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.

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.

Adaptación y Validación de la Semi-Structured Interview for Psychological Autopsy (SSIPA) en Español / Adaptation and Validation of the Semi- Structured Interview for Psychological Autopsy (SSIPA) in Spanish

Introducción: Objetivo. El objetivo de este trabajo es adaptar y validar en español la Semi-structured Interview for Psychological Autopsy (SSIPA) (Entrevista Semi-Estructurada para Autopsia Psicológica). Métodos. El instrumento está constituido por 69 ítems divididos en 4 módulos: precipitantes y estresores, motivación, letalidad e intencionalidad. Se realizó traducción y retrotraducción del instrumento original, y discusión del cuestionario resultante por un grupo de expertos. El instrumento adaptado se ha empleado para entrevistar a los familiares que voluntariamente aceptaron participar de 26 personas fallecidas presumiblemente por suicidio en la provincia de Ourense. Las entrevistas fueron grabadas digitalmente y después valoradas por medio de un formulario de toma de decisiones de forma ciega por el entrevistador y por dos evaluadores independientes. Resultados. El grado de concordancia entre evaluadores se midió por medio del estadístico kappa. La participación en el trabajo (27,6%) ha sido similar a la obtenida en Brasil (20%) en el estudio original. Los valores de kappa obtenidos son estadísticamente significativos. Se considera el grado de correlación como bueno (k> 0,60) o muy bueno (k> 0,80) en 15 pasos incluyendo 3 de los 4 pasos finales de cada módulo y el resultado final de la autopsia; moderado (k> 0,40) en 8 pasos, de los que 3 se localizan en el módulo de motivación y débil (k> 0,20) en tan sólo 2 pasos. Conclusión. La versión española de la SSIPA es un instrumento fiable para la realización de autopsia psicológica. La baja concordancia en dos de los pasos del algoritmo de toma de decisiones puede deberse a falta de precisión del cuestionario y debe mejorarse (AU)

Introduction: objectives. The aim of this work was to adapt and validate into Spanish the Semi-Structured Interview for Psychological Autopsy (SSIPA). Method. The SSIPA consists of 69 items distributed into four modules: precipitants and/or stressors, motivation, lethality, and intentionality. The original instrument was translated from Portuguese into Spanish and back translated by bilinguals persons. The resulting questionnaire was compared with the original and discussed by an expert panel. The adapted instrument was then applied to the relatives of 26 presumed suicide cases in Ourense (Spain) who voluntarily accepted to participate. Interviews were digitally recorded and evaluated using a decision-making algorithm by the interviewer and two independent judges blind to the results of the others. Results. Interrater agreement was measured using Kappa statistics. Participation in the study (27.6%) was similar to that obtained in the original study in Brazil>(20%). The Kappa values obtained were statistically significant. Correlation index was considered good (k>0.60) or very good (k> 0.80) in 15 steps including 3 out of 4 final steps of each module and the final result of the autopsy; moderate (k> 0.40) in 8 steps, 3 of them located in the motivation’s module; and weak (k> 0.20) just in 2 steps.Conclusions. The Spanish version of the SSIPA is are liable instrument for psychological autopsy studies. Low correlation in two of the algorithm steps for decision making may be due to the lack of accuracy of the questionnaire and should be improved (AU)

Students' physical and psychological reactions to forensic dissection: Are there risk factors?

The reactions of students to forensic dissection encompass psychologico-emotional and physical components. This exploratory study aimed to determine risk factors for students' adverse physical and psychological reactions to forensic dissection. All sixth-year medical students (n = 304) attending the compulsory practical course in forensic medicine in the 2005-2006 academic year were asked to complete a questionnaire at the conclusion of the five-day course. The questionnaire surveyed physical and psychological reactions (outcomes) and 47 student traits, beliefs, and behaviors (risk factors) that might predispose to adverse reactions. Multivariate ordinal logistic regression yielded five independent risk factors for negative psychological reactions: female gender, stereotypic beliefs about forensic pathologists, a less cognitive and more emotional frame of mind relative to forensic dissection, more passive coping strategies, and greater fear of death. The sole independent risk factor for physical symptoms was a less cognitive/more emotional approach to dissection. Students' reactions to forensic dissection integrate a host of inherent and dissection-related risk factors, and future interventions to improve this aspect of medical education will need to take into account the complexities underlying students' experiences with dissection.

Intervention following a sudden death: the social work-medical examiner model.

