The Role of Postmortem Examination in Medical Education
1998; Elsevier BV; Volume: 73; Issue: 8 Linguagem: Inglês
10.4065/73.8.802
ISSN1942-5546
AutoresTeresa S. Welsh, Joseph Kaplan,
Tópico(s)Forensic Entomology and Diptera Studies
ResumoHistorically, the postmortem examination was an indispensable diagnostic tool. Despite recommendations by the American Medical Association to continue performing autopsies, many physicians and medical institutions fail to recognize its utility in modern medicine, and autopsy rates have decreased to unacceptably low levels. In academic settings, requesting consent for autopsies is the responsibility of residents, who often lack the skills necessary to approach the grieving family, request consent, and follow up the autopsy results. Additionally, the information obtained at autopsies is often unused or is unavailable to families and clinicians. In order to improve the autopsy rate and enhance its clinical and educational benefits, the training of residents must be structured to emphasize the postmortem examination and to develop a standardized means of communication among clinicians, pathologists, and families. Historically, the postmortem examination was an indispensable diagnostic tool. Despite recommendations by the American Medical Association to continue performing autopsies, many physicians and medical institutions fail to recognize its utility in modern medicine, and autopsy rates have decreased to unacceptably low levels. In academic settings, requesting consent for autopsies is the responsibility of residents, who often lack the skills necessary to approach the grieving family, request consent, and follow up the autopsy results. Additionally, the information obtained at autopsies is often unused or is unavailable to families and clinicians. In order to improve the autopsy rate and enhance its clinical and educational benefits, the training of residents must be structured to emphasize the postmortem examination and to develop a standardized means of communication among clinicians, pathologists, and families. The autopsy has served a vital role in the development of modern medicine. Widely accepted by early 20th-century physicians as the "gold standard" for diagnosis, the autopsy has largely been replaced by ante-mortem diagnostic testing. Many physicians and medical institutions fail to recognize its utility in modern medicine, and autopsy rates have decreased to unacceptably low levels. In academic settings, requesting consent for autopsies is a responsibility of residents, who often lack the skills necessary to approach the grieving family, request consent, and follow up the autopsy results. Recent research shows that resident-based interventions can improve autopsy rates.' In this article, we review the literature that addresses the role of the autopsy in modem medicine and its place in medical education. On the basis of this literature, we make recommendations for an autopsy curriculum in postgraduate training. The autopsy had an important role in the development of modern medicine. It was the central means by which scientists gained an understanding of anatomy, pathology, and clinicopathologic correlation. Despite its importance, the autopsy has been criticized throughout history. Hippocrates described it as "an unpleasant, if not cruel, task."2McPtiee SJ Bottles K Autopsy: moribund art or vital science?.Am J Med. 1985; 78: 107-113Google Scholar Thomas Sydcnham, a 17th-century English physician, said, "Some physicians pompously and speciously prosecute the promotion of medicine by search into the bowels of the dead,"2McPtiee SJ Bottles K Autopsy: moribund art or vital science?.Am J Med. 1985; 78: 107-113Google Scholar Despite substantial resistance from leaders in society, the value of the postmortem examination emerged as dedicated scientists and clinicians, including Morgagni, Rokitansky, Virchow, and Osier, created the field of pathology, outlined the common diseases, and developed the science of modem medicine.1Souza VL Rosner F Increasing autopsy rates at a public hospital.J Gen Intern Med. 1997; 12: 315-317Crossref PubMed Scopus (12) Google Scholar The autopsy became widely accepted in the early 20th century, when as many as 50% of all deaths were examined postmortem.4Lowe JA Davis CJ Need we revive falling autopsy rates? Time trends in PAS hospitals in the United States.PAS Reporter. 