Declining Clinical Autopsy

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924 Arch Pathol Lab MedVol 125, July 2001 Autopsy Rates in Halifax, Nova ScotiaWood & Guha

Historical Perspective

Declining Clinical Autopsy Rates Versus IncreasingMedicolegal Autopsy Rates in Halifax, Nova Scotia

Why the Difference? A Historical Perspective

Marnie J. Wood, BSc; Ashim K. Guha, MD, PhD

The downward trend in the rate of clinical autopsies hasbeen extensively documented in the literature. This declineis of concern when the benefits of the clinical autopsy areconsidered. In contrast, the rate of medicolegal autopsies

has not been studied in such detail. What little referencethere is to medicolegal autopsy rates suggests an absenceof the same downward trend. A retrospective review ofautopsy data over a 13-year period from the Queen Eliz-abeth II Health Sciences Centre in Halifax, Nova Scotia,and from the Office of the Chief Medical Examiner of NovaScotia was conducted. This review showed a difference be-tween the rates of clinical and medicolegal autopsies forthe metro Halifax area. The clinical autopsy rate was con-sistently less than 30% and declined to 15% in 1999, whilethe medicolegal autopsy rate was consistently greater than40% and rose to 62% in 1999. The literature proposesmany reasons for the decline in the clinical autopsy rate,but none for this difference between rates. The explanation

proposed here is the changing and currently uncertain pur-pose of the clinical autopsy versus the clear, and consistentover time, purpose of the medicolegal autopsy.

(Arch Pathol Lab Med. 2001;125:924930)

The word autopsy is from the Greek, meaning to see foroneself. Along with the terms necropsy (literally, tolook at the dead) and postmortem examination (which mayinclude external and/or internal examination), autopsyhas come to refer to the systematic examination of a deadperson for medical, legal, and/or scientific purposes.1 Theautopsy is the ultimate medical consultation. 2 Histori-cally, the autopsy played a very important role in the de-

velopment of medicine. Early clinical autopsies were doneby researchers and clinicians who had followed their pa-tients throughout life and the course of their diseases. Au-topsies were more limited several centuries ago, when thepostmortem examination was carried out only until thesuspected cause of death had been demonstrated, and

Accepted for publication February 13, 2001.From the Faculty of Medicine, Dalhousie University, Halifax, Nova

Scotia (Ms Wood and Dr Guha); and the Department of Pathology,Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia (DrGuha).

Reprints: Ashim K. Guha, MD, PhD, Division of Anatomical Pathol-ogy, Mackenzie Bldg, Room 720, Queen Elizabeth II Health SciencesCentre, Victoria General Site, Halifax, Nova Scotia, Canada B3H 1V8(e-mail: [email protected]).

may only have included examination of 1 organ or a smallarea of the body.3 In those cases, the recorded cause ofdeath may have been unrelated to the actual cause or mayhave been merely a complication of the unrecognized fatal

disease. Teachers of anatomy also used the autopsy as ateaching tool. Gradually, pathology became a separatespecialty, defined by Virchow as the science that studiesthe causes, mechanisms, and consequences of diseases. 4

The task of autopsy performance has fallen to patholo-gists, and the autopsy has become a more complete andconsistent procedure. The procedure is done in an autopsysuite equipped with all the necessary tools, which may belocated at a variety of sites, such as the hospital or medicalexaminers building, but which is usually away from thegeneral hustle and bustle. Modern techniques, such as mi-croscopy, immunofluorescence, and immunoperoxidasestaining have added new dimensions to this very old pro-cedure.

