brain removal during autopsy

[scienceguy19]

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When getting consent for autopsy, do are we supposed to tell the family that the brain (and other organs) will be removed and not returned?

I keep on hearing stories in the news about families being upset that the brain was removed and not returned to the body. Well of course we can't return it, because by the time the brain is fully fixed, the body is already buried.

Are most families not aware? And if not, should we be telling them?

 

[scienceguy19]

http://www.nydailynews.com/new-york...n-found-staten-island-morgue-article-1.982716

 

[pathstudent]

When getting consent for autopsy, do are we supposed to tell the family that the brain (and other organs) will be removed and not returned?

I keep on hearing stories in the news about families being upset that the brain was removed and not returned to the body. Well of course we can't return it, because by the time the brain is fully fixed, the body is already buried.

Are most families not aware? And if not, should we be telling them?

They have a chance to specify on the consent form what they want to limit it to. Once they sign it, it is too late mate. We need brains!

While I was a resident we would do full rokitansky style autopsies regardless if we documented a saddle embolus after removing the chest plate and opening the pulmonary artery. Even though we had a cause of death we would still go through and document gallstones, benign renal cysts, paratubal cysts, leiomyoma, etc... Normal stuff that no one could possibly care about. I was always questioning the value of what we were doing, but did it because that's what you did.

Now in practice practice all autopsies are focused to answer a particular question from the doc, like "did the patient have cardiac amyloidosis? Because we thought she did but she died before we got a heart biopsy and other test were inconclusive". The only two times I have taken brains were brain only cases when asked to evaluate recurrence of tumor, and another one where she died rapidly after some rare neurological disease.

But once you've done a few of those rokitansky types, you start to wonder about the point of putting the organs back in. It is just a big slimy pile of blood guts and ****.

 

[dr4n6]

The vast majority of the time brains can be cut fresh so there should be little reason to not return them with the remainder of the body, unless your in house neuropathologist is just looking for a bit of job security and insists on fixing the brains for weeks.

 

[Autopsy101]

Laws vary by state, but I train our residents to always discuss organ retention and methods of disposal. It is especially important if you are able to take verbal consents over the phone for documentation of informed consent. We have had several families come and retrieve the brain to be buried with the body following our examination. There have been several successful lawsuits in our state against medical examiners for organ retention, so we are very cautious.

 

[Thrombus]

The key is to not ever do an autopsy again. You should be training your residents to avoid them at all costs. Actually, you should only be training residents if you are hearing from head-hunters begging for more pathologists. Leave the autoposies to the forensics people.

 

[mlw03]

I am the forensic people.

This is a tricky issue, and totally different in the hospital and forensic setting. In the forensic setting, the laws in the US and Canada are generally written to allow the medical examiner or coroner to do whatever exam they believe necessary to determine cause and manner of death. So by law, we generally don't need consent for much of anything. But law and public opinion are very different things, and how individual offices choose to handle cases where organs (usually brain, but sometimes heart or other) are kept for fixation and subsequent dissection varies quite a bit.

Since a hospital autopsy is an elective procedure, I'd argue that families should be told exactly what will be done in your institution, and then let them decide what they do and do not consent to. If this is well-explained and documented, you should avoid problems later on with accusations of keeping something without their consent.

 

[Over9000]

I certainly respect the work that forensic pathologists do, and think it is appropriate to defer all post-mortem examination requests to those who are experienced in that work.

The rare hospital autopsy can have medicolegal implications, and I am always concerned that as a pathologist who is not interested or experienced in autopsies, I will miss something important.

Should the ME or coroner decide that a hospital autopsy request is not of a medicolegal nature, I will politely decline performing it and refer the family or referring physician to pathologists who perform that work.

 

[mlw03]

The issue with this attitude is that it's becoming very common. I don't say that in a confrontational way, but rather I mean, it's getting hard to find non-forensic pathologists who are willing to do private autopsies, and many forensic pathologists often cannot take private work because of office policy, potential conflict of interest, or may just not want to spend their free time that way. There was a time when general hospital-based pathologists could competently perform a medical autopsy, and some still can, but those folks are getting harder to find.

There are also the issues like we're discussing with this thread, that there's a risk of generating bad press.