1977; 15: l-7Google Scholar, 5Kochanek KD Hudson BL advance Report of Final Mortality Statistics. 1992. Vol 43. No. 6 Suppl. US Government Printing Office, Washington (DC)1995Google Scholar, 6Guariglla P Abrahams C The impact of autopsy data on DRG reimbursement.Hum Pat.no/. 1985; 16: 1184-1186Abstract Full Text PDF PubMed Scopus (9) Google Scholar, 7Gelter SA Autopsy.Sci Am. 1983; 248: 124-129Crossref PubMed Scopus (45) Google Scholar Today, autopsies are performed in fewer than 11% of deaths.5Kochanek KD Hudson BL advance Report of Final Mortality Statistics. 1992. Vol 43. No. 6 Suppl. US Government Printing Office, Washington (DC)1995Google Scholar The reasons cited for this decline include improved technology, heightened diagnostic confidence, lack of reimbursement, fear of malpractice suits, changing standards for accrediting hospitals, and altered public perceptions.2McPtiee SJ Bottles K Autopsy: moribund art or vital science?.Am J Med. 1985; 78: 107-113Google Scholar, 8Council on Scientific Affairs Autopsy: a comprehensive review of current issues.JAMA. 1987; 258: 364-369Crossref PubMed Scopus (22) Google Scholar, 9Shapiro Ml Reimbursement for autopsy: a personal view.Arch Pathol Lab Med. 1984; 108: 473-474PubMed Google Scholar Perhaps the most influential of these reasons is improved technology. In the past, the physician would make a diagnosis based on the patient's history and findings on the physical examination, and the autopsy served as the gold standard to prove diagnostic accuracy. Today, a laboratory or radiology test is often used to confirm a diagnosis. Patients and physicians trust these modem tests. Despite tremendous advances in medical science from I960 to 1980, the rate of major misdiagnosis detected on autopsies (for which treatment might have resulted in prolongation of survival) remained stable at about 10%.10Goldman L Sayson R Robbins S Cohn LH Bettmann M Weisberg M The value of the autopsy in lhree medical eras.N Engl J Med. 1983; 308: 1000 1005Crossref PubMed Scopus (654) Google Scholar Many physicians report that cost containment is the primary force limiting the number of autopsies.6Guariglla P Abrahams C The impact of autopsy data on DRG reimbursement.Hum Pat.no/. 1985; 16: 1184-1186Abstract Full Text PDF PubMed Scopus (9) Google Scholar, 9Shapiro Ml Reimbursement for autopsy: a personal view.Arch Pathol Lab Med. 1984; 108: 473-474PubMed Google Scholar Indeed, autopsy rates declined after 1971, when the Joint Commission on Accreditation of Hospitals eliminated the required 20% autopsy rate,2McPtiee SJ Bottles K Autopsy: moribund art or vital science?.Am J Med. 1985; 78: 107-113Google Scholar Patients' families are not billed directly for the autopsy, and thus hospitals must use general funds to cover autopsy costs.4Lowe JA Davis CJ Need we revive falling autopsy rates? Time trends in PAS hospitals in the United States.PAS Reporter. 1977; 15: l-7Google Scholar From a purely financial perspective, the autopsy is often viewed as unnecessary. Interestingly, some consumers pay for their relatives' postmortem examinations, as demonstrated by the emergence of several freelance autopsy services.11Jaffa G. Need an autopsy? You might give Vidal Herrera a ring. Wall Street J 1997 Jul 2; pp 1–4Google Scholar Unfortunately, when an autopsy is performed, the information obtained is often underused. The primary physician does not regularly participate in the autopsy,12Campman SC A piece of my mind: a 'novel' idea?.JAMA. 1994; 272: 990Crossref PubMed Scopus (1) Google Scholar and autopsy reporting is often delayed for 3 or more months.13McPhee SJ Bottles K Lo B Salka G Crommte D To redeem them from death: reactions of family members to autopsy.Am J Med. 1986; 80: 665-671Abstract Full Text PDF PubMed Scopus (102) Google Scholar The potential uses of an autopsy are numerous: evaluating new therapies, studying familial diseases, and, perhaps, preserving specimens for future diagnostic testing. Some pathologists predict that a society that continues to practice medicine without regular autopsies might find itself faced with contagious diseases spreading unchecked, homicides and suicides occurring undetected, clinicians continuing to err unnoticed, and vital statistics becoming increasingly inaccurate.2McPtiee SJ Bottles K Autopsy: moribund art or vital science?.Am J Med. 1985; 78: 107-113Google Scholar No randomized controlled studies have been performed to prove the societal effects of autopsy practices, but the consensus in the literature to date suggests that the postmortem examination continues to serve an important role.1Souza VL Rosner F Increasing autopsy rates at a public hospital.J Gen Intern Med. 1997; 12: 315-317Crossref PubMed Scopus (12) Google Scholar, 2McPtiee SJ Bottles K Autopsy: moribund art or vital science?.Am J Med. 1985; 78: 107-113Google Scholar, 3King LS Meehan MC A history of the autopsy: a review.Am J Pathol. 