Consent to autopsy for neonates

Considerations for Practice in Supporting Parental Bereavement in the Neonatal Intensive Care Unit-a Systematic Review

BACKGROUND

Parental bereavement after the death of an infant in a neonatal intensive care unit (NICU) is a complex and nuanced experience. Support from healthcare practitioners can have a significant impact on bereavement experiences in the short- and long-term. Although several studies exist exploring parental perceptions of their experience of loss and bereavement, there has not been a recent review of beneficial practices and common themes in the current literature.

OBJECTIVE

This review synthesizes empirical research to identify considerations that ought to guide the caregiving practices of healthcare professionals to support parental bereavement.

SETTINGS/SUBJECTS

Data was collected from studies identified in MEDLINE, Embase, and CINAHL. The search was limited to English-language studies describing parental bereavement in the NICU population from January 1990 to November 2021.

RESULTS

Of 583 studies initially identified, 47 studies of varying geographic locations were included in this review. Various themes surrounding healthcare support in parental bereavement were identified including ensuring the opportunity for parents to spend time caring for their child, understanding their perception of infant suffering, recognizing the impact of communication experiences with healthcare providers, and offering access to alternative means of support, all of which have been described as suboptimal. Parents generally want the opportunity to say goodbye to their infant in a private and safe space, be supported through their decision-making and be offered bereavement follow-up after loss.

CONCLUSION

This review identifies methods of support in parental bereavement based on first-hand parental experiences and routine implementation of these strategies may be beneficial in supporting parents through their bereavement after the loss of a baby in the NICU.

Minimally invasive autopsy in the evaluation of fetal malformations and stillbirths: A feasibility study

BACKGROUND

Minimally invasive autopsy (MIA) using post-mortem magnetic resonance imaging with ancillary investigations is reported as accurate as conventional autopsy. This study assesses MIA's feasibility and accuracy compared to conventional autopsy.

METHOD

MIA and/or conventional autopsy were performed on malformed fetuses (14-20 weeks gestation) and stillbirths (>20 weeks gestation), with/without malformation. Concordance in diagnostic accuracy (95% confidence interval [CI]) and agreement (Kappa coefficient [k]) were assessed in malformed cases where both MIA and autopsy were conducted.

RESULTS

We enrolled 200 cases, including 100 malformed fetuses (<20 weeks) and 100 stillbirths (with/without malformations). Concordance of 97.3% was observed between MIA and autopsy in 156 malformed cases. The overall diagnostic accuracy of MIA was 96.04%.

CONCLUSION

While conventional autopsy remains the gold standard, MIA is feasible in tertiary care settings. It can be considered a potential alternative for post-mortem assessment, particularly in settings with limited facility of conventional autopsy and parental refusal.

Postmortem minimally invasive tissue sampling in communities: exploring perceptions of families, funeral workers, religious and community leaders and healthcare providers from Pakistan

BACKGROUND

Minimally invasive tissue sampling (MITS) has increasingly been used to improve the diagnosis of disease and identification of the cause of death, particularly in underserved areas. However, there are multiple barriers to accessing those who die within the community, our study aimed to explore the perceptions and insights of community members and healthcare providers regarding the feasibility of implementing MITS in community settings.

METHODS

A qualitative exploratory study was conducted. A total of twenty one in-depth interviews were conducted with deceased infants' parents, elders of the family, religious leaders, community leaders, and funeral workers. Focus group discussions were conducted with health care providers (n = 14) in two peri-urban slum areas of Karachi, Pakistan. The duration of this study was from August to October 2020. Data was analyzed using thematic analysis and was coded and merged into categories forming eight major themes.

RESULTS

In general, participants viewed minimally invasive tissue sampling (MITS) as beneficial for improving child health, though some had concerns about disrespecting the deceased during sample collection. Misinformation, fear of needles, and medical procedures were major barriers to MITS implementation. To enhance acceptance, community and religious leaders suggested using religious rulings, obtaining parental consent, ensuring confidentiality, and increasing efforts of community engagement. Community healthcare providers, along with funeral workers, recommended providing community members with grief counseling to increase study participation. Besides concerns about sampling interfering with respect for the decease, community members also raised concerns about misinformation. Further, participants provided feedback on the design and appearance of the mobile van used to collect MITS samples from children under the age of five.

CONCLUSION

This study is critical for understanding the challenges associated with implementation of community-based MITS sampling in Pakistan. Integrating the use of a mobile van for sample collection, grief counseling along with community engagement sessions and advocacy will help address community-based misinformation and develop community trust.

Community perceptions of postmortem examination and minimally invasive tissue sampling in neonates:a qualitative study in South India

BACKGROUND

Postmortem examination is the gold standard for establishing the cause of death. Minimally Invasive Tissue Sampling (MITS) of organs is a novel approach that can be used as an alternative to postmortem examination. In this study, the community perceptions in two states in South India towards neonatal postmortem and the acceptance towards the MITS technique is studied.

METHODS

In-depth interviews were conducted among the participants from Kerala and Karnataka to understand the perception towards postmortem and the acceptance of the novel MITS technique. The interviews were audio recorded, and a thematic analysis was done to identify the overarching themes and codes.

RESULTS

The knowledge and attitude of participants on conventional and MITS postmortem techniques, reasons for refusal, and the need for raising awareness were identified in the study. Participants favored the MITS techniques as it was less disfiguring and less time-consuming. The major concerns for refusal of conventional postmortem were that the procedure was disfiguring, time-consuming, and caused emotional stress to the parents.

CONCLUSIONS

Participants favored the MITS approach over conventional postmortem as it caused less disfigurement and was conducive to the religious practice of burial of the body.

Are non-invasive or minimally invasive autopsy techniques for detecting cause of death in prenates, neonates and infants accurate? A systematic review of diagnostic test accuracy

OBJECTIVES

To assess the diagnostic accuracy of non-invasive or minimally invasive autopsy techniques in deaths under 1 year of age.

DESIGN

This is a systematic review of diagnostic test accuracy. The protocol is registered on PROSPERO.

PARTICIPANTS

Deaths from conception to one adjusted year of age.

SEARCH METHODS

MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), the Cochrane Library, Scopus and grey literature sources were searched from inception to November 2021.

DIAGNOSTIC TESTS

Non-invasive or minimally invasive diagnostic tests as an alternative to traditional autopsy.

DATA COLLECTION AND ANALYSIS

Studies were included if participants were under one adjusted year of age, with index tests conducted prior to the reference standard.Data were extracted from eligible studies using piloted forms. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted following the Synthesis without Meta-Analysis guidelines. Vote counting was used to assess the direction of effect.

MAIN OUTCOME MEASURES

Direction of effect was expressed as percentage of patients per study.

FINDINGS

We included 54 direct evidence studies (68 articles/trials), encompassing 3268 cases and eight index tests. The direction of effect was positive for postmortem ultrasound and antenatal echography, although with varying levels of success. Conversely, the direction of effect was against virtual autopsy. For the remaining tests, the direction of effect was inconclusive.A further 134 indirect evidence studies (135 articles/trials) were included, encompassing 6242 perinatal cases. The addition of these results had minimal impact on the direct findings yet did reveal other techniques, which may be favourable alternatives to autopsy.Seven trial registrations were included but yielded no results.