All of this said, an autopsy is not a right in any country that I know of, but it is a shame when families can't get information they want because it's not an ME's case and there's no one available to do it privately.

I certainly respect the work that forensic pathologists do, and think it is appropriate to defer all post-mortem examination requests to those who are experienced in that work.

The rare hospital autopsy can have medicolegal implications, and I am always concerned that as a pathologist who is not interested or experienced in autopsies, I will miss something important.

Should the ME or coroner decide that a hospital autopsy request is not of a medicolegal nature, I will politely decline performing it and refer the family or referring physician to pathologists who perform that work.

 

[BlondeDocteur]

Is this an issue in academic hospitals with pathology residency programs? Or only community ones with no in-house autopsy services?

 

[deleted314957]

Is this an issue in academic hospitals with pathology residency programs? Or only community ones with no in-house autopsy services?

Yes, it certainly can be an issue. The permit should specifically state what will be retained and method of disposal to be on the safe side. And as an aside, make sure that it is the LEGITIMATE next-of-kin who signs the permit.

 

[mlw03]

Yes, it certainly can be an issue. The permit should specifically state what will be retained and method of disposal to be on the safe side. And as an aside, make sure that it is the LEGITIMATE next-of-kin who signs the permit.

This is an excellent point. Knowing who the legal NoK is/are can save your butt down the road. Where I did residency, if there was more than one NoK (say, 3 siblings) they all had ton consent to autopsy or we wouldn't do it. I agree this can be burdensome, and understand why some hospitals have no interest in doing this 10 times a year for the small amount of revenue generated.

 

[scienceguy19]

Aren't hospitals required to offer autopsy services whenever someone dies? And we have to do it for free?

IF a family consents for examination of the brain with no restrictions on the autopsy, are we obligated to examine the brain? can we choose no to do it?

 

[deleted314957]

Aren't hospitals required to offer autopsy services whenever someone dies? And we have to do it for free?

IF a family consents for examination of the brain with no restrictions on the autopsy, are we obligated to examine the brain? can we choose no to do it?

Hospitals are not required to offer them and you are nuts if you do them for free.
I never did family requested autopsies. I only did them at the request of the medical staff. I determined what the scope/extent of the autopsy would be. In my contract, the hospital paid me for this on a per case basis. Autopsies were usually quite limited in scope.

 

[scienceguy19]

are you sure about that? I was taught that hospitals are required to offer autopsies free of charge.
I get plenty of family requested autopsies. So if a family requests an autopsy and you don't want to do it, you will tell the family that you refuse?

 

[deleted314957]

are you sure about that? I was taught that hospitals are required to offer autopsies free of charge.
I get plenty of family requested autopsies. So if a family requests an autopsy and you don't want to do it, you will tell the family that you refuse?

Yes , I am sure about that. I am a retired lab medical director at a community hospital with 37 years as a physician. I refer the family to private autopsy services. ( and they almost always lose interest when they are informed of the cost) www.regional-pathology.com. they have banner ads on this forum. I don't see patients telling surgeons what operations they must perform for free.

 

[mlw03]

Same thing in Canada, as far as I'm aware. There is no "right" to a free autopsy. Most private ones cost somewhere in the ballpark of $3000, and I've heard up to $5000 if there's clinical concern for CJD. Even the academic centers do very few autopsies (path residents in my city need their FP rotation to get to the 50 autopsy number, if they wish to sit for the ABP exam. To my knowledge, the Royal College has no autopsy minimum).

I'll also point out that even in the forensic context, I decide what exam to perform on a decedent. Neither family nor police can dictate what I do. That said, I of course consider such requests and their reasons, but ultimately the choice is ours. I would not do an autopsy on a 78 year old man found dead in bed in his secure house, PMH of coronary artery stenting and a repaired AAA. CoD: Atherosclerotic cardiovascular disease. If the family wants to know if it was a CVA, acute MI, coronary thrombus, ruptured AAA, etc, they can pay for that, but very few, if any, forensic offices would autopsy that case even if the family asked for it. Most chiefs wouldn't consider that an appropriate use of taxpayer funds (and I agree, for what it's worth). That's why so many FPs use "ASCVD" - it's a very generic term.