Two basic types of autopsy exist. The clinical or aca-demic autopsy (also referred to as a hospital autopsy5) isdone at the request of the family or the physician (withpermission from the family) of the deceased.6 In this case,the cause of death is usually known. The purposes of thistype of autopsy include determining the cause of death (ifunknown), providing correlations between clinical diag-noses and symptoms, determining the effectiveness oftreatment, studying the course and extent of disease pro-cesses, and educating medical personnel.7 The secondtype, a forensic or medicolegal autopsy, is performedwhen the cause of death is not certain, usually in the caseof unexpected, unexplained, or unnatural deaths.8 These

medicolegal cases may be further divided into criminalcases, which are suspicious in nature, and noncriminalcases, in which no foul play is suspected.6 A medicolegalautopsy may be ordered by an official death investigatorto assist in determining the cause and manner of death.7

This information must be determined accurately for thedeath certificate. In all medicolegal cases, the legal au-thority (such as the provincial medical examiner in NovaScotia) has the sole power to order an autopsy, and nopostmortem procedures may be carried out without his orher permission.9 The medical examiner, if also a patholo-gist, may perform an autopsy or may refer the autopsy tobe done by a hospital pathologist.8,10

Even the general public has a vague idea of what the

performance of an autopsy entails, although they may not


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Arch Pathol Lab MedVol 125, July 2001 Autopsy Rates in Halifax, Nova ScotiaWood & Guha 925

Comparison of clinical and medicolegal au-topsy rates for Halifax, Nova Scotia, from1987 to 1999. Each point represents the au-topsy rate for a particular calendar year. Theclinical autopsy rate was calculated as thenumber of clinical autopsies performed divid-ed by the number of in-hospital deaths (ex-cluding medical examiner cases) for the sameyear multiplied by 100. The medicolegal au-topsy rate was calculated as the number of

medicolegal autopsies performed divided bythe number of deaths reported to the medicalexaminer for the same year multiplied by100.

fully understand why autopsies are done. Indeed, this lackof understanding may also exist within the medical com-

munity itself. In the last half of the century, the rate ofclinical autopsy performance has dropped.2,1113 The liter-ature suggests medicolegal autopsies are not experiencingthe same trend. Rates of autopsy are now so low thatpostmortem examination other than for medicolegal pur-poses is in jeopardy. 14 This article demonstrates a dif-ference in rate between clinical and medicolegal autopsiesusing local data and then considers reasons this differencemight exist.

CURRENT STATUS OF THE AUTOPSY

Clinical autopsy rates have been in decline for the lasthalf of the century. The figures cited are American, but

similar traits have been noted in Canada.13

As early as the1950s, concerned persons were expressing alarm over thefalling rates.14 In the early 1940s, the autopsy rate for in-hospital deaths was approximately 50%.2,13 In the 1950s,the required rate for accreditation was 25% in teachinghospitals and 20% in nonteaching hospitals.2 In the early1970s, the required rate was dropped and the numbersplummeted.2,13 By 1973, rates had fallen to 22%, and by1984, to 13.2%.2 A national study in 1994 by the Collegeof American Pathologists found 75% of hospitals had anautopsy rate less than 13.5%, and 50% had rates less than8.5%.15 In 1995, some North American hospitals had ratesas low as 7%.13 A 1996 survey of 2 major teaching hospitalsfound rates of 5% and 15%.2 In contrast, there is less lit-

erature on the rate of medicolegal autopsies. It has, how-ever, been suggested that medicolegal autopsy rates arenot falling as steeply as clinical autopsy rates.14

A retrospective review of data from the Queen Eliza-beth II Health Sciences Centre in Halifax, Nova Scotia, andthe Office of the Nova Scotia Medical Examiner confirmsa difference between clinical and medicolegal autopsyrates in the metro Halifax area. The Figure illustrates thesefindings. The rate of clinical autopsies is consistently lessthan 30%, falling to less than 20% in the final 4 yearsexamined. The medicolegal rate is consistently greaterthan 40%, rising to 62% in the last 2 years examined. Al-though the clinical autopsy rates are higher than rates re-corded in the literature, the clinical autopsy rate is far lessthan the medicolegal autopsy rate in each of the 13 years

examined. The data also demonstrate that the clinical au-topsy rate has decreased over time, while the medicolegal

autopsy rate has increased.The literature suggests a variety of reasons for the de-

crease in the number of clinical autopsies. The increasingcost of the autopsy, which fewer people seem willing topay, is almost certainly a factor. A single autopsy, depend-ing on the extent and number of extra procedures used,may cost between US $1200 and $3000.14 In Canada, thecost of clinical autopsies is covered by the hospital, andmany administrators want to spend only a small portionof their budget on autopsies.13 The budget for medicolegalautopsies is covered by the Department of Justice. A min-imum autopsy rate is no longer required for hospital ac-creditation, so there is no push to maintain a certain stan-

dard rate.