CONCLUSIONS

Current evidence is insufficient to make firm conclusions about the generalised use of non-invasive or minimally invasive autopsy techniques in relation to all perinatal population groups.PROSPERO registration numberCRD42021223254.

Cause of Death in Neonates With Neurological Insults in the Neonatal Intensive Care Unit: Insights From A MITS Pilot Study

Background

Minimally invasive tissue sampling (MITS) of organs has been used as an alternative to complete diagnostic autopsy in countries where refusal for autopsy in newborns is common for sociocultural reasons. There is a paucity of literature regarding the diagnostic utility of MITS of the brain after death in neonates with neurological insults, especially in India.

Methods

This was a prospective, preliminary single-center tertiary care hospital study in India, focused specifically on MITS of the brain after neonatal death as a diagnostic tool to identify the various neurological insults. All neonatal deaths with neurological symptoms occurring within the first 30 days of life were enrolled, irrespective of the suspected clinical diagnosis.

Results

Sixteen neonates were enrolled after death for MITS of the brain, performed for diagnostic purposes, during the study period from February 2020 to March 2021. Their gestational ages ranged from 26 to 38 weeks. All neonates had either a history of seizures and/or respiratory distress or clinical evidence of sepsis and were on ventilator support. Histopathology in all 16 neonates showed evidence of anoxia, with or without reactive astrogliosis or microgliosis. In 5 neonates with cranial ultrasound evidence of brain hemorrhage, MITS of the brain showed intraventricular hemorrhage, subdural hemorrhage, or intraparenchymal white matter microhemorrhages. Premortem blood culture–proven sepsis was seen in 9 neonates. In all cases (100%), MITS had a good diagnostic yield and was useful to establish the neurological insult in the brain.

Conclusions

MITS of the brain provides an accurate and adequate diagnosis and can be an alternative to complete diagnostic autopsy for establishing the cause of death due to neurological insults, especially in low-resource settings where obtaining consent for more invasive procedure is often challenging.

Consent to minimally invasive tissue sampling procedures in children in Mozambique: A mixed-methods study

BACKGROUND

Minimally invasive tissue sampling (MITS), also named minimally invasive autopsy is a post-mortem method shown to be an acceptable proxy of the complete diagnostic autopsy. MITS improves the knowledge of causes of death (CoD) in resource-limited settings. Its implementation requires understanding the components of acceptability, including facilitators and barriers in real-case scenarios.

METHODS

We undertook a mixed-methods analysis comparing anticipated (hypothetical scenario) and experienced (real-case scenario) acceptability of MITS among relatives of deceased children in Mozambique. Anticipated acceptability information was obtained from 15 interviews with relatives of deceased children. The interview focus was on whether and why they would allow the procedure on their dead child in a hypothetical scenario. Experienced acceptability data were obtained from outcomes of consent requested to relatives of 114 deceased children during MITS implementation, recorded through observations, clinical records abstraction and follow-up informal conversations with health care professionals and semi-structured interviews with relatives.

RESULTS

Ninety-three percent of relatives indicated that they would hypothetically accept MITS on their deceased child. A key reason was knowing the CoD to take preventive actions; whereas the need to conform with the norm of immediate child burial, the secrecy of perinatal deaths, the decision-making complexity, the misalignment between MITS' purpose and traditional values, lack of a credible reason to investigate CoD, and the impotency to resuscitate the deceased were identified as potential points of hesitancy for acceptance. The only refusing respondent linked MITS to a perception that sharing results would constitute a breach of confidentiality and the lack of value attached to CoD determination. Experienced acceptability revealed four different components: actual acceptance, health professionals' hesitancy, relatives' hesitancy and actual refusal, which resulted in 82% of approached relatives to agree with MITS and 79% of cases to undergo MITS. Barriers to acceptability included, among others, health professionals' and facilities' unpreparedness to perform MITS, the threat of not burying the child immediately, financial burden of delays, decision-making complexities and misalignment of MITS' objectives with family values.

CONCLUSIONS

MITS showed high anticipated and experienced acceptability driven by the opportunity to prevent further deaths. Anticipated acceptability identified secrecy, confidentiality and complex decision-making processes as barriers, while experienced acceptability revealed family- and health facility-level logistics and practical aspects as barriers. Health-system and logistical impediments must also be considered before MITS implementation. Additionally, the multiple components of acceptability must be taken into account to make it more consistent and transferrable.

Minimally invasive autopsy for fetuses and children based on a combination of post-mortem MRI and endoscopic examination: a feasibility study

BACKGROUND

Less invasive perinatal and paediatric autopsy methods, such as imaging alongside targeted endoscopy and organ biopsy, may address declining consent rates for traditional autopsy, but their acceptability and accuracy are not known.

OBJECTIVES

The aims of this study were to provide empirical data on the acceptability and likely uptake for different types of autopsy among key stakeholders (study 1); and to analyse existing autopsy data sources to provide estimates of the potential efficacy of less invasive autopsy (LIA) and its projected utility in clinical practice (study 2).

REVIEW METHODS

Study 1: this was a mixed-methods study. Parents were involved in research design and interpretation of findings. Substudy 1: a cross-sectional survey of 859 parents who had experienced miscarriage, termination of pregnancy for fetal anomaly, stillbirth, infant or child death, and interviews with 20 responders. Substudy 2: interviews with 25 health professionals and four coroners. Substudy 3: interviews with 16 religious leaders and eight focus groups, with 76 members of the Muslim and Jewish community. Study 2: a retrospective analysis of national data in addition to detailed information from an existing in-house autopsy database of > 5000 clinical cases that had undergone standard autopsy to determine the proportion of cases by clinical indication group for which tissue sampling of specific internal organs significantly contributed to the diagnosis.

RESULTS

Substudy 1: 91% of participants indicated that they would consent to some form of LIA, 54% would consent to standard autopsy, 74% to minimally invasive autopsy (MIA) and 77% to non-invasive autopsy (NIA). Substudy 2: participants viewed LIA as a positive development, but had concerns around the limitations of the technology and de-skilling the workforce. Cost implications, skills and training requirements were identified as implementation challenges. Substudy 3: religious leaders agreed that NIA was religiously permissible, but MIA was considered less acceptable. Community members indicated that they might consent to NIA if the body could be returned for burial within 24 hours. Study 2: in 5-10% of cases of sudden unexplained death in childhood and sudden unexplained death in infants, the final cause of death is determined by routine histological sampling of macroscopically normal organs, predominantly the heart and lungs, and in this group routine histological sampling therefore remains an important aspect of investigation. In contrast, routine histological examination of macroscopically normal organs rarely (< 0.5%) provides the cause of death in fetal cases, making LIA and NIA approaches potentially highly applicable.

LIMITATIONS

A key limitation of the empirical research is that it is hypothetical. Further research is required to determine actual uptake. Furthermore, because of the retrospective nature of the autopsy data set, findings regarding the likely contribution of organ sampling to final diagnosis are based on extrapolation of findings from historical autopsies, and prospective data collection is required to validate the conclusions.