 

[deleted314957]

Same thing in Canada, as far as I'm aware. There is no "right" to a free autopsy. Most private ones cost somewhere in the ballpark of $3000, and I've heard up to $5000 if there's clinical concern for CJD. Even the academic centers do very few autopsies (path residents in my city need their FP rotation to get to the 50 autopsy number, if they wish to sit for the ABP exam. To my knowledge, the Royal College has no autopsy minimum).

I'll also point out that even in the forensic context, I decide what exam to perform on a decedent. Neither family nor police can dictate what I do. That said, I of course consider such requests and their reasons, but ultimately the choice is ours. I would not do an autopsy on a 78 year old man found dead in bed in his secure house, PMH of coronary artery stenting and a repaired AAA. CoD: Atherosclerotic cardiovascular disease. If the family wants to know if it was a CVA, acute MI, coronary thrombus, ruptured AAA, etc, they can pay for that, but very few, if any, forensic offices would autopsy that case even if the family asked for it. Most chiefs wouldn't consider that an appropriate use of taxpayer funds (and I agree, for what it's worth). That's why so many FPs use "ASCVD" - it's a very generic term.

For the brief period I was an ME we called such natural death examinations "inspections" and they were required before cremation. (i guess because you can't get any info from exhumed ashes!) Does Canada require that?

 

[pathstudent]

Our official unofficial policy is that if a member of the medical staff requests an autopsy with a specific question we will do it, assuming the family consents of course. If it is the family pushing for the autopsy, we defer it and refer them to an outside service if they want to pursue it.

Often times it is the hospitalist that puts in the request for the family. I call the hospitalist and if he or she says it's the family driving the bus, then I refuse to do it.

Our hospital reimburses us when we have to do one. It ain't much per autopsy but if I could do 1000 autopsies a year I would be a rich man.

 

[deleted314957]

Our official unofficial policy is that if a member of the medical staff requests an autopsy with a specific question we will do it, assuming the family consents of course. If it is the family pushing for the autopsy, we defer it and refer them to an outside service if they want to pursue it.

Often times it is the hospitalist that puts in the request for the family. I call the hospitalist and if he or she says it's the family driving the bus, then I refuse to do it.

Our hospital reimburses us when we have to do one. It ain't much per autopsy but if I could do 1000 autopsies a year I would be a rich man.

essentially my exact former practice/policy.

 

[BlondeDocteur]

I am fairly certain though that at teaching hospitals autopsies are free. It's on the consent: "this is a service provided free of charge."

And on our autopsy consent forms there are itemized lists the consenting physician + non-physician have to read out, and the family must agree to each and every one of them in order for the autopsy to proceed. It's explicitly stated that the brain can be removed (of course not every autopsy requires it and it's not performed every time, but the family must agree to it should the case warrant it).

 

[deleted314957]

I am fairly certain though that at teaching hospitals autopsies are free. It's on the consent: "this is a service provided free of charge."

I am fairly certain though that at teaching hospitals autopsies are free. It's on the consent: "this is a service provided free of charge."

And on our autopsy consent forms there are itemized lists the consenting physician + non-physician have to read out, and the family must agree to each and every one of them in order for the autopsy to proceed. It's explicitly stated that the brain can be removed (of course not every autopsy requires it and it's not performed every time, but the family must agree to it should the case warrant it).

I am sorry, but this makes NO sense. Why in the hell would someone expect that the time of a physician , for 2-3 hours ( not to mention any TC time ) be worth NOTHING!!
This is part of the slave tradition our field seems to have devolved into. Do you not value your time and professional expertise?!? You, Blondie, seem to be starting out on a mind set that will let you retire on an elementary school s pension. I expected, demanded and got more. It is time that the folks in our field grow a pair.
And, as an aside, the bit about "service provide free of charge" was not negotiated with your group/self I'll bet. Just don't do it!! And, a pathologist's contract makes no distinction between "teaching" hospitals
and a regular community hospital. The terms of a contract are the terms of a contract.

 

[BlondeDocteur]

I have no idea, and I'm certainly not taking a position, just reporting the facts. I imagine that since the faculty are salaried rather than compensated on a services-rendered basis, the hospital simply 'eats' any associated cost of the in-house hospital autopsies in order to subsidize the pathology training program. Who knows. But they're free.

 

[pathstudent]

I am fairly certain though that at teaching hospitals autopsies are free. It's on the consent: "this is a service provided free of charge."