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Also, physicians do not realize the importanceof the autopsy because medical education no longer em-phasizes this procedure.14 Physicians graduating in thepast 10 years from two thirds of medical schools have notbeen exposed to an autopsy. Why should doctors careabout having autopsies performed when they dont evenunderstand what the procedure involves? 13 Physicianswho do not realize the importance of clinical autopsiesare probably less likely to request permission to performautopsies. Many physicians take comfort in the perceivedcertainty that new clinical diagnostic tools can replace theautopsy, making it out-of-date and unnecessary. Thisopinion has led to a reduction in the clinical autopsy rate.The clinical autopsy might, however, still be useful in elu-

cidating the limits and weak areas of new diagnostic tools.The fear physicians have that an autopsy will reveal a mis-take in treatment and lead to litigation prevents manyfrom requesting an autopsy. No one wants to know abouterrors in this time of litigation. 16 There is evidence tosuggest these fears are ungrounded. A study by Haque etal17 at the University of Texas Medical Branch at Galvestonfound only 2 of 6168 clinical autopsies provided resultsleading to malpractice suits. Many more autopsies provideevidence that exonerates hospital staff of wrong-do-ing.10,14,17 The clinical autopsy is also losing prestigeamong pathologists and is competing for time with otherlaboratory duties. In addition, family objections based onmisconceptions may result in permission for a clinical au-

topsy not being granted. It is also possible that physicians


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are simply not asking for the familys permission to per-form a clinical autopsy because they are not trained todeal with this uncomfortable situation.14,18

These reasons may explain the decline in number ofclinical autopsies; however, they do not explain why therate of medicolegal autopsies is not declining as well. Thecost of both procedures is equally high, and neither typeof autopsy is emphasized in medical education. Granted,families of the deceased are not able to refuse permission

for a medicolegal autopsy to be performed, but patholo-gists may be equally reluctant to perform this time-con-suming procedure if newer techniques exist to obtain thesame information. An examination of the history of theclinical and medicolegal autopsy may provide some in-sight into the recent difference in performance rates.

THE CLINICAL AUTOPSY

The knowledge of normal versus abnormal anatomydates as far back, and perhaps further, as 1500 BC, whenanimal entrails were examined for clues to the future.1

During the mummification process, the Egyptians alsogathered such information about humans. As early as 400BC, Hippocrates believed that disease resulted from nat-ural causes,3 in contrast to the belief in supernatural, spir-itual, and humor disturbance causes held by the major-ity of the population at that time. These mistaken beliefswould initially prevent the clinical autopsy from findingan accepted place in medicine. It took a long time for theconnection to be made between disease and associatedchanges in the organs of the body. The autopsy did havean early place in medicolegal cases and in the furtherstudy of anatomy. Around 300 BC, Herophilus was usingdissections to teach anatomy, and he wrote a treatise onhuman anatomy but paid no attention to abnormalities ofstructure.1 In this manner, empirical knowledge of anato-my was gradually gathered. In 200 BC, Erasistratus was

probably the first to carry out dissections to look forchanges due to disease. However, when Galen popular-ized disturbances in the 4 body humors as the cause ofdisease,3 he sent medicine on a long-lasting wild goosechase.

In the 13th century, dissections were being done duringplagues in order to better understand the illness. 4

These procedures were paid for by the state and illustratethat people were beginning to see the autopsy as morethan a way to learn anatomy. The first recorded autopsyperformed in the New World was in 1533. Female con-joined twins were dissected to determine if they had 1soul or 2.3 At the end of the 15th century, the Italian phy-sician Antonio Benivieni was the champion of the autopsy.

