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. 2001 Dec 15;323(7326):1426.

Getting consent for necropsies

Perhaps we should seek consent to show necropsies to students

Julian L Burton 1
PMCID: PMC1121869  PMID: 11744571

Editor—Sayers and Mair highlight the reasons for which hospital (consent) necropsies are performed and for which clinicians are now faced with the task of seeking informed consent—to confirm the cause of death, to answer diagnostic queries, and to obtain and retain material for research and teaching.1 Another key use of a necropsy, not mentioned on the consent form, is in undergraduate teaching. Many medical students will encounter the necropsy during their training, either witnessing the whole procedure or as a demonstration of the pathological findings of the procedure in which organs and tissues are displayed (perhaps with the patient's body in the background) before their return to the body.

Should explicit informed consent be obtained to use necropsy in this way? The short report by Westberg et al in the same issue serves to highlight the importance of obtaining consent for students to witness invasive procedures such as a vaginal examination, even though most patients do not object.2 Necropsy is no less invasive. Whether patients and relatives would object to a group of students viewing the body after death is not known. It is established, however, that “an important precondition for good education of medical students is that patients are prepared to participate in training.”3 Failure to obtain consent denies the autonomy of both the patient and the relatives.

Some people argue that, once death has occurred and the decision to allow a necropsy has been taken, the worst is over and therefore the presence of students at the necropsy is of no consequence and does not require consent. This denies relatives the opportunity to be altruistic and know of the benefits that come to students from the procedure. We should be as concerned that consent is adequate as we are with who obtains it.

References

  • 1.Sayers GM, Mair J. Getting consent for autopsies: who should ask what, and why? BMJ. 2001;323:521. . (1 September.) [Google Scholar]
  • 2.Westberg K, Lynøe N, Lalos A, Löfgren M, Sandlung M. Getting informed consent from patients to take part in the clinical training of students: randomised trial of two strategies. BMJ. 2001;323:488. doi: 10.1136/bmj.323.7311.488. . (1 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Lynøe N, Sandlung M, Westberg K, Duchek M. Informed consent in clinical training–patient experiences and motives for participating. Med Educ. 1998;32:465–471. doi: 10.1046/j.1365-2923.1998.00237.x. [DOI] [PubMed] [Google Scholar]
BMJ. 2001 Dec 15;323(7326):1426.

Most relatives give consent once reasons for necropsy are explained

Irene Scheimberg 1,2, Alan W Bates 1,2, Abigail Lee 1,2

Editor—As pathologists performing a large number of perinatal autopsies, we read Sayers and Mair's personal view with a mixture of sadness and disbelief.1-1 We do not want to increase the relatives' and (in our case) parents' grief with detailed descriptions of postmortem procedures. But current levels of information available mean that most already know the basics, and people want to have a choice. Most of the detailed explanations of what might happen to tissues and organs at a postmortem examination have been added to the consent form at the insistence of parents' pressure groups.

Teaching is essential for new doctors, all of whom need to learn at least the basics of pathology if they are going to be capable clinicians. Most of the research projects requiring postmortem tissues are clinicopathological studies. Almost all of them use tissues that will be retained for histological diagnosis anyway. Because we now need consent to retain even tissues used for diagnosis, clinicians could explain that this retention might help relatives in the future (including in future pregnancies and similar diseases in another member of the family).

Most pathologists retain full organs for teaching and training or research only at the specific request of a clinician. We are surprised that some doctors are prepared to give parents and relatives the consent form and let them deal with it by themselves in such a traumatic period.

Until recently there has not been much training in communications skills in medical schools, but surely opting out of the patient-doctor relationship at this time is not an answer. The main reasons for a hospital necropsy are to explain to the relatives what happened to the patient and to help the clinicians understand the disease process. It is not the pathologist who primarily benefits from a necropsy.

In our experience, most parents (and most hospital postmortem examinations are performed in perinatal cases) agree to the requests in the consent form for a postmortem examination once the reasons are explained to them, especially by a doctor they have met and trust. We are surprised that Sayers and Mair find it acceptable for a person whom the parents or relatives have never met before to come and talk to them at this time or at the time of the necropsy.

If clinicians want to discuss any aspect of the necropsy, including the reasons for requests other than diagnosis, we are all happy to help.

References

  • 1-1.Sayers GM, Mair J. Getting consent for autopsies: who should ask what, and why? BMJ. 2001;323:521. . (1 September.) [Google Scholar]
BMJ. 2001 Dec 15;323(7326):1426.

Bereavement teams might ask for consent for necropsy

M Holbrook 1, G Morgan 1

Editor—As we work in histopathology we have a keen interest in the process of hospital necropsy and getting consent for necropsies.2-1 We can assure all clinicians that pathologists across the United Kingdom are acutely aware of the Alder Hey scandal, and caution abounds within the profession.

Custom does indeed dictate that clinicians involved in patient care approach relatives to seek consent for necropsy, but, although the new consent forms may be overly detailed, the amount of information one is required to give relatives in order to obtain genuinely informed consent has not changed. The total time needed to achieve consent has not altered greatly, although a small amount of time is required to take the relatives through the layout of what can be a slightly confusing form.

The process of asking relatives whether they want some parts of the body or some specific organs left intact is unhelpful to them and also to the pathologist. Indeed, incomplete necropsies, without the option to take samples for microscopic examination or toxicology tests, often fail to give the definitive answers desired; the utility of doing only a partial necropsy should often be questioned. It is also unrealistic, when one considers the logistics involved, to suggest that pathologists should consult families (in the middle of the procedure) when something interesting is found that may require the results of histological tests to diagnose fully.

As Sayers and Mair state, doctors are expected to be sensitive, but therefore why do they propose that a pathologist—not previously known to the patient or family and therefore less able to empathise with their situation—should approach relatives for consent?2-1 Staffing issues should also be considered. Clinicians are stretched for time, but moving the onus to pathology, which currently has the biggest consultant staffing crisis of any specialty, would only make matters worse.

Given the changes in the medicolegal climate, new, detailed consent forms are a necessity. Maybe the best way forward is to consider employing specially trained bereavement teams to deal with this process.

References

  • 2-1.Sayers GM, Mair J. Getting consent for autopsies: who should ask what, and why? BMJ. 2001;323:521. . (1 September.) [Google Scholar]

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