CONCLUSIONS

LIA is viable and acceptable (except for unexplained deaths), and likely to increase uptake. Further health economic, performance and implementation studies are required to determine the optimal service configuration required to offer this as routine clinical care.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Decisions to consent for autopsy after stillbirth: Aboriginal and Torres Strait Islander women's experiences

BACKGROUND

The stillbirth rate for Australian Aboriginal and Torres Strait Islander infants is twice that for non-Indigenous infants. Autopsy is the gold standard for fetal investigation; however, parental consent is often not given. There is little research investigating the drivers of parents' decision-making for autopsy after stillbirth.

AIMS

The current study explored the reasons why Aboriginal and Torres Strait Islander women did or did not give permission to autopsy after stillbirth.

MATERIALS AND METHODS

Five Aboriginal and/or Torres Strait Islander women participated in semi-structured interviews. Thematic analysis was conducted within a phenomenological framework.

RESULTS

Five themes were identified as reasons for giving permission - to find out why the baby died; to confirm diagnosis; to understand future risk; to help others; and doubt about maternal causes. Four themes were identified as reasons for declining permission - not asked in a sensitive manner; not enough time to think; distress about the autopsy procedure; and unwilling to agree. There was a lack of acceptability of the lengthy timeframe for the availability of autopsy results as families usually wait between three and nine months. This lengthy waiting period negatively impacted upon families' health and wellbeing.

CONCLUSIONS

It is important for health professionals to understand the factors that parents consider when giving permission for autopsy after stillbirth. It is hoped that an increase in autopsy rate will enhance the understanding of the causes of stillbirth and ultimately decrease the stillbirth rate for Aboriginal and Torres Strait Islander families.

Factors Influencing Acceptance of Post-Mortem Examination of Children at a Tertiary Care Hospital in Nairobi, Kenya

BACKGROUND

Clinical autopsies are not often part of routine care, despite their role in clarifying cause of death. In fact, autopsy rates across the world have declined and are especially low in sub-Saharan Africa.

OBJECTIVES

We set out to identify factors associated with acceptance of pediatric autopsies among parents of deceased children less than five years old, and examined local preferences for minimally invasive tissue sampling (MITS) procedures during post-mortem (PM) examinations.

METHODS

From December 2016 to September 2017, we contacted 113 parents/next of kin who had been previously approached to consent to a PM examination of their deceased child as part of a Kenyan study on cause of death. Interviews occurred up to three years after the death of their child.

FINDINGS

Seventy-three percent (83/113) of eligible study participants were enrolled, of whom 62/83 (75%) had previously consented to PM examination of their child. Those who previously consented to PM had higher levels of education, were more likely employed, and had more knowledge about certain aspects of autopsies than non-consenters. The majority (97%) of PM consenters did so because they wanted to know the cause of death of their child, and up to a third believed autopsy studies helped advance medical knowledge. Reasons for non-consent to PM examination included: parents felt there was no need for further examination (29%) or they were satisfied with the clinical diagnosis (24%). Overall, only 40% of study participants would have preferred MITS procedures to conventional autopsy. However, 81% of autopsy non-consenters would have accepted PM examination if it only involved MITS techniques.

CONCLUSION

There is potential to increase autopsy rates by strengthening reasons for acceptance and addressing modifiable reasons for refusals. Although MITS procedures have the potential to improve autopsy acceptance rates, they were not significantly preferred over conventional autopsies in our study population.

Learning From Investigation After Death

OBJECTIVES

The acceptability of traditional postmortem examination to bereaved families, coupled with a misguided professional view about their limited utility, has led to decrease in this ultimate investigation. Research recurrently demonstrates that postmortem examination provides clinically relevant information despite ever-improving diagnostic techniques. This review examines postmortem examination for children who die in PICU-whether consented or nonconsented (legally mandated). It explores how such investigations might provide useful information and suggests that PICU and pathology teams work together to provide information for bereaved families to either enable them to consent to postmortem interventions or understand necessary forensic processes. Newer technologies such as postmortem imaging and laparoscope-assisted/ultrasound-guided tissue sampling are reviewed, with the hope that greater acceptability to families may lead to a welcome resurgence in postmortem information for clinicians, tempered by realization that widespread acceptance of their equivalence to standard techniques by most forensic services is awaited.

DATA SOURCES

Literature review.

STUDY SELECTION

Journal articles describing practices in pediatric and adult postmortem examination.

DATA EXTRACTION

Not available.

DATA SYNTHESIS

Not available.

CONCLUSIONS

The PICU team have a duty to help bereaved parents understand what postmortem investigations are available, or might be mandated, after the death of their child. A thoughtful, unhurried, and compassionate discussion should be arranged with expert pathology teams and any specialists who have cared for the child to explain how investigations can provide information about what is involved-including availability and suitability of newer techniques. This should include information about when a child's body, organs, or tissues will be available for the funeral, necessary legal procedures and how and when results will be explained to them.

Conventional vs virtual autopsy with postmortem MRI in phenotypic characterization of stillbirths and fetal malformations

OBJECTIVE

To compare virtual autopsy using postmortem magnetic resonance imaging (MRI) with conventional autopsy with respect to phenotypic characterization of stillbirths and malformed fetuses, and acceptability to parents.

METHODS

This was a prospective diagnostic evaluation study, conducted from June 2013 to June 2015, including stillbirths and pregnancies terminated owing to fetal malformation at ≥ 20 weeks' gestation, for which parental consent to both conventional autopsy and postmortem MRI was obtained. Cases of maternal and obstetric cause of fetal demise were excluded. Whole-body postmortem MRI (at 1.5 T) was performed prior to conventional autopsy. Taking conventional autopsy as the diagnostic gold standard, postmortem MRI findings alone, or in conjunction with other minimally invasive prenatal and postmortem investigations, were assessed and compared for diagnostic accuracy.

RESULTS

Parental consent for both conventional autopsy and postmortem MRI was obtained in 52 cases of which 43 were included in the analysis. In 35 (81.4%) cases, the final diagnosis based on virtual autopsy with postmortem MRI was in agreement with that of conventional autopsy. With conventional autopsy as the reference standard, sensitivity, specificity, positive and negative predictive values of postmortem MRI were, respectively: 77.7%, 99.8%, 97.4% and 98.0% for whole-body assessment; 93.1%, 99.0%, 87.1% and 99.5% for the nervous system; 61.0%, 100.0%, 100.0% and 96.7% for the cardiovascular system; 91.1%, 100.0%, 100.0% and 98.0% for the pulmonary system; 80.6%, 99.8%, 96.7% and 98.7% for the abdomen; 96.2%, 99.7%, 96.2% and 99.7% for the renal system; and 66.7%, 100.0%, 100.0% and 97.2% for the musculoskeletal system. Virtual autopsy was acceptable to 96.8% of families as compared with conventional autopsy to 82.5%.