1973; 73: 514-544PubMed Google Scholar, 4Lowe JA Davis CJ Need we revive falling autopsy rates? Time trends in PAS hospitals in the United States.PAS Reporter. 1977; 15: l-7Google Scholar, 7Gelter SA Autopsy.Sci Am. 1983; 248: 124-129Crossref PubMed Scopus (45) Google Scholar, 8Council on Scientific Affairs Autopsy: a comprehensive review of current issues.JAMA. 1987; 258: 364-369Crossref PubMed Scopus (22) Google Scholar, 9Shapiro Ml Reimbursement for autopsy: a personal view.Arch Pathol Lab Med. 1984; 108: 473-474PubMed Google Scholar, 10Goldman L Sayson R Robbins S Cohn LH Bettmann M Weisberg M The value of the autopsy in lhree medical eras.N Engl J Med. 1983; 308: 1000 1005Crossref PubMed Scopus (654) Google Scholar, 11Jaffa G. Need an autopsy? You might give Vidal Herrera a ring. Wall Street J 1997 Jul 2; pp 1–4Google Scholar, 12Campman SC A piece of my mind: a 'novel' idea?.JAMA. 1994; 272: 990Crossref PubMed Scopus (1) Google Scholar, 13McPhee SJ Bottles K Lo B Salka G Crommte D To redeem them from death: reactions of family members to autopsy.Am J Med. 1986; 80: 665-671Abstract Full Text PDF PubMed Scopus (102) Google Scholar, 14Creagan FT How to break bad news—and not devastate the patient.Mayo Clin Proc. 1994; 69: 1015-1017Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 15Tolle SW Elllot DL Hickam DH Physician attitudes and practices at the time of patient death.Arch Intern Med. 1984; 144: 2389-2391Crossref PubMed Scopus (47) Google Scholar, 16Reynolds RC Autopsies—benefits to the family.Am J Clin Pathol. 1978; 69: 220-222PubMed Google Scholar, 17Clayton SA Slvak Sl Improving the autopsy rate of a university hospital.Am J Med. 1992; 92: 423-428Abstract Full Text PDF PubMed Scopus (37) Google Scholar Residents are often the first medical person to be notified of a death in the hospital. Requesting an autopsy, although often low on the list of priorities, is the most important way for residents to influence the autopsy rate. In one study, 45% of families who had "denied autopsy consent" reported that they had never been asked.13McPhee SJ Bottles K Lo B Salka G Crommte D To redeem them from death: reactions of family members to autopsy.Am J Med. 1986; 80: 665-671Abstract Full Text PDF PubMed Scopus (102) Google Scholar Recently, a resident-based intervention was successfully used to increase autopsy rates at a public hospital.1Souza VL Rosner F Increasing autopsy rates at a public hospital.J Gen Intern Med. 1997; 12: 315-317Crossref PubMed Scopus (12) Google Scholar Medical residents were trained in a 2-hour didactic session about requesting permission for autopsy. The chief resident had a key role in this intervention by reviewing all deaths and personally requesting the autopsy consent when permission had not been obtained by the medical team. Autopsy rates more than doubled during the period of intervention but returned to baseline when the study concluded. This study supports the hypothesis that resident education and a systematic review of all deaths can improve the autopsy rate. Requesting an autopsy is always difficult, but appropriately preparing the family can make the process less awkward. Families are more likely to accept bad news and follow the physician's advice if they view the physician as a partner with the patient against illness.14Creagan FT How to break bad news—and not devastate the patient.Mayo Clin Proc. 1994; 69: 1015-1017Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Family members are less likely to agree to an autopsy if they cannot see a clear reason for it.13McPhee SJ Bottles K Lo B Salka G Crommte D To redeem them from death: reactions of family members to autopsy.Am J Med. 1986; 80: 665-671Abstract