 21. 30. 2. 19.loc. et al. Bauer FW.280:1245-1248. Ermenc B. Washington. families. N Engl J Med. Arch Pallwl Lab Med. Some ethical reflections on the obligations of pathologists. Nichols L. et al. JAMA 1998. Chren MM. JAMA. 1983.Itemp/ -bdTrLT::l!bssldl06query. Britton M. .221:1471-1474. 2000. Aronica P. JAMA. Accuracy of the clinical diagnoses (1955 to 1965) Boston City Hospital. Newman WP Ill. Burger B. The autopsy.govlcgi-binlbdquerylD?dI06:337 :. 1996. 1972. Goldman L. 26. 23. Burton AMERICAN JOURNAL OF MEDICAL QUALITY 24. Robbins S. hospitals.75:29-40. 25. Are autopsies obsolete? Am J CUn Pathol.114:117-119.