Post mortem scientific sampling and the search for causes of death in intensive care: what information should be given and what consent should be obtained?

PURPOSE: The search for cause of death is important to improve knowledge and provide answers for the relatives of the deceased. Medical autopsy following unexplained death in hospital is one way to identify cause of death but is difficult to carry out routinely. Post mortem sampling (PMS) of tissues via thin biopsy needle or 'mini incisions' in the skin may be a useful alternative. A study was undertaken to assess how this approach is perceived by intensive care doctors and also to evaluate how this practice is considered in ethical terms in France. METHODS: A study of PMS practices immediately after death in 10 intensive care departments was performed. The medical director of each centre was interviewed by telephone and asked to describe practices in their unit and to outline the questions raised by this practice. RESULTS: PMS is routinely performed in 70% of the units which responded, without systematically obtaining formal consent and without precise rules for communicating results. Approaches to PMS differed between centres, but all physicians felt that PMS is useful for the scientific information it gives and also for the information it provides for relatives. All physicians regret the lack of standards to structure PMS practices. CONCLUSION: Information from post mortem examinations is important for society to inform about causes of death, for doctors to improve practices and for decision-makers responsible for organising care. Debate persists regarding the balance between individual rights and community interests. It is suggested that an approach for identifying cause of death could easily be integrated into the relationship between carers and relatives, provided full transparency is maintained.

Importance of explanation before and after forensic autopsy to the bereaved family: lessons from a questionnaire study.

To investigate how bereaved families felt about the explanation received before and after forensic autopsies, the authors conducted a cross-sectional survey of the bereaved families whose next of kin underwent a forensic autopsy at the two Departments of Forensic Medicine and a few bereaved families of crime victims. Of 403 questionnaires sent, 126 families responded. Among 81.5% of the respondents who received an explanation from policemen before the autopsy, 78.8% felt that the quality of the explanation was poor or improper. In Japan, the law has restricted disclosure of information from a forensic autopsy. Despite legal restrictions, 82% wanted to hear from the person who conducted the autopsy. However, police explained the results of autopsy to 65.2% of respondents. Among the families whose frustration and anger increased after autopsy, 86.4% had not been satisfied with the explanation before the autopsy. Additionally, 57.7% had not been informed on the autopsy findings at the time of the questionnaire when more than 2 years had passed after the autopsy. These results reminded us of the importance of an explanation before and shortly after a forensic autopsy for a better understanding and acceptance by bereaved families.

Uptake of the Perinatal Society of Australia and New Zealand perinatal mortality audit guideline.

BACKGROUND: Deficiencies in investigation and audit of perinatal deaths result in loss of information thereby limiting strategies for future prevention. The Perinatal Society of Australia and New Zealand (PSANZ) developed a clinical practice guideline for perinatal mortality in 2004. AIMS: To determine the current use and views of the PSANZ guideline, focussing on the investigation and audit aspects of the guideline. METHODS: A telephone survey was conducted of lead midwives and doctors working in birth suites of maternity hospitals with over 1000 births per annum in Australia and New Zealand. RESULTS: Sixty-nine of the 78 eligible hospitals agreed to participate. A total of 133 clinicians were surveyed. Only 42% of clinicians surveyed were aware of the guideline; more midwives than doctors were aware (53 vs 28%). Of those, only 19% had received training in their use and 33% reported never having referred to them in practice. Implementation of even the key guideline recommendations varied. Seventy per cent of respondents reported regularly attending perinatal mortality audit meetings; midwives were less likely than doctors to attend (59 vs 81%). Almost half (45%) of those surveyed reported never receiving feedback from these meetings. The majority of clinicians surveyed agreed that all parents should be approached for consent to an autopsy examination of the baby; however, most (86%) reported the need for clinician training in counselling parents about autopsy. CONCLUSIONS: Effective implementation programmes are urgently required to address suboptimal uptake of best practice guidelines on perinatal mortality audit in Australia and New Zealand.

The impact of declining clinical autopsy: need for revised healthcare policy.