And on our autopsy consent forms there are itemized lists the consenting physician + non-physician have to read out, and the family must agree to each and every one of them in order for the autopsy to proceed. It's explicitly stated that the brain can be removed (of course not every autopsy requires it and it's not performed every time, but the family must agree to it should the case warrant it).

Yes. There is no charge to the family for an autopsy, if we agree to do it. It is a service we provide for the medical staff. The hospital system we work at agreed at some point to reimburse the pathologists when they did perform one. You can't bill insurance or Medicare for an autopsy as you can't get reimbursed for performing "medicine" on dead people.

If we don't perform it then it is up to the family to find someone that will and that is where the private services come in. I believe the local coroner will do one for 3000.

I don't want to make it sound like I am constantly denying families autopsies. As I have written before we only do 5 a year and only refuse to take one about once every 2-3 years. There used to be 250 a year at my hospital in the 80s. I hope the trend continues until we hit 0 a year.

 

[mlw03]

For the brief period I was an ME we called such natural death examinations "inspections" and they were required before cremation. (i guess because you can't get any info from exhumed ashes!) Does Canada require that?

No, there's no requirement to view the body before a cremation can occur in the province in which I live, nor was there such a requirement in the state I did my fellowship. We do, however, review the death certificate before cremation can occur to look for any 'red flags' that may suggest a non-natural death. If we see such a red flag we start with getting more history from the doc and/or family, medical records, and if need be, have the body brought in for exam. That's usually not necessary, as I can certify an accidental death from a hip fracture or head injury in the elderly via medical record review. The issue isn't not knowing what happened; rather, it's that many docs out in the community have no idea how to properly fill out a death certificate. That said, despite doing that (and I think most offices in US/Canada do similarly) I have no doubt there are delayed accidents, suicides, and (rare) homicides that slip through the cracks and get inappropriately certified as natural deaths by community physicians.

 

[dr4n6]

Going to disagree with much of the above re. a families right to a hospital autopsy. If their relative dies in your hospital, and you department/group provides anatomical pathology services, then you have a moral/ethical obligation to that family to perform an autopsy. True, you will not be paid for your time, but you were reimbursed for the ante-mortem pathology services on that patient and this is just part of the spectrum of the continuum of care to that patient.

 

[pathstudent]

Going to disagree with much of the above re. a families right to a hospital autopsy. If their relative dies in your hospital, and you department/group provides anatomical pathology services, then you have a moral/ethical obligation to that family to perform an autopsy. True, you will not be paid for your time, but you were reimbursed for the ante-mortem pathology services on that patient and this is just part of the spectrum of the continuum of care to that patient.

Really. If an octagenerian gets pneumonia, septic and dies of end organ failure, I have a moral obligation to do an autopsy because the family is mad and feels the icu attending didn't do enough to save grandpa?

What "care" am I providing?

 

[mlw03]

Going to disagree with much of the above re. a families right to a hospital autopsy. If their relative dies in your hospital, and you department/group provides anatomical pathology services, then you have a moral/ethical obligation to that family to perform an autopsy. True, you will not be paid for your time, but you were reimbursed for the ante-mortem pathology services on that patient and this is just part of the spectrum of the continuum of care to that patient.

I too will disagree with that opinion. I believe in a right to necessary healthcare for living persons (which is a separate, huge debate that branches off into socialized medicine), but care for the deceased, in my view, is not a right. It is a luxury that families and hospital can or cannot choose to provide. We live and work in a world of limited resources. Until that changes (which of course will never happen... resources are virtually all limited), choices have to be made about how to spend those resources.

 

[BlondeDocteur]

Really. If an octagenerian gets pneumonia, septic and dies of end organ failure, I have a moral obligation to do an autopsy because the family is mad and feels the icu attending didn't do enough to save grandpa?

What "care" am I providing?

Ostensibly, if your autopsy finds evidence of overwhelming sepsis and MSOF, you are providing closure to the family and validation of the treatment team's care. If your autopsy find something that they missed, then it's a game-changer. You've allowed pathology residents to perform a natural death autopsy and see the spectrum of pathology first-hand, so when the situation comes up again they can accurately diagnose it-- or realize something's off, it's not a natural death after all, since they've seen sepsis and MSOF.