In 1507 he published the first book of anatomical pathol-ogy, titled Remarkable Hidden Causes of Disease.3,4 This wasthe very beginning of clinicopathologic correlation and setthe stage for wider acknowledgement of the link betweendisease and body structure.

During the 17th century, clinical autopsies and the re-cording of their results became more common. While theprevailing view was still that clinical autopsies were awaste of time, in 1679 the Sepulchretum was published. TheSepulchretum contained a collection of autopsy reportsfrom noted physicians of the time.3 The reports were in-consistent and contained few clinicopathologic links, butthis book set the stage for the clinical autopsy to assumea place of importance in medicine. By the 18th century,reference to clinical autopsy reports could be found in

many journals.3 Physician Hermann Boerhaave was pub-lishing far more detailed reports than had been seen be-fore. Boerhaave was also the first to begin placing impor-tance on the complete clinical history of the patient, stat-ing, Everything pertaining to the case must be listed: northat least thing neglected which a critical reader mightrightly seek to understand the malady.3 This attitude canbe seen throughout the following century, as the clinicalautopsy became the end of the complete story of an ill-

ness. The clinical autopsy was gaining a major place inmedicine. Italian physician Morganis work at the Univer-sity of Padua solidified the correlation between clinicalsymptoms and pathologic findings, and pathology becamethe basis for medicine of the time.3,19

Xavier Bichat, a French physician in the 19th century,felt very strongly about the place of the clinical autopsyin medicine: You can take notes for 25 years, from morn-ing to evening, by the patients bedside on diseases of thelung, heart and stomach, and the result will be a long listof confusing symptoms, leading to incoherent conclusions.Open a few bodies, and you will see darkness immediate-ly recede. 4 Bichat was also the first to consider lookingfarther than the organs and examine their component tis-sues. This was before the time of the microscope, but hestill made much progress in this area. At this point, au-topsies were still done by clinicians. Clinicopathologic cor-relations allowed diseases to be defined much more clearlyand their progression over time noted. The developmentof the microscope allowed others to pick up where Bichathad left off, and pathology was revolutionized. The grossexamination of the body was joined by the first of manyhigh-tech companions. In fact, the limits of gross exami-nation alone were being recognized.

Rokitansky (mid-19th century) worked at the Patholog-ical Institute at Vienna and began the separation betweenpathologists and clinicians. Rokitansky performed or ob-

served autopsies on almost every patient who died in thehospital (more than 30 000).1 He attempted to work back-ward, using autopsy results to determine the clinical find-ings.19 Although many of his theories proved incorrect,Rokitansky provided a huge databank of autopsy infor-mation. His advances were spread throughout the world.Around the same time, a German physician, Virchow, be-lieved that pathology was a science in its own right, sep-arate from the clinical side of medicine. Virchow was alsoa leader in setting forth a regular and definite techniquefor the autopsy, and he emphasized a long, complete au-topsy.3,4,19

At the beginning of the 20th century, most clinicianswere still spending a great deal of time in the autopsy

room, confirming or clarifying diagnoses. ProminentAmerican physicians spent time in Europe learning ana-tomical pathology from the masters.19 Sir William Oslerwas a Montreal physician who worked at Johns Hopkinsand turned the place upside down. 19 Osler championedthe autopsy, following his patients to the autopsy roomand even leaving detailed instructions for his own autop-sy.19 He is quoted as writing, To investigate the causes ofdeath, to examine carefully the condition of organs, aftersuch changes have gone on in them as to render existenceimpossible, and to apply such knowledge to the preven-tion and treatment of disease, is one of the highest objectsof the physician. 19 This expresses the use of the clinicalautopsy at the time, which was to elucidate disease pro-cesses and the effects of treatment. Clinical autopsies soon


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came to have another use. In 1910, an American report byFlexner was published. The report stated that good hos-pitals had high autopsy rates, otherwise physicians couldbury their mistakes.3 This report was followed by the Ca-bot Report in 1912, which revealed many diagnostic errorswere occurring in American hospitals and could be foundonly through autopsies. Through these reports, the clinicalautopsy became associated with quality control.3,19

