Revisiting Posthumous Analysis

Fedra Pavlou’s editorial (“Autopsy on the Slab?”) in the June 2015 issue of The Pathologist, highlighted that not much has changed in the 20 years since publishing my own article on this emotive subject (1). Historically, autopsies were extremely important as they opened up a new world of understanding of disease. As Bichat said, “You can take notes for 25 years, from morning to evening by the patients’ bedsides on diseases of the lung, heart, and stomach and the result will be a long list of confusing symptoms leading to incoherent conclusions. Open a few bodies and you will see darkness immediately recede.”

Indeed, in the early years of the 20th century, autopsies proved to be the best way to obtain important information that was impossible to glean in any other way. And, that was why clinicians requested them as a matter of course. In those days, academic institutions were performing detailed autopsies (at a rate of 100 percent in some cases) and new knowledge about the effects of tumors and infectious diseases was readily available. But, fast forward to today and we are largely stuck in a rut with 21st century autopsies performed similarly to the 1900s. We definitely need to move on and that was the thrust of my article published in 1996!

In my view – and I’m going to reiterate my 20-year-old comments because, as I say, so little seems to have changed – autopsies won’t become the norm until they can compete with today’s requirements for speed and cost-effectiveness. The drive is for efficiency and the cost of performing an autopsy simply to restate the clinician’s findings that the patient did have widespread carcinomatosis will no longer suffice in a time where cost benefits are high on the financial agenda.

My proposal still stands that we pathologists need to change our attitude to the autopsy and no longer see it as a thorough study. Instead, we need to take a selective approach. Yes, keep with the Rokitansky tradition when needed, but for the vast majority of cases we can perform “partial” autopsies in a similar way to how surgical pathologists examine and sample surgical specimens. We can, for example, in many circumstances sample sections from the organs of interest, in addition to select metastatic nodules and perhaps a few other organs that appeared abnormal on gross inspection to answer the clinician’s questions in short order. And, we should be able to deliver the final autopsy report within 48 hours. Yes, there will be exceptions – but they will be in the minority.

To enable this timelier process we need to approach the autopsy as if it is a surgical specimen. The pathologist will align his or her thinking with the very reason they have the opportunity to do the procedure – because somebody had some questions that need fast, accurate and concise answers. The clinician will be pleased if they get the answers, even partial answers, presented in a two- or three-page report within a few days. They don’t need an old-fashioned report numbering 15 pages or more that go into fine detail about every organ in the patient’s body weeks or even months after ordering the autopsy. They simply want the relevant facts and they want them as quickly as possible. Such a partial autopsy will require a great deal of skill and disease knowledge on the part of the pathologist in deciding what to focus on and what to ignore. And, that will no doubt require specialist training and our academic institutions will need to be able to support such teaching.

So, in 1996, I was optimistic that my proposal for a selective, partial autopsy approach should result in an increase in the number of autopsies performed. But, that hasn’t been the case. However, I do maintain my optimism as posthumous analysis is the logical way forward; we just need to consider it as the future for our field rather than continue to hold on to our now antique autopsy traditions.