Full Text PDF PubMed Scopus (102) Google Scholar Frequent meetings with patients and their families to discuss the severity of the disease, the proposed diagnostic testing, and the planned course of treatment allow physicians and families to share a common understanding at the time of death. Continuity of care is essential at the end of life, and most physicians agree that it is the primary physician's responsibility to share bad news with the family.15Tolle SW Elllot DL Hickam DH Physician attitudes and practices at the time of patient death.Arch Intern Med. 1984; 144: 2389-2391Crossref PubMed Scopus (47) Google Scholar We suggest that the resident who is serving as the primary physician should be responsible for contacting the patient's family and requesting their consent for an autopsy. This conversation is difficult for most residents. Creagan,14Creagan FT How to break bad news—and not devastate the patient.Mayo Clin Proc. 1994; 69: 1015-1017Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar a Mayo Clinic oncologist, provided the following recommendations for breaking the news: (1) introduce yourself; (2) speak slowly and deliberately; (3) be certain to speak to the specified contact person; (4) warn of the gravity of the situation, "I am saddened to bring you bad news"; (5) be unambiguous, "Your loved one has died"; and (6) then be supportive. Autopsy consent should not be obtained by telephone contact. Meeting with the family at the hospital or even driving to their home18Warren JW Muncie Jr, HL Magaziner J Hall-Craggs M Organ-limited autopsies: obtaining permission for postmortem examination of the urinary tract.Arch Pathol Lab Med. 1995; 119: 440-443PubMed Google Scholar is recommended. Concerns regarding the cost, the time delay to the mortician's office, the means of transportation, and the method for notification of the postmortem findings must be addressed. Questions about body mutilation can be dealt with by comparing an autopsy to an operation-emphasize that the patient feels no pain, the incisions will not show, and the body remains whole. Providing details of the procedure is unnecessary. When requesting consent, residents must be prepared for resistance. Even among well-prepared families, only 36% will grant permission for an autopsy.18Warren JW Muncie Jr, HL Magaziner J Hall-Craggs M Organ-limited autopsies: obtaining permission for postmortem examination of the urinary tract.Arch Pathol Lab Med. 1995; 119: 440-443PubMed Google Scholar We suggest that family support is the resident's responsibility as the primary physician. Grieving the death of a loved one is stressful, and increased mortality among surviving spouses has been reported.19Helsing KJ Szklo M Mortality after bereavement.Am J Epidemiol. 1981; 114: 41-52PubMed Google Scholar A prompt review of the autopsy findings can provide comfort, reassurance, and alleviation of guilt for the grieving family.16Reynolds RC Autopsies—benefits to the family.Am J Clin Pathol. 1978; 69: 220-222PubMed Google Scholar Residents should arrange for a meeting after the death to support the family, answer any remaining questions, and provide the preliminary autopsy report in understandable terms. Physicians fail in this follow-up; 94% report that they are available for the family after a patient's death, but less than 10% initiate contact.15Tolle SW Elllot DL Hickam DH Physician attitudes and practices at the time of patient death.Arch Intern Med. 1984; 144: 2389-2391Crossref PubMed Scopus (47) Google Scholar In one survey, many families complained that the report arrived more than 3 months after the death and that the medical jargon was difficult to interpret. Less than half of the families discussed the results with a physician.13McPhee SJ Bottles K Lo B Salka G Crommte D To redeem them from death: reactions of family members to autopsy.Am J Med. 1986; 80: 665-671Abstract Full Text PDF PubMed Scopus (102) Google Scholar Perimortem family support is clearly necessary but often forgotten, The autopsy was developed for the purpose of education, "to see with one's own eyes.3King LS Meehan MC A history of the autopsy: a review.Am J Pathol. 