The purpose of the clinical autopsy has shifted since its

beginnings as a tool for teaching anatomy and a way tosearch for the soul. As information about human anatomywas gathered, the autopsy gradually became a way to ex-plore disease processes. Pathology, and the autopsy as itstool, then became a science in its own right for gatheringmore information about disease processes. In the first partof this century, the clinical autopsy became a method ofmonitoring the quality of care and the diagnostic abilitiesof physicians and their equipment. Throughout the lasthalf of the 20th century, the importance of the autopsy tothe medical community and the public had to be defend-ed. This is a long fall from the esteemed position the au-topsy held a short 100 years ago. Administrators, physi-cians, and the public may be falling into the same trap.There is a tendency to place much faith in new, high-techdiagnostic techniques, such as ultrasound, magnetic res-onance imaging, computed tomography, and endoscopy.The belief is that these procedures illustrate all there is tobe known about a particular disease and make autopsyresults redundant. However, this faith in high-tech diag-nostic tools over the clinical autopsy may be somewhatmisplaced. As Lundberg20 pointed out, there is a gap be-tween how well high-tech diagnostic medicine performsin theory and how well it performs when human decisionmaking (how and when to use the technology) is addedto the equation. Several studies have shown that the au-topsy should still be considered the gold standard in di-

agnosis and that autopsies are absolutely necessary to as-sure the quality of care given to patients, both those treat-ed successfully and, especially, those who die. In a studyby Nichols et al21 at a major tertiary-care center, 44.9% ofautopsies found at least 1 undiagnosed cause of death. Forexample, a patient with cirrhosis had what was interpret-ed radiologically to be a scar. On necropsy, a rare mixedhepatocellular and cholangiocarcinoma was discovered. Intwo thirds of these cases the undiagnosed cause of deathwas determined to have been treatable. These misdiag-noses were often related to patient inability to relatesymptoms or the masking of symptoms by other treat-ments. In another study, Burton et al22 found a 44% dis-cordance between the clinical and autopsy diagnosis of

neoplasms at the Medical Center of Louisiana at New Or-leans. Furthermore, Roosen et al23 looked at autopsies per-formed on patients dying in the medical intensive careunit. In spite of more modern diagnostic techniques, 16%of these autopsies found missed major diagnoses, thetreatment of which might have prolonged survival. Final-ly, Sonderegger et al24 showed a drop in the frequency ofmajor missed diagnoses from 30% to 14% over 20 years,mainly due to a decrease in the misdiagnosis of cardio-vascular disease. The autopsy rate at this facility in Zurich,Switzerland, was approximately 90% consistently over thestudy period, a record that enhances the credibility of thefindings. While the purpose of the clinical autopsy maynot be as clear as in the past, it can be seen from thesestudies that the autopsy has a large role to play in quality

assurance and in elucidating the limitations of diagnostictechniques. It can therefore be concluded that the autopsyis still a cost-effective and useful procedure.

THE MEDICOLEGAL AUTOPSY

Forensic pathology is generally considered a recentlydeveloped subspecialty of pathology dealing with the ex-amination of living or dead persons to provide expertopinion regarding the cause, mechanism, and manner of

disease, injury, or death. This discipline is also concernedwith identifying persons, determining the significance ofbiological and physical evidence, correlating and recon-structing wounds, performing comprehensive medicolegaldeath investigations,7 and applying medical knowledge tolegal issues. However, the history of forensic medicine andthe postmortem examination actually dates back to antiq-uity, when bodies were most often examined to determineif death occurred as a result of suicide or homicide. Theancient Greeks felt suicide to be a rebellion against thegods and the Romans saw it as a crime against the state.As such, there was great stigma attached to the familiesof those who committed suicide. In 1184, the Roman Cath-olic Church added suicide to canon law, further adding tothe importance of distinguishing it from other manners ofdeath.16

