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March 12, 2015

Autopsies are becoming less common. Here's how that affects medicine.

Daily Briefing

Although autopsies can be integral to getting to the root of "medical mysteries," just 5% of individuals who die in hospitals are autopsied, slowing scientific advances and leaving some family vulnerable to potential undiagnosed genetic conditions, Melinda Beck writes for the Wall Street Journal.

Why autopsies have become a rare breed

In the 1960s, 50% of all people who died in hospitals were autopsied. Since then, the percentage has steeply declined. 

According to the Journal, a main reason for the decrease in autopsies was the decision in the 1970s to abolish a rule requiring hospitals to autopsy 20% to 25% of patients to maintain accreditation. In addition, neither Medicare nor private insurance companies cover autopsies—which can run up to $2,000 or more—and grieving families can be averse to discussing the prospect of an autopsy.

Meanwhile, some doctors say a misguided belief that physicians can know everything about their patients from lab tests and modern imaging technology has decreased the perceived necessity of autopsies. Dylan Miller, chair of the autopsy resourced committee for the College of American Pathologists, says, "We think we always know what's going on inside our patients, but that's a fallacy. There's as much to be gained from an autopsy as ever." 

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'We can learn so much from the people we've lost'

Experts say autopsies can provide information to family members of the deceased about undiagnosed medical issues. In fact, studies show that nearly 10% to 30% of autopsies performed reveal previously undiagnosed ailments.

For example, Sarah Friend was 12-years-old when she died suddenly at a water park in Texas. An autopsy revealed she had hypertrophic cardiomyapathy (HCM), a hereditary condition in which the heart muscle thickens and can cause cardiac arrest. After conducting the autopsy, the medical examiner encouraged Sarah's family members to get tested for the condition. Sarah's mother, Laura, found she was at-risk and now gets her heart checked regularly. Friend notes that her grandmother and uncle also died of heart complications, but neither underwent an autopsy. She says, "I keep wondering, could we have found this earlier?"

Even when a patient's death seems obvious, autopsies can still reveal unknown information, pathologists say. A 2008 study found that 54 sudden deaths outside of hospitals that were previously attributed to coronary artery disease were actually found to be caused by alternate health issues.

Ben Margolis, director of the Autopsy Center of Chicago, says discovering whether a family member's death can be attributed to a hereditary condition can be helpful in spurring lifestyle or diet changes, noting, it could "se[t] a family on a different course."

However, some people remain averse to autopsies for religious reasons or because they are scare d of having their family members cut open. "People often say they are open to learning more medical information, but they're still afraid of the concept," says Lisa Salberg, CEO of the Hypertrophic Cardiomyopathy Association, adding, "But we can learn so much from the people we've lost."

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Autopsies can also help console families. "If they are feeling guilty or angry or confused, it may help to hear that the tumor was very advanced and there was nothing more anybody could do," says Margolis.

How hospitals are helping

Some teaching hospitals offer autopsies at the family's request for no cost. For instance, Johns Hopkins Medicine in Baltimore uses autopsies as a way to help train pathology students. "If there's something we missed, we'd like to know, and we'd also like to know when we are right," says Barbara Crain, director of the autopsy service for the hospital.

Autopsies can be especially helpful in determining how individual cancers spread and change in terminal stages. They can also help differentiate Alzheimer's disease from alternate forms of dementia, which can help family members evaluate their risk.

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Researchers hope that alternate forms of autopsies—such as partial autopsies of specific organs and virtual autopsies conducted via MRI machines or CT scans—could help increase interest. However, experts note that virtual autopsies often cost as much as a traditional autopsy and cannot "definitively" determine a cause of death.

Still, some hospitals are creating their own post-mortem investigative techniques. For instance, Mount Sinai Health System in New York City plans to offer "minimally invasive" autopsies, which would use small surgical tools to remove targeted tissues samples for addition studies. Pathologists from other institutions say some of the most helpful autopsy data come from "molecular autopsies," which combine conventional autopsies and DNA tests and can provide patients' families with a complete picture of hereditary disease (Beck, Wall Street Journal, 3/9).

The takeaway: Fewer hospitals are performing autopsies on patients, a decline that has adverse effect on medicine's understanding of disease and death. Key factors driving the decline include cost and stigma.

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