CONCLUSIONS

Virtual autopsy using postmortem MRI and other minimally invasive investigations can be an acceptable alternative to conventional autopsy when the latter is refused by the parents. Postmortem MRI is more acceptable to parents and can provide additional diagnostic information on brain and spinal cord malformations. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Post-mortem magnetic resonance (PMMR) imaging of the brain in fetuses and children with histopathological correlation

Post-mortem magnetic resonance (PMMR) imaging is rapidly emerging as an alternative, "less invasive", and more widely accepted investigative approach for perinatal deaths in the UK. PMMR has a high diagnostic accuracy for congenital and acquired fetal neuropathological anomalies compared to conventional autopsy, and is particularly useful when autopsy is non-diagnostic. The main objectives of this review are to describe and illustrate the range of common normal and abnormal central nervous system (CNS) findings encountered during PMMR investigation. This article covers the standard PMMR sequences used at our institution, normal physiological post-mortem findings, and a range of abnormal developmental and acquired conditions. The abnormal findings include diseases ranging from neural tube defects, posterior fossa malformations, those of forebrain and commissural development as well as neoplastic, haemorrhagic, and infectious aetiologies. Neuropathological findings at conventional autopsy accompany many of the conditions we describe, allowing readers to better understand the underlying disease processes and imaging appearances.

[Fetal autopsies : Relic or still a gold standard?]

BACKGROUND

Fetal autopsy rates are decreasing in Western countries although post-mortem examinations render important information for the parents concerning the cause of abortion and risk of recurrence in future pregnancies.

OBJECTIVE

The intention of the presented study was to analyze the development of fetal autopsies in Germany during the last decade and to review accessible information obtained by fetal autopsy.

MATERIAL AND METHODS

Reports of fetal autopsies conducted in two German university Institutes of pathology between 2005 and 2014 were evaluated retrospectively. Demographic data and the correlation between clinical diagnoses and autopsy findings were assessed. In addition, differences between spontaneous and induced cases of abortion and differences between the institutes were also documented.

RESULTS

Overall, 428 fetal autopsies were performed, whereby the number of autopsies decreased by 24.2% during the study period. Of the examined fetuses 29.7% were induced abortions which as expected exhibited different malformations compared to cases of spontaneous abortion (p < 0.001). There was no evidence of a malformation or other cause of death in 27.1% of the cases and 95.7% of these abortions occurred spontaneously. A discrepancy between clinical and autopsy findings was evident in 6.8% of cases and 3.5% of the autopsy examinations revealed at least one additional malformation compared to the prenatal clinical data.

CONCLUSION

Despite improvements in prenatal diagnostics, fetal autopsies remain an important diagnostic tool even today contributing additional information in a considerable number of cases potentially revising clinical diagnoses.

Factors affecting uptake of postmortem examination in the prenatal, perinatal and paediatric setting

Background

Postmortem examination is the single most useful investigation in providing information to parents about why their baby or child died. Despite this, uptake remains well below the recommended 75%.

Objective

To address the question ‘what are the barriers and motivators to perinatal, prenatal and paediatric PM examination?’

Search strategy

Key databases including Pubmed and CINAHL; Cochrane library, websites of relevant patient organisations, hand search of key journals, first and last authors and references.

Selection criteria

Peer‐reviewed qualitative, quantitative or mixed methods research examining factors affecting uptake or decline of perinatal or paediatric postmortem examination.

Data collection and analysis

Narrative synthesis; findings were compared across studies to examine interrelations.

Main results

Seven major themes describing barriers to postmortem uptake were identified: dislike of invasiveness, practicalities of the procedure, organ retention issues, protective parenting, communication and understanding, religion and culture and professional or organisational barriers. Six major themes related to factors which facilitated parental consent were identified: desire for information, contributing to research, coping and well‐being, respectful care, minimally invasive options, and policy and practice. There were a number of themes in the literature that reflected best practice.

Conclusion

Findings highlight the need for better health professional education and the fact some concerns may be mitigated if less invasive methods of postmortem were routinely available. New consent packages and codes of practice may have a positive impact on perception of examination after death. The landscape is changing; further research is necessary to assess the impact on postmortem uptake rates.

Tweetable abstract

Systematic review to explore the barriers and motivators to perinatal, prenatal and paediatric postmortem examination.

Systematic review to explore the barriers and motivators to perinatal, prenatal and paediatric postmortem examination.

Death scene investigation: parents’ experiences

This article presents the results of a study undertaken to evaluate how parents experience voluntary Death Scene Investigation (DSI) in their homes. In total, 35 parents were interviewed using semi-structured qualitative interview guidelines developed for this project. These focused on the parents’: 1) appraisal of information provided prior to the DSI and motivation for participating in the study, 2) experience of, and reactions to the DSI, and 3) thoughts and reactions following the DSI. The evaluation shows that performing a DSI is an important part of providing good care for bereaved parents following Sudden Infant Death Syndrome. If such an investigation is undertaken by professionals with extensive professional knowledge and experience in meeting bereaved parents in an empathic and caring manner, it can be a positive experience for parents, and help support them in coping with the painful death of their infant.

Whole-Body MRI Virtual Autopsy Using Diffusion-weighted Imaging With Background Suppression (DWIBS) at 3 T in a Child Succumbing to Chordoma

BACKGROUND

We report the use of diffusion-weighted imaging with background suppression (DWIBS) in pediatric virtual magnetic resonance imaging (MRI) autopsy of a child who succumbed to chordoma.

CASE DESCRIPTION

A 10-year-old girl who succumbed to relapse of a chordoma underwent whole-body virtual MRI autopsy 12 hours postmortem with short Tau inversion recovery (STIR) and DWIBS on 3 T, which demonstrated the primary mass, local and cardiac invasion, and metastatic disease to the thorax, abdomen, head/neck, and musculoskeletal system.

CONCLUSIONS

Postmortem virtual MRI autopsy including DWIBS successfully demonstrated the transthoracic spread of chordoma and invasion of the heart, resulting in blood-borne metastases. Motion and respiratory artifact were not factors during virtual autopsy using DWIBS on 3 T, making ideal use of this technology.

Incidence and enteral feed antecedents of severe neonatal necrotising enterocolitis across neonatal networks in England, 2012-13: a whole-population surveillance study

BACKGROUND

Necrotising enterocolitis is a neonatal gastrointestinal inflammatory disease with high mortality and severe morbidity. This disorder is growing in global relevance as birth rates and survival of babies with low gestational age improve. Population data are scant and pathogenesis is incompletely understood, but enteral feed exposures are believed to affect risk. We aimed to quantify the national incidence of severe necrotising enterocolitis, describe variation across neonatal networks, and investigate enteral feeding-related antecedents of severe necrotising enterocolitis.

METHODS

We undertook a 2-year national surveillance study (the UK Neonatal Collaborative Necrotising Enterocolitis [UKNC-NEC] Study) of babies born in England to quantify the burden of severe or fatal necrotising enterocolitis confirmed by laparotomy, leading to death, or both. Data on all liveborn babies admitted to neonatal units between Jan 1, 2012, and Dec 31, 2013, were obtained from the National Neonatal Research Database. In the subgroup of babies born before a gestational age of 32 weeks, we did a propensity score analysis of the effect of feeding in the first 14 postnatal days with own mother's milk, with or without human donor milk and avoidance of bovine-origin formula, or milk fortifier, on the risk of developing necrotising enterocolitis.