During the 6th century, Justinian law called medicolegalexperts to testify in cases of rape, criminal abortion, andmurder. Attitudes at the time were still against openingthe bodies of the deceased, but external postmortem ex-aminations were done and the evidence obtained wasused in court.16 Subsequently, during the medieval period,dissections of corpses were done in Italy at the Universityof Bologna under the control of the faculty of law to solvelegal matters. There is also a report dating from 1302 of acourt-ordered autopsy done at the University of Bolognato investigate the suspicious death of a nobleman.3 Fur-

thermore, there was a Chinese publication in the 13th cen-tury that was much ahead of its time. Titled His Yuan Luor Instructions to the Coroner, it dealt with findings in casesof infanticide, drowning, hanging, poisoning, and assault.In Germany during the 16th century, the code of Bam-burg, and later the broader penal codes, brought about arequirement for medical testimony in putative forensiccases. These codes also allowed the opening of bodies toexamine the depth of and damage caused by wounds.16

Today, a murder case would be thrown out of court with-out complete autopsy results.

Throughout history, there have always been religiousbarriers to the performance of autopsies. Clinical autopsiesin some cultures were forbidden. For example, Jewish laws

stated that an autopsy was a disgrace to the body, andprior to the 18th century, clinical autopsies were not per-mitted. However, there is a passage in the Talmud allow-ing an autopsy if the evidence provided might save thelife of an accused murderer.16 This illustrates that even re-ligious authorities at times have recognized the impor-tance of the forensic autopsy and its difference from aclinical autopsy.

The field of legal medicine continued to grow, and inthe 18th century the first series of lectures on the topicwas given at the University of Edinburgh by Sir AndrewDuncan. As the field expanded, Europeans developed 2different ways of providing medicolegal professionals forsociety to use. On the continent and in Scotland, the uni-versities and associated hospitals took over the provision


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of specially trained physicians. In England, the coronersystem was established under the constabulary. A coronerwas an official of the court with no medical training. Thecoroners responsibility was to investigate deaths fallingunder his jurisdiction. During the investigation, the coro-ner often consulted a police surgeon, usually a generalpractitioner with some special training. A pathologist wasconsulted only if an autopsy was required. The term cor-oner was derived from crowner. A crowner was a represen-

tative of the King, who collected taxes, convened court,and distributed the property of those found guilty of mur-der. Because of the latter responsibility, the crowner be-came associated with death and its investigation.16

The coroner system began in America in the 17th cen-tury, but was gradually abolished because of the potentialfor political interference. This system was replaced by thedistrict attorneys office, which took over the legal aspectsof death investigation, and the medical examiners office,which took over the medical aspects of the investigation.The medical examiners office is staffed by trained forensicpathologists.16 The College of American Pathologists firstformed the Committee on Forensic Pathology in 1952.2 Itspriority was to increase forensic training for pathologistsand raise the standards in what was becoming a subspe-cialty. Through the 1960s and 1970s, funding becameavailable for fellowships in this subspecialty.

In Nova Scotia, Canada, the medical examiners office isunder the jurisdiction of the Department of Justice. It isthe budget of this department that pays for medicolegalautopsies. Deaths falling under the jurisdiction of themedical examiner include death from any unnatural en-tity, when a medical cause of death cannot be establishedwith reasonable accuracy, death occurring while a personis in custody (jail or psychiatric), and death by unduemeans or when there may be medical culpability.7 Alldeaths meeting one of these descriptions must be reported

to the medical examiner, who becomes responsible for theinvestigation and for the ordering of a medicolegal autop-sy if deemed necessary.6,7