I get mlw03's point, in a world of limited resources you just have to make some bets based on prior probability and can't give everyone everything they want every time, but still... there's a theoretical utility.

 

[pathstudent]

Ostensibly, if your autopsy finds evidence of overwhelming sepsis and MSOF, you are providing closure to the family and validation of the treatment team's care. If your autopsy find something that they missed, then it's a game-changer. You've allowed pathology residents to perform a natural death autopsy and see the spectrum of pathology first-hand, so when the situation comes up again they can accurately diagnose it-- or realize something's off, it's not a natural death after all, since they've seen sepsis and MSOF.

I get mlw03's point, in a world of limited resources you just have to make some bets based on prior probability and can't give everyone everything they want every time, but still... there's a theoretical utility.

Please. You don't find game changers when everything already fits before death. And if the the patient can't oxygenate on her own, and the blood cultures are positive and BP can't be maintained and the creatinine is 5 and the lactate is through the roof, then there's your closure.

Now if the patient dies unexpectedly then that is a different story.

But no matter what hospital autopsies are not the future. They are part of the past. Even where I trained they had dropped 90% over a period of 15-20 years. And the drop is not about saving money.

 

[mlw03]

Ostensibly, if your autopsy finds evidence of overwhelming sepsis and MSOF, you are providing closure to the family and validation of the treatment team's care. If your autopsy find something that they missed, then it's a game-changer. You've allowed pathology residents to perform a natural death autopsy and see the spectrum of pathology first-hand, so when the situation comes up again they can accurately diagnose it-- or realize something's off, it's not a natural death after all, since they've seen sepsis and MSOF.

I get mlw03's point, in a world of limited resources you just have to make some bets based on prior probability and can't give everyone everything they want every time, but still... there's a theoretical utility.

Be careful how you use this phrase. I can't give a lecture on death certification on here, but a doctor 'missing something' does not make a non-natural death. I'm not trying to chastise or anything like that, just making a teaching point for the residents and med students on this forum. Legal culpability for a missed diagnosis and manner of death certification are separate things.

 

[BlondeDocteur]

Good point. I know it was poorly worded but I actually did mean natural death in a medicolegal sense, not a missed diagnosis that was still natural. And I definitely know my example was pretty pie-in-the-sky, but at this *very* early stage in my pathology career I think there's still benefit-- even if it's just giving residents practice and experience. You know, seeing 1000 normal CXRs so you can pick up the Pancoast tumor in a blink.

 

[turtle1966]

Good point. I know it was poorly worded but I actually did mean natural death in a medicolegal sense, not a missed diagnosis that was still natural. And I definitely know my example was pretty pie-in-the-sky, but at this *very* early stage in my pathology career I think there's still benefit-- even if it's just giving residents practice and experience. You know, seeing 1000 normal CXRs so you can pick up the Pancoast tumor in a blink.

In my experience, autopsies are essential in learning pathology. Once learned, however, its practice is a serious liability to private pathologists, in more than one way.

 

[pathstudent]

Good point. I know it was poorly worded but I actually did mean natural death in a medicolegal sense, not a missed diagnosis that was still natural. And I definitely know my example was pretty pie-in-the-sky, but at this *very* early stage in my pathology career I think there's still benefit-- even if it's just giving residents practice and experience. You know, seeing 1000 normal CXRs so you can pick up the Pancoast tumor in a blink.

But giving residents experience is not the point of medicine or in this case trying to coerce family members to consent to evisceration of their loved one when it doesn't add any new information about why or how he or she died.

I found my university autopsies so silly because we would document that the patient had a para tubal cyst or had gallstones or that the breast had FCC. What was the point of that. Pure silliness

 

[ketosisevangelist]

HIPPA violation.

 

[mlw03]

But giving residents experience is not the point of medicine or in this case trying to coerce family members to consent to evisceration of their loved one when it doesn't add any new information about why or how he or she died.

I found my university autopsies so silly because we would document that the patient had a para tubal cyst or had gallstones or that the breast had FCC. What was the point of that. Pure silliness

There are points to hospital autopsies still. Here's an example. 78 year old man with SoB, imaging shows widely metastatic cancer. Patient has no interest in work-up, dies soon thereafter in hospital care. I will NOT accept that case for a forensic autopsy, nor will most jurisdictions. There is a clear, natural CoD. But maybe the family wants to know what kind of cancer? That's the place for a hospital autopsy, where (hopefully), the gross, H&E, and IHC will allow for a reasonable determination of tumour site of origin.

