In most Western countries the number of autopsies performed in hospitals has been decreasing every year since 1955. Critics, including pathologist and former JAMA editor George Lundberg, have charged that the reduction in autopsies is negatively affecting the care delivered in hospitals, because when mistakes result in death, they are often not investigated and lessons therefore remain unlearned.
When a person has given permission in advance of their death, autopsies may also be carried out for the purposes of teaching or medical research.
An autopsy is frequently performed in cases of sudden death, where a doctor is not able to write a death certificate, or when death is believed to result from an unnatural cause. These examinations are performed under a legal authority (Medical Examiner or Coroner or Procurator Fiscal) and do not require the consent of relatives of the deceased. The most extreme example is the examination of murder victims, especially when medical examiners are looking for signs of death or the murder method, such as bullet wounds and exit points, signs of strangulation, or traces of poison. Many religions such as Judaism and Islam usually discourage the performing of autopsies on their adherents. Organizations such as Zaka in Israel and Misaskim in the USA generally guide families how to ensure that an unnecessary autopsy is not made.
In medicine
Autopsies are important in clinical medicine as they can identify medical error and assist continuous improvement.A study that focused on myocardial infarction (heart attack) as a cause of death found significant errors of omission and commission, i.e. a sizable number cases ascribed to myocardial infarctions (MIs) were not MIs and a significant number of non-MIs were actually MIs.
A systematic review of studies of the autopsy calculated that in about 25% of autopsies a major diagnostic error will be revealed. However, this rate has decreased over time and the study projects that in a contemporary US institution, 8.4% to 24.4% of autopsies will detect major diagnostic errors.
A large meta-analysis suggested that approximately one third of death certificates are incorrect and that half of the autopsies performed produced findings that were not suspected before the person died. Also, it is thought that over one fifth of unexpected findings can only be diagnosed histologically, i.e. by biopsy or autopsy, and that approximately one quarter of unexpected findings, or 5% of all findings, are major and can similarly only be diagnosed from tissue.
One study found that "Autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis, among others".
Focusing intubated patients, one study found "abdominal pathologic conditions--abscesses, bowel perforations, or infarction--were as frequent as pulmonary emboli as a cause of class I errors. While patients with abdominal pathologic conditions generally complained of abdominal pain, results of examination of the abdomen were considered unremarkable in most patients, and the symptom was not pursued".
In veterinary medicine
Post-mortem examination is far more common in veterinary medicine than in human medicine. For many species that exhibit few external symptoms (sheep), or that are not suited to detailed clinical examination (poultry, cage birds, zoo animals), it is a common method used by veterinarians to come to a diagnosis.
Types
There are three main types of autopsies:- Medico-Legal Autopsy or Forensic or coroner's autopsies seek to find the cause and manner of death and to identify the decedent. They are generally performed, as prescribed by applicable law, in cases of violent, suspicious or sudden deaths, deaths without medical assistance or during surgical procedures.
- Clinical or Pathological autopsies are performed for to diagnose a perticular disease or research purposes. They aim to determine, clarify, or confirm medical diagnoses that remained unknown or unclear prior to the patient's death.
- Anatomical or academic autopsies are performed by students of anatomy for study purpose only.
Forensic autopsy
A forensic autopsy is used to determine the cause of death. Forensic science involves the application of the sciences to answer questions of interest to the legal system. In United States law, deaths are placed in one of five manners:
In some jurisdictions, the Undetermined category may include deaths in absentia, such as deaths at sea and missing persons declared dead in a court of law; in others, such deaths are classified under "Other". But, medical examiners also attempt to determine the time of death, the exact cause of death, and what, if anything, preceded the death, such as a struggle. A forensic autopsy may include obtaining biological specimens from the deceased for toxicological testing, including stomach contents. Toxicology tests may reveal the presence of one or more chemical "poisons" (all chemicals, in sufficient quantities, can be classified as a poison) and, the quantity of those chemicals. Because post-mortem deterioration of the body, together with the gravitational pooling of bodily fluids, will necessarily alter the bodily environment, toxicology tests may overestimate, rather than underestimate, the quantity of the suspected chemical. http://www.relentlessdefense.com/autopsy.html
Most states require the State medical examiner to complete an autopsy report and many mandate that the autopsy be videotaped.
Following an in-depth examination of all the evidence, a medical examiner or coroner will assign a manner of death as one of the five listed above, and detail the evidence on the mechanism of the death.
Clinical autopsy
Clinical autopsies serve two major purposes. They are performed to gain more insight into pathological processes and determine what factors contributed to a patient's death. Autopsies are also performed to ensure the standard of care at hospitals. Autopsies can yield insight into how patient deaths can be prevented in the future.Within the United Kingdom, clinical autopsies can only be carried out with the consent of the family of the deceased person as opposed to a medico-legal autopsy instructed by a Coroner (England & Wales) or Procurator Fiscal (Scotland) to which the family cannot object.
Prevalence
In 2004 in England and Wales, there were 514,000 deaths of which 225,500 were referred to the coroner. Of those, 115,800 (22.5%) resulted in post-mortem examinations and there were 28,300 inquests, 570 with a jury.In the United States, autopsy rates fell from 17% in 1980 to 14% in 1985 and 11.5% in 1989, although the figures vary notably from county to county.
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