The medicolegal autopsy differs from the clinical autop-sy in several ways, one of which is that it has not expe-rienced the same decline in rate or prestige. If anything,the forensic autopsy has had a recent gain in popularity,especially among the general public. Autopsy results arefeatured in news reports of suspicious deaths. Televisionnetworks, such as A&E and TLC, are full of specials onmedical examiners offices and forensic medicine. Evenpopular television shows, like the X-Files, often featurescenes of an autopsy (usually done by the female charac-ter, alone, late at night in a dark and spooky room). An-

other difference is that the medicolegal autopsy seeks toanswer a specific legal question: What is the cause andmanner (natural, homicide, suicide, accidental) of death inthis case?16 This question has remained constant for themedicolegal autopsy throughout time, in contrast to theclinical autopsy, which seeks to answer many questions.While the point of a medicolegal autopsy remains focused,the adequate answering of this question often requires anextensive investigation. The medical examiner has thepower to determine the extent of the autopsy to be per-formed, but medicolegal autopsies are rarely limited.7 Tocontribute as much as possible to the prosecution of theguilty and the defense of the innocent, there is an extraemphasis on completeness during a forensic case. Theonly thing worse than no autopsy is a partial autopsy in

forensic cases.25 A partial autopsy may lead to a later ex-humation of the body, as what seemed to be unimportantat the time turns out to be vital to the case. While theactual dissection is often the same as the clinical autopsy,the medicolegal postmortem examination often begins atan earlier stage, the place of death. Here the position, lo-cation, clothing, personal effects, signs of death, and in-juries are correlated with the circumstances and docu-mented.6,7 Careful observations of the surroundings must

be made and meticulous notes kept.16 Also, a forensic in-vestigation may involve trying to determine informationreadily available in a clinical case, such as the identity ofthe deceased and time of death. The external examinationmay also take on additional importance in a forensic case.There is often much information to be gathered from ex-ternal wounds. The speed and angle of a striking auto-mobile may be determined from the characteristics ofabrasions. Bullet exit wounds can be distinguished fromthe entrance wounds and help distinguish a homicidefrom a suicide.16 All of this information is key to a medi-colegal case. The objectives of the medicolegal autopsy, aslisted by Knight,6 are to make a positive identification ofthe body and to assess the size, physique, and nourish-

ment; to determine the cause of death; to determine themode of dying and the time of death when necessary andpossible; to demonstrate all external and internal abnor-malities, malformations, and diseases; to detect, describe,and measure any external and internal injuries; to obtainsamples for analysis, including microbiological and his-tologic examination, as well as any other necessary inves-tigations; to retain relevant organs and tissues as evidence;to obtain photographs and video films for evidential andteaching use; to provide a full written report of the autop-sy findings; to offer an expert interpretation of those find-ings; and to restore the body to the best possible cosmeticcondition before release to relatives.

The autopsy is a vital tool in medicolegal investigationsfor which there is no substitute. The nature of a medico-legal case is that there is not an adequate clinical picturewith which to determine a cause and manner of death.The information gathered through an autopsy is especiallyimportant in cases of suspected foul play. The medicolegalautopsy does not seem to be facing the same problem asthe clinical autopsy, that is, a decline in the rate of perfor-mance. One reason may be that medicolegal autopsies arenot funded by the hospital and therefore do not competefor limited funds with treatments and diagnostic proce-dures, which are often perceived to provide greater yield.The political reality is that stable funding of medicolegalcases generally exists as a result of jurisdiction lying withthe Department of Justice and not with the Department ofHealth in most systems. This reality may play a role incausing the observed rate differences between medicolegaland clinical autopsies. Or, perhaps it is because the pur-pose of the medicolegal autopsy has remained clear andunchanged through the centuries. Also, there is no pro-cedure that could provide the same amount of informationwith which to replace the medicolegal autopsy. OscarSchultz in 1932 in a study for the National Academy ofSciences of the United States said, The determination ofthe cause of death in an exact and scientific manner re-quires a necropsy. 16

CONCLUSIONS

The decline of clinical autopsy rates means the benefitsthese autopsies could provide are being missed. The pur-