In Western countries, autopsy rates for patients deceased in hospitals have dropped to record lows, while the average frequency of major errors in clinical diagnoses has more than doubled during the same time period. Meanwhile, the Institute of Medicine and the U.S. Department of Health and Human Services have called attention to the high frequency of errors affecting patient safety, bringing the issue of public safety to the forefront of public health concerns. Although autopsies represent a vital tool for the acquisition of new medical knowledge and for medical quality assurance, health care professionals, insurers, and politicians apparently have not chosen the right approach to solve the problem of declining autopsy rates. The present article reviews the current status of clinical autopsies and addresses causes and consequences of their neglect and appeal the urgent need to revise the policy for clinical autopsy.

Student perceptions of medico-legal autopsy demonstrations in a student-centred curriculum.

OBJECTIVES: Teaching autopsies in undergraduate medicine, although traditionally considered valuable by both educators and students, have been marginalised in modern curricula. This study explored medical students' experiences of the medico-legal autopsy demonstrations which formed part of their training in forensic medicine. METHODS: In this phenomenological study, qualitative data obtained by interviewing 10 Year 4 medical students from various socio-cultural backgrounds were interpretively examined. One-to-one, semi-structured interviews were tape-recorded and transcribed. The data were thematically organised and then analysed using a theoretical framework of three dimensions of learning, namely, cognitive, emotional and societal. RESULTS: Students still perceive autopsies as essential even in the context of self-directed learning. They identified a better understanding of anatomy and traumatology as the main cognitive benefits. At an emotional level students felt they had developed a degree of clinical detachment and would be better equipped to deal with issues surrounding death. Although socialisation influenced students' feelings about the autopsy, it did not detract from their appreciation of the educational value of the experience. CONCLUSIONS: The results support previous findings from both students, prior to curriculum reform, and medical educators who were canvassed for their opinions in relation to a modern curriculum. Besides the obvious cognitive advantages, educators should be mindful of the hidden curriculum that emanates from autopsies because it impacts on the development of professionalism and ethical behaviours of future medical practitioners.

[Psychological autopsy and its limitation in application].

The suicide were analyzed depending only on the death scene and cadaver features but not on the psychological autopsy (PA) that also enables the determination of the manner of death in China for a long time. There are significant differences between PA and the traditional risk assessment of suicide. The goals of PA are to find out the features of individuality, the patterns of behavior and the possible motives of suicide. The methods of PA involve investigating, collecting and analyzing all related information of the deceased. There are many limitations of PA in application mainly due to the lack of the standard procedures. Although an improved procedure has recently developed by Berman, many problems need to be solved before the actual application of PA in China.

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.

To see for myself: informed consent and the culture of openness.

Informed consent needs to be practised within a culture of openness if it is to enhance public trust in medical procedures around death. Openness should entail patients not just receiving information from doctors, but also having the right to see certain medical procedures. This article proposes in particular that it would be desirable for the public to be allowed to attend an autopsy of a person they do not know. Evidence from the UK, where members of the public may go backstage to witness the process of cremation, the other technical process in which dead bodies are violently but legitimately assaulted, suggests benefits from a policy of openness. When a family consents to cremation in Britain, their consent is only minimally informed, but the system has nothing to hide, and trust is high. This suggests that the opportunity for lay people also to witness certain medical procedures might do more to restore public trust in medical procedures around death than a narrow interpretation of informed consent in which information is controlled by the profession.

The impact of Maori cultural values on forensic science practice in New Zealand.

Forensic science aims to serve society by advancing justice. It is accepted that some actions taken by the state in the interests of advancing justice, such as postmortem examinations, may impinge on values held by members of groups within society. Such actions have the potential to cause cultural offense. It is important that forensic scientists are aware of these issues and that as a profession we should take actions, where possible, to reduce any potential offense and consequently reduce unnecessary distress. This paper examines the impact of these issues on forensic practice in New Zealand, and, in particular, in relation to the cultural values of Maori, the indigenous people of New Zealand. Interviews and workshops were used to identify forensic practices involving a risk of cultural offense. Particular issues were identified in regard to crime scene attendance and examination, postmortem attendance and sample storage, disposal, and return. This paper describes the response developed by the Institute of Environmental Science and Research Limited (ESR) to address these issues, including a cultural awareness training package and reference brochure.

The UK postmortem organ retention crisis: a qualitative study of its impact on parents.