But yeah, paratubal cysts are silly... there's a lot of crap I had to document as a path resident that I now feel comfortable lumping under the "unremarkable" descriptor.

 

[Over9000]

Going to disagree with much of the above re. a families right to a hospital autopsy. If their relative dies in your hospital, and you department/group provides anatomical pathology services, then you have a moral/ethical obligation to that family to perform an autopsy. True, you will not be paid for your time, but you were reimbursed for the ante-mortem pathology services on that patient and this is just part of the spectrum of the continuum of care to that patient.

this is wrong. anyone who is not an expert in death should not be doing autopsies. that includes all non-forensic pathologists. otherwise the standard of care is not being met, and the whole procedure of the autopsy is devalued.

There are points to hospital autopsies still. Here's an example. 78 year old man with SoB, imaging shows widely metastatic cancer. Patient has no interest in work-up, dies soon thereafter in hospital care. I will NOT accept that case for a forensic autopsy, nor will most jurisdictions. There is a clear, natural CoD. But maybe the family wants to know what kind of cancer? That's the place for a hospital autopsy, where (hopefully), the gross, H&E, and IHC will allow for a reasonable determination of tumour site of origin.

But yeah, paratubal cysts are silly... there's a lot of crap I had to document as a path resident that I now feel comfortable lumping under the "unremarkable" descriptor.

That is still not reason to do an unreimbursed hospital post, nor is it grounds for insurance etc to pay for one.

if the family or clinical staff want an autopsy, i get the coroner. if the coroner does not think it needs m.e. input, then i decline to do it. all pathologists would be right to have my approach, for i am not an expert in death investigation nor is anyone who is not forensically trained.

 

[pathstudent]

Good point. I know it was poorly worded but I actually did mean natural death in a medicolegal sense, not a missed diagnosis that was still natural. And I definitely know my example was pretty pie-in-the-sky, but at this *very* early stage in my pathology career I think there's still benefit-- even if it's just giving residents practice and experience. You know, seeing 1000 normal CXRs so you can pick up the Pancoast tumor in a blink.

Actually I do agree with you. In a physician teaching hospital, autopsies are important even if they aren't "necessary" in a particular case.

As someone who is not in training I don't view them as a benefit to me but as a service I provide to the medical staff.

 

[pathstudent]

this is wrong. anyone who is not an expert in death should not be doing autopsies. that includes all non-forensic pathologists. otherwise the standard of care is not being met, and the whole procedure of the autopsy is devalued.




That is still not reason to do an unreimbursed hospital post, nor is it grounds for insurance etc to pay for one.

if the family or clinical staff want an autopsy, i get the coroner. if the coroner does not think it needs m.e. input, then i decline to do it. all pathologists would be right to have my approach, for i am not an expert in death investigation nor is anyone who is not forensically trained.

Wrong answer. Hospital autopsies are part of your ap boards. If you didn't do a cytopath fellowship, can you handle a thyroid fna.. If you didn't do a heme path fellowship can you handle a straightforward case of follicular lymphoma or classical Hodgkin lymphoma?

 

[mlw03]

I disagree with this notion as well. I would argue the ABP disagrees as well, since autopsy pathology is tested on AP boards and there is (for now at least) an autopsy requirement for AP board eligibility.

this is wrong. anyone who is not an expert in death should not be doing autopsies. that includes all non-forensic pathologists. otherwise the standard of care is not being met, and the whole procedure of the autopsy is devalued.




That is still not reason to do an unreimbursed hospital post, nor is it grounds for insurance etc to pay for one.

if the family or clinical staff want an autopsy, i get the coroner. if the coroner does not think it needs m.e. input, then i decline to do it. all pathologists would be right to have my approach, for i am not an expert in death investigation nor is anyone who is not forensically trained.

 

[dr4n6]

I think the real issue here boils down to dollars and not competency. If hospital based pathologists were reimbursed for doing an autopsy there would be far less discussion on this topic.

 

[Over9000]

I think the real issue here boils down to dollars and not competency. If hospital based pathologists were reimbursed for doing an autopsy there would be far less discussion on this topic.

