[Clinical autopsies. Practical approach, legal foundations and ethical considerations]

[Autopsy rates in Germany]

BACKGROUND

In 2015 the German professional Association of Pathologists conducted a survey to establish a baseline for an autopsy rate in Germany and to collect data from 2005-2014, as hospitals must meet a fixed autopsy quota to receive the supplementary payment for autopsies as stated in the law for hospital structure (KHSG 10.12.2015).

MATERIAL AND METHODS

The survey comprised 12 questions and was sent to 450 institutes of pathology. The overall return rate was 38%. The data of the different institutional types was grouped and statistically analyzed.

RESULTS

Of 86.416 reported autopsies on deceased adults in Germany from 2005-2014, 47% took place in university hospitals, 36% in local hospitals and 17% in privately run practices. Out of 4320 autopsies on deceased children and adolescents, the majority (83%) were performed at university hospitals, 8%, and 9%, respectively, at the other two entity types. Of the 14.047 fetal autopsies, 55% were done at university hospitals, 25% at other hospitals and 20% at private practices. From 2005 to 2014 the overall number of autopsies decreased by 30%, independently of the institute type. Within each group of institution types there was a wide range in numbers and rate of autopsies done per year: university hospitals total 0‑428, quota of 3,4-19,4%; local hospitals 0‑324, quota of 1,1-30,8%; private practices 0‑268, quota 0,4-5,2%.

CONCLUSION

To this day, there is no universal system to document and register hospital autopsy rates in Germany. Due to the high range of yearly autopsy rates even within the different groups of institute types, the threshold for the autopsy rate that must be met to obtain the supplementary payment should be low in the beginning.

[History of the anatomical and clinical autopsy]

The history of the autopsy is naturally also a part of the history of anatomy and pathology and spans over about 2300 years. The first documented autopsies were conducted in about 300 B.C. Thereafter, due to the prohibition of dissections due to religious, social, or hygienic reasons, a long period of stagnation took place. With the onset of the Renaissance in the 15th and 16th century, interest in the ancient sciences such as anatomy began to rise and consequently an increasing number of dissections for anatomical studies were conducted. Nevertheless, it took nearly 200 years until clinical symptoms and/or causes of disease and death were correlated with anatomical findings. In the second half of the 19th century, the clinical autopsy based on the combination of macroscopic and microscopic findings became more and more important as a precondition for the systematic description of diseases. Based on autopsy findings and together with several new techniques, modern pathology could be established at the beginning of the 20th century as a source of scientific knowledge for the clinical medicine and as a theoretical discipline of its own.

[Validation of medical ethical decisions at the bedside by the autopsy : Experience of the ethics committee at the Stuttgart Clinic]

BACKGROUND

Ethics consultations in a clinical setting can be challenging, specifically with respect to limiting therapeutic interventions in terminally ill patients. Some decisions will even be controversial.

OBJECTIVE

Can a clinical autopsy be used to confirm the recommendations given by the ethics committee, i. e. limitation of therapy to palliative care?

MATERIAL AND METHODS

We report an exemplary case of a patient with endocarditis and subsequent septic cerebral infarction. During treatment in the intensive care unit (ICU) two ethics consultations were held. Both times the patient' s clinical condition and prognosis were controversially discussed. The patient died after a recommendation had been given for supportive care. The subsequent autopsy, which is described in detail, confirmed a fatal set of symptoms with extensive destruction of the heart and disseminated brain infarcts.

CONCLUSION

Clinical autopsies are crucial for an objective description of diseases and can corroborate the decision to limit therapeutic intervention in end of life care. It is a valuable tool in evaluating the quality of decision making in ethics counseling.

[Proposals for standardization of autopsy reports]

The decline in the number of autopsies not only in Germany has been attributed to several reasons. Complaints of clinicians about a non-uniform layout of autopsy reports may be one important reason. The lack of initiatives concerning standardization of autopsy reports contributes to a poor comparability of autopsy reports from different institutions and even within one institution. In order to promote harmonization of a protocol for autopsy results proposals for a standardization of autopsy protocols are given. These proposals are based on using modules for different parts of the autopsy protocols, thus giving different institutions the possibility to modify these modules.

[Autopsy-a procedure of medical history?]

An autopsy is an important tool of quality assurance in clinical medicine. It serves to determine the exact cause of death, unravel unexpected complications of disease processes including adverse or any other effects of treatment as well as to validate the official mortality statistics. An autopsy also makes an important contribution to training medical students and physicians; however, the rate of clinical autopsies has been declining drastically for decades, the causes being manifold. Lack of interest among clinicians, mainly due to inadequate knowledge of the advantages of autopsy seems to play a special role. The lack of reasonable reimbursement has also been discussed as another possible cause. In order to counteract this negative trend, efforts should be made to work on the awareness of medical students and young clinicians so that an autopsy is perceived as a general measure of quality assurance and physician self-control. Furthermore, a realistic reimbursement of financial and personnel expense is necessary.

[Public perceptions of hospital autopsies: results of a representative survey]

BACKGROUND

The number of hospital autopsies has been declining for many years-in Germany as well as in other western countries. One possible reason for this could be the public's negative view of autopsies.

METHODS

Therefore, a representative survey was conducted to study the attitudes of the German population on postmortem examinations.

RESULTS

In total, 84% of respondents generally accept hospital autopsies, while only 10% are in principle opposed to this practice. Many respondents (72%) would agree to the autopsy of their own dead body and 65% to the autopsy of relatives. Altogether, 9% of respondents had already been in a situation where a relative had died in a hospital and they were asked for permission to perform an autopsy. Of these 90, 56% agreed to and 44% refused autopsy.

CONCLUSION

The data suggest that the attitudes of the public are surprisingly positive and do not explain declining autopsy rates. Medical and institutional reasons must be considered instead as the possible cause of declining autopsy rates.