1973; 73: 514-544PubMed Google Scholar The physician of the 1940s worked closely with the pathologist, often assisting with the autopsy. Unfortunately, the busy physicians of the 1990s have placed autopsies extremely low on the list of their priorities, and thus mailbox notification has replaced the hands-on approach. The resident can restore the utility of the postmortem examination by assisting in the autopsy, reviewing the microscopic slides, reading the pathology literature, and sharing the gathered information at mortality conferences. The Accreditation Council for Graduate Medical Education requires all internal medicine residency programs to incorporate pathology into the teaching program: All deaths must berevie wed,…autopsies should be performed on at least 15% of deaths on the medical teaching service. Residents should be present at autopsies or should review the gross pathologic specimens at the time the autopsies are performed on their patients and should review the autopsy reports. Formal teaching sessions with reviews of autopsy, biopsy, and/or surgical pathology cases must be regularly scheduled.20American Medical Association Program requirements for residency education in internal medicine.Grad Med Educ Dir. 1996-1997; : 72-84Google Scholar The following barriers inhibit the institution of these recommendations. (1) Residents often lack the skills necessary to request an autopsy, approach the pathologist, and integrate the information into an educational format. (2) The team approach does not allow one resident to bond with a patient and establish the type of relationship needed to facilitate autopsy permission. (3) Attending physicians who are unaware of the requirements, unimpressed by the value of postmortem examinations, and concerned about potential litigation fail to motivate their residents to request autopsies. (4) Hospital administrators and directors of pathology lack the Financial incentives to encourage regular, complete autopsies. (5) Often, pathologists are unable to contact the resident at the time of the autopsy. Instituting a formal program to educate and involve residents in obtaining autopsy consent can substantially improve the autopsy rate.20American Medical Association Program requirements for residency education in internal medicine.Grad Med Educ Dir. 1996-1997; : 72-84Google Scholar Involving residents in the process of the postmortem examination can be accomplished in several ways. (1) New residents can be initiated with a basic curriculum including end-of-life decisions, death and dying, the grieving process, how to break bad news, how to request an autopsy, and how to conduct a postmortem family conference. (2) The pathology department can participate in the development of the curriculum in die following ways: encouraging residents to gown and glove for the autopsy, reviewing the microscopic slides, reading the pathology literature, and presenting cases at mortality conferences. (3) Continuity of care should be the top priority in the creation of the residents' hospital and clinic schedules. (4) Staff physicians involved in resident training may need education regarding the residents' goals and requirements. (5) A "Resident's Autopsy Request Form" (Appendix I) could be distributed to all nursing stations for the purpose of improving communication between the resident and the pathologist. Autopsy Request Form for Residents Residents: Please provide the following information for the pathologist. Please be available to be reached by telephone or pager during the next 24 hours to attend the autopsy. Pathologists: Please notify___________________________ (the resident serving as the patient's primary physician) when the aulopsy is performed. Pager #____________Evening telephone #______________ Patient's name:__________________________________________________________ Date and time of death:________________________________________ Underlying cause of death:________________________________________________ Immediate cause of death:_______________________________________ Concomitant medical problems:___________________________________________ Brief clinical history: Medications:______________________________ Potential or known infectious diseases:_________ Specific question to be answered from the autopsy: Choose one: ___We prefer a complete autopsy ___We prefer a limited or organ-specific autopsy to answer the above question for the following reason:_____________________________________________________________
Referência(s)