OBJECTIVE: To explore the impact of postmortem organ retention on parents who made enquiries about their babies and children when the retention of hearts and other organs removed at postmortem and stored without explicit knowledge or consent of the next-of-kin came to public attention in the UK during 1999-2004. DESIGN: Qualitative study conducted 2003-2004. Data were collected via semi-structured, qualitative interviews and focus groups. PARTICIPANTS: 39 parents who had been affected by organ retention. SETTING: Participants were recruited via three parental peer support groups and two NHS Hospital Trusts. RESULTS: Transcripts of the interviews and focus groups were analysed using a thematic approach that sought patterns within the data and highlighted important similarities and differences between participants' accounts. Participants reported the distressing impact organ retention had on their lives; their need for information about the retention of their babies' or children's organs; and the difficulties in their decision making about disposal of retained body parts and tissue blocks and slides. Analysis indicated that organ retention had evoked unresolved bereavement issues and a renewal of grief as well as an opportunity for some parents to resolve ongoing bereavement concerns. CONCLUSIONS: Parents in this study wanted NHS teams to appreciate the difficulties organ retention had caused them, deal with their enquiries proactively with openness and honesty, and facilitate an environment where they felt supported and could gain the answers to their questions and concerns that were provoked by postmortem organ retention. Such issues may also have implications for the care of other parents and relatives of deceased children.

Relatives' attitudes towards medico-legal investigation and forensic autopsy: a study from South Delhi.

Relatives of deceased persons on whose bodies a medico-legal autopsy had been performed at the All India Institute of Medical Sciences, New Delhi, India were personally asked to complete a questionnaire. The aim of study was to determine surviving family members' attitudes towards medico-legal investigation and forensic autopsy. The majority of the relatives showed a positive attitude towards forensic autopsy but were not aware of the detailed procedure of the autopsy. They wanted sufficient information to be provided before the autopsy. They showed a great interest in autopsy results i.e. the cause of death. It was concluded that sufficient relevant explanations given before the autopsy improves the relatives' acceptance and helps alleviate the suffering of the bereaved. The experience and opinions of relatives may help an autopsy surgeon in more effective management of medico-legal cases.

Postmortem tissue donation for research: a positive opportunity?

Previous research using human brain tissue has increased the understanding of many brain disorders, such as Alzheimer's disease and Creutzfeldt Jakob disease. However, there are other conditions, such as multiple sclerosis, which remain poorly understood and which require further investigation. The ongoing decline in the consented postmortem rate poses a threat to tissue collections and, consequently, future research. In the setting of the new Human Tissue legislation the authors set out to ascertain whether families recently and suddenly bereaved were willing to grant authorization for tissue samples and/or organs to be retained for research purposes at the time of medico-legal postmortem examination in adequate numbers to support the establishment of a brain and tissue bank. During the 2-year pilot phase of the project, 96% of families authorized retention of tissue samples for research and 17% agreed to whole brain donation. Respondents to a short questionnaire indicated that they were not further distressed by the approach and the majority were of the opinion that research donation should be offered to all bereaved families. This research concludes that the overwhelming majority of families who are recently and suddenly bereaved are willing to authorize research use of tissue taken at the time of postmortem examination.

Reversing the slow death of the clinical necropsy: developing the post of the Pathology Liaison Nurse.

The adult clinical necropsy has been declining for many years and is nearing extinction in many hospitals. In Norwich, to prevent this from occurring, a Pathology Liaison Nurse (PLN) was appointed, resulting in a modest reversal of the trend. In 2005, the number of adult clinical necropsies increased to 58 (clinical necropsy rate = 2.4%) from its nadir of 34 (clinical necropsy rate = 1.4%) in 2003. Moreover, consent is now much more likely to be full and to allow histopathological and other studies. The PLN ensures that consent is properly and fully obtained, in line with current legislation. She also plays an important role in arranging for feedback to be given by clinicians to the families after the examination, and in teaching and training Trust staff about death, bereavement, and related matters. This paper describes how the role of PLN was established and evaluated, and gives details of the current state of the adult clinical necropsy in Norwich.

The perinatal autopsy: pertinent issues in multicultural Western Europe.