FINDINGS

During the study period, 118 073 babies were admitted to 163 neonatal units across 23 networks, of whom 14 678 were born before a gestational age of 32 weeks. Overall, 531 (0·4%) babies developed severe necrotising enterocolitis, of whom 247 (46·5%) died (139 after laparotomy). 462 (3·2%) of 14 678 babies born before a gestational age of 32 weeks developed severe necrotising enterocolitis, of whom 222 (48·1%) died. Among babies born before a gestational age of 32 weeks, the adjusted network incidence of necrotising enterocolitis ranged from 2·51% (95% CI 1·13-3·60) to 3·85% (2·37-5·33), with no unusual variation from the adjusted national incidence of 3·13% (2·85-3·42), despite variation in feeding practices. The absolute risk difference for babies born before a gestational age of 32 weeks who received their own mother's milk within 7 days of birth was -0·88% (95% CI -1·15 to -0·61; relative risk 0·69, 95% CI 0·60 to 0·78; number needed to treat to prevent one case of necrotising enterocolitis 114, 95% CI 87 to 136). For babies who received no compared with any bovine-origin products within 14 days of birth, the absolute risk difference was -0·65% (-1·01 to -0·29; relative risk 0·61, 0·39 to 0·83; number needed to treat 154, 99 to 345). We were unable to assess the effect of human donor milk as use was low.

INTERPRETATION

Early feeding of babies with their own mother's milk and avoidance of bovine-origin products might reduce the risk of necrotising enterocolitis, but the absolute reduction is small. Owing to the rarity of severe necrotising enterocolitis, international collaborations are needed for adequately powered preventive trials.

FUNDING

National Institute for Health Research.

Willingness to Know the Cause of Death and Hypothetical Acceptability of the Minimally Invasive Autopsy in Six Diverse African and Asian Settings: A Mixed Methods Socio-Behavioural Study

BACKGROUND

The minimally invasive autopsy (MIA) is being investigated as an alternative to complete diagnostic autopsies for cause of death (CoD) investigation. Before potential implementation of the MIA in settings where post-mortem procedures are unusual, a thorough assessment of its feasibility and acceptability is essential.

METHODS AND FINDINGS

We conducted a socio-behavioural study at the community level to understand local attitudes and perceptions related to death and the hypothetical feasibility and acceptability of conducting MIAs in six distinct settings in Gabon, Kenya, Mali, Mozambique, and Pakistan. A total of 504 interviews (135 key informants, 175 health providers [including formal health professionals and traditional or informal health providers], and 194 relatives of deceased people) were conducted. The constructs "willingness to know the CoD" and "hypothetical acceptability of MIAs" were quantified and analysed using the framework analysis approach to compare the occurrence of themes related to acceptability across participants. Overall, 75% (379/504) of the participants would be willing to know the CoD of a relative. The overall hypothetical acceptability of MIA on a relative was 73% (366/504). The idea of the MIA was acceptable because of its perceived simplicity and rapidity and particularly for not "mutilating" the body. Further, MIAs were believed to help prevent infectious diseases, address hereditary diseases, clarify the CoD, and avoid witchcraft accusations and conflicts within families. The main concerns regarding the procedure included the potential breach of confidentiality on the CoD, the misperception of organ removal, and the incompatibility with some religious beliefs. Formal health professionals were concerned about possible contradictions between the MIA findings and the clinical pre-mortem diagnoses. Acceptability of the MIA was equally high among Christian and Islamic communities. However, in the two predominantly Muslim countries, MIA acceptability was higher in Mali than in Pakistan. While the results of the study are encouraging for the potential use of the MIA for CoD investigation in low-income settings, they remain hypothetical, with a need for confirmation with real-life MIA implementation and in populations beyond Health and Demographic Surveillance System areas.

CONCLUSIONS

This study showed a high level of interest in knowing the CoD of a relative and a high hypothetical acceptability of MIAs as a tool for CoD investigation across six distinct settings. These findings anticipate potential barriers and facilitators, both at the health facility and community level, essential for local tailoring of recommendations for future MIA implementation.

Factors influencing the uptake of neonatal bereavement support services - Findings from two tertiary neonatal centres in the UK

BACKGROUND

Research on perinatal bereavement services is limited. The aim of the study was to compare the uptake of bereavement support services between two tertiary neonatal units (NNU), and to investigate influencing factors.

METHOD

The medical and bereavement records of all neonatal deaths were studied from January 2006 to December 2011. Data collected included parent and baby characteristics, mode of death, consent for autopsy and bereavement follow-up. The categorical data were compared by chi-square or Fisher's exact test and continuous data by Wilcoxon signed-rank test; a multivariable regression analysis was performed using STATA 12.0.

RESULTS

The neonatal deaths of 297 babies (182 in NNU1 and 115 in NNU2) with full datasets were analysed. Baby characteristics were similar between units except for lower median gestational age in NNU1 (p = 0.03). Significantly more NNU1 parents were non-Caucasian (p < 0.01), from lower socio-economic status (p = 0.01) and had previous stillbirth/miscarriage (p = 0.03). More babies had care withdrawn in NNU2 (p < 0.01). A significantly higher proportion of parents from NNU1 (61 %) attended bereavement follow-up compared to NNU2 (34 %; p < 0.01). On multivariable analysis, significantly more parents who were married or co-habiting (p = 0.02) and consented for an autopsy (p = 0.01) attended bereavement services.

CONCLUSION

Uptake of bereavement services varied between the two NNUs, which could be due to differences in the ethnic and socio-economic mix of the population. Significantly more parents who were married or co-habiting, or consented for autopsy, attended bereavement follow up services.

X-ray phase contrast tomography; proof of principle for post-mortem imaging

OBJECTIVE

To demonstrate the feasibility of using X-ray phase-contrast tomography to assess internal organs in a post-mortem piglet model, as a possible non-invasive imaging autopsy technique.

METHODS

Tomographic images of a new-born piglet were obtained using a free-space propagation X-ray phase-contrast imaging setup at a synchrotron (European Synchrotron Radiation Facility, Grenoble, France). A monochromatic X-ray beam (52 keV) was used in combination with a detector pixel size of 46 × 46 µm(2). A phase-retrieval algorithm was applied to all projections, which were then reconstructed into tomograms using the filtered-back projection algorithm. Images were assessed for diagnostic quality.

RESULTS

Images obtained with the free-space propagation setup presented high soft-tissue contrast and sufficient resolution for resolving organ structure. All of the main body organs (heart, lungs, kidneys, liver and intestines) were easily identified and adequately visualized. In addition, grey/white matter differentiation in the cerebellum while still contained within the skull was shown.

CONCLUSION

The feasibility of using X-ray phase-contrast tomography as a post-mortem imaging technique in an animal model has been demonstrated. Future studies will focus on translating this experiment to a laboratory-based setup.