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poses of the clinical autopsy may have changed, but itappears there is still much it can contribute. The clinicalautopsy is still valuable as the gold standard by whichdiagnostic tools, treatment methods, and clinical decision-making procedures can be measured.26 How do you as-sess the quality of care given to your sickest patients, theones who die? 27 We have shown in this article that thelimitations of diagnostic tools can be defined through clin-ical autopsies. Furthermore, there is a need to evaluate

clinical decision-making procedures to prevent the sameerrors being made repeatedly.3 Autopsy results can alsoshow otherwise unknown adverse effects of treatments,such as the dose-related cardiotoxicity of doxorubicin. Thetoxic effects of many chemotherapy drugs can be moni-tored through autopsy results, and future doses and treat-ment protocols then can be altered appropriately. Clinicalautopsy performance is very important in the study, treat-ment, and prevention of disease. Even at the current lowrates, autopsies have helped elucidate conditions such asshock, cardiovascular disease, aging, and cancer.14 In 1case that was reported, a male infant with hypoplastic leftheart syndrome died after corrective surgery. Those in-volved in his care attended the autopsy, which providedan opportunity to learn more about the syndrome, to eval-uate the surgical technique, and to perform quality as-sessment.28 New environmental diseases, such as someforms of asthma, are constantly being discovered, andsome may be missed due to the low clinical autopsy rate.The hazards of occupational exposures to agents like as-bestos have been proven through clinical autopsies. Thishas resulted in major changes to working conditions. Aclinical autopsy may reveal the presence of a contagiousdisease and allow the quick treatment of unknowingly ex-posed individuals.27 An epidemic may be averted throughearly warning. Another case illustrating the great impor-tance of incidental autopsy findings is one in which a

breast lump found on autopsy was determined to be in-vasive ductal carcinoma. Informing female family mem-bers of this finding and advising them of their increasedrisk could potentially save a life.29 Clinical autopsies mayalso be used to monitor public health and ensure the ac-curacy of vital statistics.14,27 Vital statistics are used to de-termine the public health policies and to assess the effec-tiveness of public health services. These statistics are com-piled from the information on death certificates. Kircheris cited30 as having found that there is approximately a10% error rate in death certificate diagnoses when com-pared to autopsy results. The death statistics, which areused to develop public health strategies, are based on theless-representative facts on the death certificates. The per-

formance of autopsies at a high rate may correct the mis-information and have a great impact on public health pol-icy. For example, Kircher also found the death certificatediagnosis of heart disease is an inaccurate reflection ofthe actual incidence, which is lower.30 This is significantwhen the amount of money spent on preventive strategiesfor heart disease is considered. Clinical autopsies are alsovery important in the monitoring of levels of clinically si-lent diseases, such as coronary artery disease.14 Withoutthe performance of autopsies, only guesses can be madeas to their incidence. There are also extensive benefits forthe families of those on whom clinical autopsies are per-formed. Relatives often do not understand how everythinghappened. An autopsy can provide information about howa loved one died and ease the familys mind regarding the

extent of suffering. A family may also be made aware ofthe benefits autopsy research can provide for future treat-ments. In this way, the family may be able to see somegood come out of the death. However, for the family toreap these benefits, autopsy results must be made avail-able in an understandable format.

It may be that a lack of perceived purpose for the clin-ical autopsy, whereas that of the medicolegal autopsy re-mains constant and clear, has contributed to the isolated

decline in the clinical autopsy rate. The guidelines of theCollege of American Pathologists25 state the current pur-poses of the autopsy as follows: to establish a cause ofdeath, determine the manner of death, compare premor-tem and postmortem diagnoses, produce vital statistics,and to monitor the health of the public. These purposesare as important to medicine today as past purposes werein their time. These purposes would be better served byan increase in the clinical autopsy rate. There is a fairlylarge amount of literature expressing concern over the de-cline in frequency and illustrating the many positives tobe gained through clinical autopsies. This suggests theprocedure does not suffer from a complete loss of interestbut, more likely, is lagging behind in the fight for limitedfunds. The clinical autopsy rate at the Queen Elizabeth IIHealth Sciences Centre in Halifax, Nova Scotia, is not aslow as has been published for other hospitals, but the rateis falling. The medical community might benefit from at-tempts to increase the rate of clinical autopsy performance.Future research into ways of increasing the clinical autop-sy rate is needed.

References

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Declining Clinical Autopsy