From Death to Death Certificate: a Call for Preventing Autopsy from Dying

The article by James R. Gill, MD is informative and interesting [1]. Dr. Gill gives an excellent overview of medicolegal death investigation and death certification. We could not agree more with Dr. Gill that postmortem toxicological analysis, particularly for ethanol and drugs of abuse, plays a large role in the forensic investigation of natural and unnatural deaths. Care must be taken with the interpretation of postmortem concentrations as they must be interpreted in light of the autopsy findings and circumstances.

It is estimated that discrepancies between the clinical diagnosis and the autopsy findings could be as high as 25 % [2]. The National Association of Medical Examiners position paper [3] clearly states that a complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings.

Unfortunately, consented autopsy is on the verge of extinction. Turnbull and colleagues [4] point out that the decline of consented autopsy is one of the most rapid changes in medical practice: autopsy rates of 25 % were routine in the UK 30 years ago, yet the rate was 0.5 % in 2013. This substantial decline has also been noted throughout Europe, the USA, and elsewhere [4].

Apparently, the burden of routine tests, heavy teaching duties, and laborious administrative tasks which pathologists have to deal with in academia, certainly discourage the most experienced pathologists to engage in the practice of autopsies. The post mortem examination is a time-consuming procedure both in terms of the actual performance of autopsy and the subsequent laborious analysis of histological preparations [5].

Indeed, in a recent editorial by Stephen A. Geller, MD entitled “Who will do my autopsy?” the author opines that staff pathologists supervising autopsies in teaching programs rarely claim autopsy as their primary interest and usually have other major responsibilities [6]. These factors, together with the paucity of autopsies performed, make it very difficult for a resident-in-training to become proficient in autopsy technique and, most importantly, autopsy/macroscopic interpretation. Autopsy services are often overseen by relatively young pathologists whose teachers themselves had only limited experience. Dr. Geller further makes a comparison that years ago, it was not unusual to perform as many as four or five autopsies in a day. Now, any increase in autopsy numbers beyond a few weeks can be a logistical and physical burden in most departments [6]. Despite continuing evidence that autopsy reveals important unexpected diagnoses in a relatively high number of cases, autopsy rates in US hospitals are already well below 5 % [6].

Besides its traditional educational value, consented autopsy provides the most accurate means of determining cause of death, and therefore should remain the gold standard of forensic assessment [7]. We believe that an autopsy should be performed in any drug fatal intoxication cases. We agree with Turnbull and colleagues that one way to address this problem is to raise the awareness. This should include physicians, the general public, healthcare policy makers, and politicians regarding benefits of autopsy and to address preconceived ideas about this procedure [8], such that clinicians, hospital managers, insurance payers, and politicians should work together, in preventing this highly valuable medical practice from falling further toward extinction.

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