ADVANCES IN KNOWLEDGE

Appropriate image processing and analysis enable the simultaneous visualization of both soft- and hard-tissue structures in X-ray phase-contrast images of a complex, thick sample.

Diagnostic accuracy and limitations of post-mortem MRI for neurological abnormalities in fetuses and children

AIM

To compare the diagnostic accuracy of non-invasive cerebral post-mortem magnetic resonance imaging (PMMRI) specifically for cerebral and neurological abnormalities in a series of fetuses and children, compared to conventional autopsy.

MATERIALS AND METHODS

Institutional ethics approval and parental consent was obtained. Pre-autopsy cerebral PMMRI was performed in a sequential prospective cohort (n = 400) of fetuses (n = 277; 185 ≤ 24 weeks and 92 > 24 weeks gestation) and children <16 years (n = 123) of age. PMMRI and conventional autopsy findings were reported blinded and independently of each other.

RESULTS

Cerebral PMMRI had sensitivities and specificities (95% confidence interval) of 88.4% (75.5 to 94.9), and 95.2% (92.1 to 97.1), respectively, for cerebral malformations; 100% (83.9 to 100), and 99.1% (97.2 to 99.7) for major intracranial bleeds; and 87.5% (80.1 to 92.4) and 74.1% (68 to 79.4) for overall brain pathology. Formal neuropathological examination was non-diagnostic due to maceration/autolysis in 43/277 (16%) fetuses; of these, cerebral PMMRI imaging provided clinically important information in 23 (53%). The sensitivity of PMMRI for detecting significant ante-mortem ischaemic injury was only 68% (48.4 to 82.8) overall.

CONCLUSIONS

PMMRI is an accurate investigational technique for identifying significant neuropathology in fetuses and children, and may provide important information even in cases where autolysis prevents formal neuropathological examination; however, PMMRI is less sensitive at detecting hypoxic-ischaemic brain injury, and may not detect rarer disorders not encountered in this study.

Indications, advantages and limitations of perinatal postmortem imaging in clinical practice

Just as there is a range of paediatric imaging techniques available during life, a similar repertoire is available as part of the foetal and perinatal postmortem examination. In this article, we review the literature regarding the diagnostic utility of postmortem radiography, US, CT and MRI in this clinical setting. There is limited direct evidence on the diagnostic utility of any of these techniques, apart from postmortem MRI, which when combined with other noninvasive investigations, has been shown to be highly sensitive and specific for many foetal postmortem diagnoses. The main disadvantages of postmortem MRI include the longer duration of imaging, the need for appropriate training in the interpretation of normal postmortem changes, and possible non-diagnostic imaging examinations in early gestation foetuses. As less-invasive autopsy becomes increasingly available, the true utility of these techniques will evolve, and clinical guidelines for maximal diagnostic yield can be developed.

Post-mortem MRI as an alternative to non-forensic autopsy in foetuses and children: from research into clinical practice

Although post-mortem MRI (PMMR) was proposed as an alternative to conventional autopsy more than a decade ago, the lack of systematic validation has limited its clinical uptake. Minimally invasive autopsy (MIA) using PMMR together with ancillary investigations has now been shown to be as accurate as conventional autopsy in foetuses, newborns and infants and is particularly useful for cerebral, cardiac and genitourinary imaging. Unlike conventional autopsy, PMMR provides a permanent three-dimensional auditable record, with accurate estimation of internal organ volumes. MIA is becoming highly acceptable to parents and professionals, and there is widespread political support and public interest in its clinical implementation in the UK. In the short to medium term, it is desirable that a supraregional network of specialist centres should be established to provide this service within the current National Health Service framework.

What do bereaved parents want from professionals after the sudden death of their child: a systematic review of the literature

Background

The death of a child is a devastating event for parents. In many high income countries, following an unexpected death, there are formal investigations to find the cause of death as part of wider integrated child death review processes. These processes have a clear aim of establishing the cause of death but it is less clear how bereaved families are supported. In order to inform better practice, a literature review was undertaken to identify what is known about what bereaved parents want from professionals following an unexpected child death.

Methods

This was a mixed studies systematic review with a thematic analysis to synthesize findings. The review included papers from Europe, North America or Australasia; papers had to detail parents’ experiences rather than professional practices.

Results

The review includes data from 52 papers, concerning 4000 bereaved parents. After a child has died, parents wish to be able to say goodbye to them at the hospital or Emergency Department, they would like time and privacy to see and hold their child; parents may bitterly regret not being able to do so. Parents need to know the full details about their child’s death and may feel that they are being deliberately evaded when not given this information. Parents often struggle to obtain and understand the autopsy results even in the cases where they consented for the procedure. Parents would like follow-up appointments from health care professionals after the death; this is to enable them to obtain further information as they may have been too distraught at the time of the death to ask appropriate questions or comprehend the answers. Parents also value the emotional support provided by continuing contact with health-care professionals.

Conclusion

All professionals involved with child deaths should ensure that procedures are in place to support parents; to allow them to say goodbye to their child, to be able to understand why their child died and to offer the parents follow-up appointments with appropriate health-care professionals.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2431-14-269) contains supplementary material, which is available to authorized users.

Minimally invasive, imaging guided virtual autopsy compared to conventional autopsy in foetal, newborn and infant cases: study protocol for the paediatric virtual autopsy trial

Background

In light of declining autopsy rates around the world, post-mortem MR imaging is a promising alternative to conventional autopsy in the investigation of infant death. A major drawback of this non-invasive autopsy approach is the fact that histopathological and microbiological examination of the tissue is not possible. The objective of this prospective study is to compare the performance of minimally invasive, virtual autopsy, including CT-guided biopsy, with conventional autopsy procedures in a paediatric population.

Methods/Design

Foetuses, newborns and infants that are referred for autopsy at three different institutions associated with the University of Zurich will be eligible for recruitment. All bodies will be examined with a commercial CT and a 3 Tesla MRI scanner, masked to the results of conventional autopsy. After cross-sectional imaging, CT-guided tissue sampling will be performed by a multifunctional robotic system (Virtobot) allowing for automated post-mortem biopsies. Virtual autopsy results will be classified with regards to the likely final diagnosis and major pathological findings and compared to the results of conventional autopsy, which remains the diagnostic gold standard.

Discussion

There is an urgent need for the development of alternative post-mortem examination methods, not only as a counselling tool for families and as a quality control measure for clinical diagnosis and treatment but also as an instrument to advance medical knowledge and clinical practice. This interdisciplinary study will determine whether virtual autopsy will narrow the gap in information between non-invasive and traditional autopsy procedures.

Trial Registration

ClinicalTrials.gov: NCT01888380

Bereaved parents' intentions and suggestions about research autopsies in children with lethal brain tumors

OBJECTIVE

To determine bereaved parents' perceptions about participating in autopsy-related research and to elucidate their suggestions about how to improve the process.