Western Europe is in a demographic transition with increasing multicultural societies. Health professionals have to understand the background, religious and cultural aspects of parents to counsel them regarding an autopsy in the event of a perinatal loss. Autopsy rates have declined over the past decades, the major limiting factor being the granting of permission for an autopsy, possibly because of adverse publicity or reluctance of doctors to obtain consent. Autopsy has proved its value in revealing unsuspected findings. The public can be convinced of this utility by means of good information notwithstanding their religious or cultural background.

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.

The psychological autopsy: solving the mysteries of death.

The psychological autopsy is an important assessment tool used to identify aspects of a person's life that explain any lingering mystery that shrouds their death. In addition to answering questions of the past, the psychological autopsy has significant implications for the future. Statistics obtained from mortality data affect the course of health care research, the flow of resources, and ultimately public health policy. From a public health perspective, the misclassification of suicides as accidents or deaths from natural causes can negatively affect research funding and policy development related to suicide prevention efforts, making a standardized and accurate procedure imperative. Although the psychological autopsy was developed initially as a tool to assist the coroner in clarifying the cause of death, this procedure has transcended the confines of forensic science and has applications in the many arenas of litigation and public health policy.

Communicating with families about post-mortems: practice guidance.

In January 2001 the Chief Medical Officer announced the Public Inquiry (Redfern Report) into post-mortem practice at Alder Hey Hospital in Liverpool. It was expected that this inquiry report would influence post-mortem practice in general and communication with parents in particular and in May 2003 a code of practice for clinical staff was produced by the Department of Health (DH) (2003a). This article discusses the code of practice Families and Post Mortems and explores the relevance of these recommendations to neonatal and children's nurses.

Exploring chronically ill seniors' attitudes about discussing death and postmortem medical procedures.

Proxy decisions about postmortem medical procedures must consider the dead patient's likely preferences. Ethnic- and sex-based attitudes surely underlie such preferences but lack sufficient characterization to guide decisions. Therefore, this exploratory study interviewed Mexican-American, Euroamerican, and African-American seniors in San Antonio, Texas, for their attitudes about discussing death before it occurs and about organ donation, autopsy, and practice on cadavers. A rigorous content analysis identified themes. Majority attitudes of an ethnic group or sex subgroup here may characterize the group generally. Attitudes about discussing death differed only by ethnic group. Mexican Americans and Euroamericans favored such discussions, but African Americans did not. Attitudes about the postmortem procedures differed by ethnic group and sex. Overall, Mexican Americans viewed the procedures most favorably; Euroamericans, less so; and African Americans, least so. Men and women differed further within ethnic groups. Mexican-American men and women split evenly over organ donation, the men expressed no majority preference about autopsies and the women agreed to them, and the men refused and the women agreed to practice on their cadavers. Euroamerican men expressed no majority preferences, but Euroamerican women agreed to organ donation, had no majority preference about autopsies, and refused practice on their cadavers. African-American men expressed no majority preferences, and African-American women expressed none about organ donation or autopsies but refused practice on their cadavers. If confirmed, these ethnic- and sex-based attitudes can help health professionals tailor postmortem care to individual patients' preferences.

Posttraumatic stress symptoms following forensic dental identification: Mt. Carmel, Waco, Texas.

OBJECTIVE: This study was conducted to determine risk factors for posttraumatic stress in medical care professionals who perform postmortem identifications. METHOD: Thirty-one dentists (29 men and two women) who had identified the dead from the fire at the Branch Davidian compound in April 1993 were compared to 47 dentists (45 men and two women) who lived in the area but had not identified any of these remains. Posttraumatic symptoms in both groups were measured by using the Impact of Event Scale and the Brief Symptom Inventory. For the remains handlers only, the subjective distress of handling remains and the social support received during the procedure were reported. RESULTS: Higher scores on the Impact of Event Scale intrusion subscale, the overall Impact of Event Scale, and the obsessive-compulsive subscale of the Brief Symptom Inventory were found for the remains handlers than for the comparison group. Within the remains handler group, distress was significantly related to the hours of exposure to the remains, prior experience handling remains, age, and the support received from spouses and co-workers during the identifications. CONCLUSIONS: Posttraumatic stress symptoms can be expected in some health professionals who perform postmortem identifications. Prior experience and social support may mitigate some of these responses.