This is probably the case. The procedure has been undervalued/unvalued and so there is no incentive to perform it for any reason other than intellectual curiosity, which is not a part of the mission statement in community hospitals.

With that in mind, pathologists rarely, if ever, perform them, and thus their skills in the procedure atrophy. When one comes up, the pathologist is so out of practice with them that it would be a stretch to say they would be competently performed. Plus, medical autopsies often gloss over very important things that forensic examinations don't, and this is where the biggest errors would occur since they would affect living individuals directly through the justice system. I know I would not be able to comment in a competent fashion on whether an in-hospital death was or was not anything but natural, and because of that I will not handle autopsies.

 

[pathstudent]

This is probably the case. The procedure has been undervalued/unvalued and so there is no incentive to perform it for any reason other than intellectual curiosity, which is not a part of the mission statement in community hospitals.

With that in mind, pathologists rarely, if ever, perform them, and thus their skills in the procedure atrophy. When one comes up, the pathologist is so out of practice with them that it would be a stretch to say they would be competently performed. Plus, medical autopsies often gloss over very important things that forensic examinations don't, and this is where the biggest errors would occur since they would affect living individuals directly through the justice system. I know I would not be able to comment in a competent fashion on whether an in-hospital death was or was not anything but natural, and because of that I will not handle autopsies.

Again. Bad answer. What skills of yours diminish? Deniers do the dissection. It is not like you are trying to solve a crime.

 

[Over9000]

Again. Bad answer. What skills of yours diminish? Deniers do the dissection. It is not like you are trying to solve a crime.

...until it turns out, long after the fact, you were supposed to be doing just that.

 

[deleted314957]

...until it turns out, long after the fact, you were supposed to be doing just that.

I am not a fan of autopsies ( and I have forensic boards) but it is a bit of a stretch to believe that a boarded AP pathologist cannot do a competent job with the VAST majority of hospital associated deaths.
As MLW has kind of inferred, the most egregious mistake is certifying an accident/homicide/suicide as "natural". e.g. Old guy falls and breaks hip (accident), goes to hospital, lingers 5 weeks with typical medical course and dies and primary calls death "natural" due to pneumonia. ( May not even be aware of initial accident); a not uncommon occurrence. As part of your AP training you should have, at least, minimal FP training which includes proper death certification skills.
And, realistically, you are not going to be solving forensic mysteries in the hospital cases as long as you know the distinction between legit ME cases and non-me cases. (which should be part of your skill set).
I don't blame you for wanting to dodge autopsies but I certainly would not , on your own volition, demean your own skills, to the point that you aver you cannot do a competent, basic autopsy. Come on, they're not THAT big a deal.

 

[Over9000]

I am not a fan of autopsies ( and I have forensic boards) but it is a bit of a stretch to believe that a boarded AP pathologist cannot do a competent job with the VAST majority of hospital associated deaths.
As MLW has kind of inferred, the most egregious mistake is certifying an accident/homicide/suicide as "natural". e.g. Old guy falls and breaks hip (accident), goes to hospital, lingers 5 weeks with typical medical course and dies and primary calls death "natural" due to pneumonia. ( May not even be aware of initial accident); a not uncommon occurrence. As part of your AP training you should have, at least, minimal FP training which includes proper death certification skills.
And, realistically, you are not going to be solving forensic mysteries in the hospital cases as long as you know the distinction between legit ME cases and non-me cases. (which should be part of your skill set).
I don't blame you for wanting to dodge autopsies but I certainly would not , on your own volition, demean your own skills, to the point that you aver you cannot do a competent, basic autopsy. Come on, they're not THAT big a deal.

I see what you're saying, but I have more experience working the wards and running codes than investigating death, yet the system dictates I should be able to do the latter but not the former. Personally I believe I should do neither for I lack the experience, knowledge, and interest to do the best possible job. Though I could do a "usual" autopsy without issue, its the small details that make or break cases, and I am not comfortable with those. The impact of the outcomes of death investigation can affect people as much as inpatient medicine does. To say otherwise is to reduce the gravity of forensic pathology.

I respect the work of forensics and believe that those interested and experienced in death investigation and autopsy should be the providers of such a service. Most of my work is cancer diagnosis, which really doesn't overlap with that.