The suddenly bereaved are faced with not only a very difficult grief experience, but also a lack of access to supportive services to assist them in working through that grief. The social work-medical examiner model was developed in an effort to address the challenge of reaching this population. The model provides a connection between social work practice and families experiencing sudden death. The model is rooted in services embedded within social work practice--crisis intervention, grief support, and referral assessment. In addition, the model demonstrates a mutually beneficial relationship between the social worker and the ME--each benefiting from the intricacies of the model process. Social work has had a prominent voice in the advancement of end-of-life care as it relates to families grieving long-term illness. The intervention described in this model expands this care, showing how social work practice can reach the suddenly bereaved population. The implementation of this model provides the field of social work a rare opportunity to reach a vulnerable population in need of support.

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.

Could pre-mortem computerised tomography scans reduce the need for coroner's post-mortem examinations?

INTRODUCTION: Post-mortem examinations may result in considerable distress to the bereaved family. This audit was undertaken to examine whether computerised tomography (CT) scanning prior to death might reduce the need for post-mortems without compromising the accuracy of recording the cause of death. SUBJECTS AND METHODS: The case notes of 100 consecutive patients who had a coroner's post-mortem, because the cause of death was unknown, were reviewed by four senior clinicians. Along with the likely cause of death, the clinicians gave their opinion as to whether a CT scan would have enabled certification of death without the need for a post-mortem. Concordance between the post-mortem findings and the clinical events surrounding death was explored. RESULTS: It would have been possible to perform a pre-mortem CT scan on 90 of the 100 patients. A pre-mortem CT scan would have given the cause of death in 59 (66%) of these. In 30 patients, the cause of death established by the post-mortem was at variance with the clinical events surrounding death and clinically relevant information, such as recent surgery, was not recorded on the death certificates of 26 patients. CONCLUSIONS: The use of a pre-mortem CT scan and involvement of senior clinicians in the process of establishing cause of death will improve the accuracy and may obviate the need for a post-mortem in some patients. However, if a post-mortem is needed, the clinical notes should always be available for the pathologists and a senior member of the patient's team should attend the post-mortem to help accurate death certification.

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.

[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.

Lessons learnt from the organ retention controversy.

This paper examines the lessons to be learnt from the organ retention controversy in the Republic of Ireland. The paper emphasises the importance of good communication between clinicians and families of deceased persons and a move away from a medical culture based on paternalism to a partnership approach between clinicians and patients based on mutual trust and understanding. A model of authorisation rather than consent is proposed as the way forward for dealing with the difficult and traumatic experience of asking families for permission to carry out a post mortem examination on their deceased child.

The autopsy: knowledge, attitude, and perceptions of doctors and relatives of the deceased.

CONTEXT: Despite the crucial role that autopsy plays in the development of the science and practice of medicine, autopsy rates have been declining throughout the world in recent decades. OBJECTIVE: To identify factors influencing the acceptance of autopsies in Nigeria. DESIGN: Cross-sectional survey of the knowledge, attitude, and perceptions of doctors and relatives of deceased patients on factors influencing acceptance of autopsy at the University College Hospital, Ibadan, Nigeria. RESULTS: Only 38% of relatives had satisfactory knowledge about autopsy and about 50% of doctors knew that physicians' desire for autopsy should not override patients' consent. Doctors identified difficulty in obtaining consent from relatives of deceased patients, administrative problems in requesting autopsy, and delay in obtaining autopsy report as major reasons responsible for the decline in autopsy requests, whereas relatives of the deceased cited fear of mutilation, concerns about delaying the funeral, and objection by the patient before death as reasons for refusal to grant permission for an autopsy. Sociodemographic factors such as age, occupation, religion, ethnicity, and level of education significantly influenced willingness to give consent for autopsy. CONCLUSIONS: There is need for concerted effort on the part of clinicians, pathologists, the public, and the government to resuscitate and sustain the practice of autopsy in Nigeria.

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.

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.

Psychological autopsy and its limitation in application / 法医学杂志

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.

The autopsy and the elderly patient in the hospital and the nursing home: enhancing the quality of life.

The autopsy is the ultimate "peer review." Yet the autopsy has nearly disappeared from hospitals in the United States and around the world. It is rarely performed in the nursing home or other long-term care (LTC) setting. As a result, all of society has lost much, in terms of quality of health care, the skills of physicians, and insights gained through autopsy-based research. The elderly have the lowest rate of autopsies of any age group. This is a paradox, since the greatest quality and quantity of knowledge would accrue from the often surprising findings revealed at autopsy that reflect the acknowledged "multiple simultaneous illnesses" occurring in older persons. This review and analysis describe why autopsy rates have fallen in hospitals and offer rationales and solutions for reversing this trend in the nursing home and other LTC settings.

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.

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.