STUDY DESIGN

A prospective multicenter study was conducted to collect tumor tissue by autopsy of children with diffuse intrinsic pontine glioma. In the study, parents completed a questionnaire after their child's death to describe the purpose for, hopes (ie, desired outcomes of), and regrets about their participation in autopsy-related research. Parents also suggested ways to improve autopsy-related discussions. A semantic content analytic method was used to analyze responses and identify themes within and across parent responses.

RESULTS

Responses from 33 parents indicated that the main reasons for participating in this study were to advance medical knowledge or find a cure, a desire to help others, and choosing as their child would want. Parents hoped that participation would help others or help find a cure as well as provide closure. Providing education/anticipatory guidance and having a trusted professional sensitively broach the topic of autopsy were suggestions to improve autopsy discussions. All parents felt that study participation was the right decision, and none regretted it; 91% agreed that they would make the choice again.

CONCLUSION

Because autopsy can help advance scientific understanding of the disease itself and because parents reported having no regret and even cited benefits, researchers should be encouraged to continue autopsy-related research. Parental perceptions about such studies should be evaluated in other types of pediatric diseases.

Conflict resolution in end-of-life decisions in the neonatal unit

End-of-life decisions are always stressful for families and professionals. As the decades pass, ethics and the law both change, even in one society, and cannot always provide perfect choices for each individual patient. Conflict should rarely arise in the neonatal unit. High-quality communication and compassion should allow professionals and families to build a team approach to the care of their child, even when the infant is imperilled. Each unit should have structures in place to deal with conflict, and every senior professional must be trained in conflict resolution so that the care of the family is outstanding.

Interventions for supporting parents' decisions about autopsy after stillbirth

BACKGROUND

Stillbirth remains one of the least understood areas of infant death and accurate data on the causes of stillbirth are the cornerstone of stillbirth prevention. An autopsy examination remains the gold standard post-mortem investigation for stillbirth. However, decisions about post-mortem investigations, particularly autopsy are difficult. The purpose of this review is to examine the effectiveness of methods to help parents who have experienced a stillbirth decide whether to have post-mortem investigations, including whether to have an autopsy performed.

OBJECTIVES

The primary objectives were a) to examine the effectiveness of interventions to support parents' decisions about autopsy consent after a stillbirth on outcomes for parents, and b) to determine autopsy rates. Secondary objectives were to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10), MEDLINE (1966 to 24 July 2012) and EMBASE (1980 to 24 July 2012), Current Controlled Trials metaRegister (mRCT) (18 September 2012) and the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (18 September 2012). We also searched the websites of the Stillbirth and Neonatal Death Charity (SANDS) and International Stillbirth Alliance (ISA) (18 September 2012) and then subsequently searched the websites of all the ISA member organisations.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions designed specifically to support parents who have experienced a stillbirth make decisions about their options for post-mortem investigations including all investigations after stillbirth compared with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations against the selection criteria. 

MAIN RESULTS

No studies meeting the review inclusion criteria were identified. A search of 40 websites associated with supporting parents who experience stillbirth also found little reference to, or information about autopsy or other post-mortem examinations.

AUTHORS' CONCLUSIONS

Support for parents making decisions about autopsy or other post-mortem examinations after stillbirth must rely on the ad hoc knowledge and experience of those involved at the time.

Postmortem biopsy to obtain lung tissue in congenital diaphragmatic hernia

BACKGROUND

The accrual of human tissues from autopsies for diagnostic and translational research has decreased significantly over the last decades.

OBJECTIVES

The objective of this study was to evaluate our experience with lung biopsy through a minithoracotomy as an alternative for obtaining postmortem tissue when full autopsy is refused in congenital diaphragmatic hernia (CDH) patients.

METHODS

Within 2 h of death we routinely asked parents for permission to perform an autopsy. Starting in 2001, parents who refused autopsy were asked permission for a postmortem lung biopsy. Pathology autopsy and biopsy reports were compared to clinical records.

RESULTS

Between 2001 and 2009, 46 patients died from CDH. Permission for autopsy was granted in 5 patients (11%). Of the remaining 41 patients, the parents of 15 (33%) agreed to postmortem lung biopsy. In all cases, additional findings were reported from the autopsy or biopsy, without changing the originally reported cause of death. In 1 case, we isolated fibroblasts from the lung biopsy using standardized cell culture techniques. Parents were able to take their child home with a minimal delay following biopsy.

CONCLUSIONS

Parents refusing a full autopsy frequently agree to postmortem organ biopsy. This approach should therefore be considered as a valuable alternative, when permission for full autopsy is declined, for obtaining human tissues for both diagnostic and research purposes and is potentially applicable to other anomalies.

Decision influences and aftermath: parents, stillbirth and autopsy

BACKGROUND

Stillbirth, among the most distressing experiences an adult may face, is also a time when parents must decide whether an autopsy or other post-mortem examinations will be performed on their infant. Autopsies can reveal information that might help explain stillbirth, yet little is known about how people make this difficult decision.

OBJECTIVES

This study examines the influences on decisions about autopsy after stillbirth among Australian parents.

DESIGN

The study involved secondary analysis of transcripts of three focus groups using qualitative content analysis.

PARTICIPANTS AND SETTING

Seventeen parents of 14 stillborn babies participated in consultations around the revision of a perinatal mortality audit guideline.

RESULTS

Parents shared the decision making. Four decision drivers were identified: parents' preparedness or readiness to make decisions; parental responsibility; concern for possible consequences of an autopsy and the role of health professionals. Each decision driver involved reasons both for and against autopsy. Two decision aftermath were also present: some parents who agreed to an autopsy were dissatisfied with the way the autopsy results were given to them and some parents who did not have an autopsy for their infant expressed some form of regret or uncertainty about the choice they made.

CONCLUSIONS

To make decisions about autopsy after stillbirth, parents need factual information about autopsy procedures, recognition that there might be fear of blame, an environment of trust, and health services and professionals prepared and skilled for difficult conversations.

Perinatal postmortems: what is important to parents and how do they decide?

BACKGROUND

Falling consent rates for postmortems, regardless of age of death, have been widely reported in recent years. The aim of this study was to explore parental attitudes to, and decision-making about, a perinatal postmortem after termination for fetal abnormality, late miscarriage, or stillbirth.

METHODS

A prospective self-completion questionnaire was given to 35 women and their partners. The participants had experienced second or third trimester pregnancy loss in a single fetal medicine and delivery unit in the United Kingdom and were making decisions about having a postmortem. They were asked to complete a questionnaire about their attitudes to, and expectations of, a perinatal postmortem.

RESULTS

Thirty-one questionnaires were received from parents of 17 babies (49% of those asked; 16 from mothers, 15 from fathers). Parents of nine babies (53%) said they would agree to a full postmortem, of three babies to a limited postmortem, and of four babies to an external examination only; one couple were undecided. The most important issues for the parents in this study that related to their decisions about a postmortem centered on the need for information, both for future planning and about what had happened. Moderately important issues related to altruism, which is, improving medical knowledge and helping other parents experiencing similar bereavement. Among the lowest scoring issues were potential barriers, such as concerns about cultural or religious acceptability of a postmortem, funeral delays, and what would happen to the baby's body.

