The Diagnostic and Management Autopsy
What is the diagnostic and management autopsy (DMA)?
The “diagnostic and management autopsy” involves an expert review of the diagnostic decisions made before death. The review is conducted by specialists in the patient’s conditions – possibly pathologists, but also physicians from other departments (1) – and can often provide additional information on the cause of death and any potential diagnostic errors that were made prior to death. It is especially useful in situations where a complete diagnostic autopsy is not possible. It’s important to note, however, that the DMA is not a replacement for the traditional autopsy; rather, it can be considered another option to gain critical information to improve clinical performance.
For example, a DMA of a patient death from a coronary stent thrombosis would involve a review of medical decisions in the days leading up to that death by a group of experts in coagulation and vascular disorders. Those experts will be more familiar with the tests, treatments, and decision-making related to the patient’s cause of death than a single pathologist who is unlikely to have expert knowledge about blood clotting.
How did the DMA come into existence?
The idea grew organically out of a particular case. The patient in question had a coronary stent thrombosis, but was told he could wait a few months before having coronary bypass surgery. The next day, he died. Obviously, our first question – and the family’s – was, “Who said you could wait three months, and why?” But that’s not a question you answer by cutting open a body in a case of obvious stent thrombosis. That’s a question you answer by reviewing the records.
Eventually, the hospital began to send us cases to review. The clinical leaders said, “If you can review these cases and make recommendations, we can begin to improve.” And as a result, the safety ratings at the University of Texas in Galveston have dramatically increased! I think that when recommendations come from a team of experts, it’s easier to push through the necessary changes. Often, they’re just simple points of education – things that have changed since the clinicians were in medical school. So there’s a lot of improvement to be had simply by implementing these DMAs.
Why do we need the DMA?
The number of complete diagnostic autopsies performed has declined dramatically over the last few decades (2). Why? Families may object to traditional autopsies because of cultural, religious, or even aesthetic preferences – it’s an invasive procedure that many prefer not to permit for their deceased relatives. Not every hospital has the time and resources to conduct autopsies – some don’t even have autopsy suites anymore. Additionally, we’re now able to glean more information than ever without the need for a full autopsy: laboratory tests are more sensitive, imaging has improved, and genetic and genomic studies have exploded.
When discussing uncommon diseases, community hospitals often tell us, “We don’t have patients with that disease here.” But these patients are scattered all over the world – so it’s reasonably likely that they do, in fact, have patients with the disease; they’re just not being diagnosed. And without a DMA, you might never know that.
The DMA allows us to offer a different kind of autopsy to those for whom the traditional autopsy is inaccessible or unpalatable: an expert review, focused on the patient’s medical records, that can reveal more information about the cause of death and flag up any possible errors without the need to “disturb” the body further. It can be performed at any time after death, as long as the patient’s medical record is still available. Thus, it is possible for us to perform DMAs even on cases that are decades old – without the need to exhume a body. This both pleases family members seeking answers and simultaneously allows practitioners to perform quality control checks and improve the standard of care for future patients.
- M Laposata, “A new kind of autopsy for 21st century medicine”, Arch Pathol Lab Med, 141, 887–888 (2017). PMID: 28661212.
- “Death of the Autopsy?”, The Pathologist, 33, 18–27 (2017). Available at: bit.ly/2escu4Q
Michael Laposata is Chairman of the Department of Pathology at the University of Texas Medical Branch at Galveston, USA.