CONCLUSIONS

Bereaved parents who participated in this study, where postmortem consent rates were relatively high, thought that their need for knowledge eclipsed assumed barriers when deciding whether or not to have a postmortem for their baby.

The value of neonatal autopsy

BACKGROUND AND OBJECTIVE

Neonatal autopsy rates were in decline internationally at the end of the last century. Our objective was to assess the current value of neonatal autopsy in providing additional information to families and healthcare professionals.

METHODS

We conducted a review of neonatal autopsies performed in a tertiary perinatal centre over an 11-year period. Primary outcomes measured were the annual neonatal autopsy rates and concordance rates between clinical and autopsy diagnoses of the primary cause of death. Secondary outcomes were the clinical, genetic and audit value of the examinations. Findings were used to inform the consent process, and the effect this had on institutional post-mortem rates was assessed over the subsequent 5-year period.

RESULTS

There was a marked decline in the annual neonatal autopsy rate from 73% in 1994 to 48% in 2004. 164 cases met the inclusion criteria for review. Complete concordance for cause of death was reached in 91% of cases. Previously unsuspected or unconfirmed clinical conditions, other than the primary cause of death, were uncovered at autopsy in 85 cases. Detailed information on inheritable conditions was obtained in 45 cases. Findings with perceived 'audit value' for clinical practice were identified in 29 cases. The dissemination of this information to staff and families contributed to the stabilisation of the consent rate in the following 5-year period.

CONCLUSION

Neonatal autopsy remains a valuable diagnostic tool as it provides critical clinical and audit information for healthcare professionals and families.

Bereaved parents' perceptions of the autopsy examination of their child

OBJECTIVE

In this study we explored parental views of their child's autopsy, their experiences with autopsy-related processes, and the impact of the examination on their grief.

METHODS

A survey design with a mailed questionnaire was used. The inclusion criteria were that an autopsy had been performed on the child and it was at least 3 months since his or her death. The questionnaire consisted of nonidentifying demographic details about the child, a standardized grief measure (parts A and B of the Texas Revised Inventory of Grief), and 28 questions with response sets and opportunities for comment. Fifty-three parents participated.

RESULTS

Our findings suggest a complexity of perceptions associated with pediatric autopsy examination. A distinction was identified between the informational and altruistic benefits of autopsy and its supportive qualities. Ninety percent of parents valued autopsy as a means of finding out why their child died, and 77% appreciated its contribution to medical knowledge. The general unequivocal helpfulness for bereaved parents commonly ascribed to autopsy examinations was not found. Parents expressed uncertainty about their perceptions of autopsy. Forty-one percent of the parents felt that it helped them live with their loss and 30% found it a comfort, whereas 42% of the parents felt that their child's autopsy examination added to their grief. The results underscore the necessity for open discussion with parents about the realities of what autopsy can offer them.

CONCLUSIONS

Our results add to the knowledge about the meaning of autopsy for grieving parents and challenge some current beliefs.

Current techniques in postmortem imaging with specific attention to paediatric applications

In this review we discuss the decline of and current controversies regarding conventional autopsies and the use of postmortem radiology as an adjunct to and a possible alternative for the conventional autopsy. We will address the radiological techniques and applications for postmortem imaging in children.

Reorientation of care in the NICU

Where possible, both parents should be present whenever bad news is broken. Professional calm and carefully chosen words are essential. Staff must be aware of cultural and religious beliefs of the family, and should be cognizant of linguistic and educational capabilities. The unexpected collapse and death of an infant is rare but is exceptionally demanding on communication skills. Time must be given for the family to ask questions, and staff should acknowledge the tragedy and the uncertainty, but should convey a determination to discover the truth for the family. A predictable deterioration allows staff and family to work together towards a "guided consensus" over future management. Compassionate care involves time, comfort and dignity for the child and parents. It is crucial for the family to receive empathetic support from senior nursing and medical staff. Mementoes may help the grieving process. Necropsy may also play an important role in allowing the families to rebuild their lives.

Requesting perinatal autopsy: multicultural considerations

The subject of perinatal autopsy is not frequently seen in the literature. Perinatal loss, particularly stillbirth, frequently remains unexplained, despite current technology and diagnostic procedures. Parents may automatically refuse an autopsy, despite the potentially valuable information it could provide about the current pregnancy and subsequent pregnancies and despite the possible comfort the results could provide for relatives. Other reasons for declining an autopsy could be cultural or religious prohibitions. In addition, healthcare providers sometimes lack the knowledge of circumstances under which a postmortem examination is permitted, and fail to use culturally sensitive and culturally competent discussions about the reasons a postmortem examination is important and permissible. This purpose of this article is to provide information on selected cultural and religious groups to assist the nurse who is seeking consent for a perinatal autopsy.

Clinical, educational, and epidemiological value of autopsy

The autopsy is now often regarded as of marginal use in modern clinical practice. In this Review we contend that the autopsy remains an important procedure with substantial, if largely underused, potential to advance medical knowledge and improve clinical practice. Many doctors lack familiarity with autopsy practices, and are insufficiently aware of the benefits for not only bereaved families but also present and future patients. In this Review, which has an international perspective, we consider the ascent and decline of the autopsy, the legal frameworks that govern its use, the value and potential pitfalls of alternatives to the conventional method, and the autopsy's role in undergraduate medical education. We also draw attention to the continuing ability of autopsies to improve the completeness and reliability of death certification, which is important for public-health strategies and for some bereaved families.

Neonatal death after hypoxic ischaemic encephalopathy: does a postmortem add to the final diagnoses?

BACKGROUND

Case review after fatal perinatal asphyxia may have medicolegal implications. Accurate diagnosis of cause of death is therefore essential.

OBJECTIVE

To determine consent rate and utility of autopsy after fatal grade III hypoxic ischaemic encephalopathy (HIE) presumed to be secondary to birth asphyxia.

DESIGN

A retrospective clinical review from January 1995 to December 2002.

SETTING

Regional tertiary referral neonatal unit, Wellington, New Zealand.

POPULATION

Inclusion criteria were gestation >/=37 weeks, resuscitation after delivery and clinical course of grade III HIE. Exclusions were a recognised major lethal malformation.

METHODS

Review of clinical records including the autopsy report.

MAIN OUTCOME MEASURES

Consent for autopsy, change in diagnosis after autopsy.

RESULTS

Twenty-three infants died during the time period with a major diagnosis of grade III HIE. Three did not meet inclusion criteria. Of the remaining 20, 11 were female. Median gestation at birth was 40 weeks (range 38-42 weeks) and median birth weight was 3568 g (range 2140-4475 g). In 8/17 of the infants for whom length and head measurements were available, the Ponderal Index suggested intrauterine growth retardation. The 16/20 infants had an autopsy. Four of these were Coroner's cases giving an autopsy rate of 80% with a rate by consent of 60%. In 10 (62.5%) infants, significant new information was added to the clinical diagnoses.

CONCLUSIONS

Neonatal HIE is a symptom rather than a final clinical diagnosis. A full autopsy is required to fully explore the reasons for fatal neonatal HIE and may provide information that is important medicolegally.