When a patient in the ICU died from severely low levels of oxygen due to an overwhelming pneumonia, Stephen Ruoss, MD, asked the family for permission to perform an autopsy. Even though the case was somewhat straightforward, Ruoss, an intensivist in the ICU, was surprised that the autopsy revealed an unanticipated contributing factor to the cause of death. The patient had an atrial septal defect, a condition that doesn’t necessarily reveal itself except under severe circumstances such as serious pneumonia.

"The autopsy provided a nice reminder that hidden explanations may exist in people who are suddenly more substantially sick than we would have otherwise guessed, and we can and should use added clinical tools (in this case, an echocardiogram) to investigate," he said.

For years, autopsies were the mainstay of medical discovery. Fifty years ago, non-forensic autopsies were performed on roughly half of all hospital deaths. Today, non-forensic autopsies occur in less than 10 percent of deaths at most non-academic hospitals. At Stanford, the autopsy rate has remained steady at 15 to 20 percent, said Andrew Connolly, associate director of the Autopsy Service.

"We’re not looking to increase the overall autopsy rate at Stanford, but to make sure autopsies are not neglected in some settings as a tool for investigating diagnostic accuracy and response to therapy," said Connolly, associate professor of pathology. "At academic medical centers, with advanced and complex care, autopsies provide numerous benefits to the families and medical staff.” 

Autopsies are not conducted just to establish cause of death or rule out diagnostic or treatment errors, but to provide valuable retrospective insights into an individual patient’s pathophysiology. Autopsies are particularly beneficial in cases where the clinical team has some unanswered questions, either about various diagnostic entities or the patient’s response to treatment. In 10 to 30 percent of cases, autopsies still reveal significant undiagnosed medical problems, said Connolly. Physicians on services that deliver cutting edge treatment, such as transplant or complex cardiac surgeries, often look to autopsies to determine how well therapies actually worked, information that can refine future treatment protocols.

Ruoss views autopsies as an extension of a holistic approach to medical management. Just as multiple ideas and considerations come into play when treating patients, he believes autopsies provide a way to learn something new even after death.

"As I tell my patients’ families, we often have revelations about added things that we weren’t aware of that played a role in someone’s deterioration and demise, and that has huge potential to be educationally useful for physicians," said Ruoss, a professor of medicine in Pulmonary and Critical Care.

Talking to families
In the past, physicians almost always were the ones to initiate the autopsy discussion. But today, as families become more attuned to the genetic and hereditary basis of many diseases, that discussion is just as likely to be initiated by next of kin.

"Families should be guided to understand the benefits of an autopsy, and physicians are often the key link to make that happen," said Donald Regula, MD, director of autopsy services. Autopsies can uncover inherited or familial diseases that may lead to earlier diagnosis and treatment for family members and guide future family planning. They can provide a sense of closure to families by confirming a specific cause of death. And they provide an altruistic benefit as well. The knowledge gained during the autopsy may assist others to live longer and better lives from what is ultimately learned by examining the course and scope of the disease process.

Physicians may be assisted in the logistics of the autopsy consenting process by the on-call Decedent Care chaplain. During business hours, Chaplain Susan Scott (650-736-1040 and by pager) is available to speak with families faced with the death of a loved one. She can help families bridge the divide between grief and the quest for knowledge that an autopsy might bring.

Autopsy basics
Autopsies are available to any patient with a Stanford medical record, regardless of whether they die at Stanford hospital, at home or at another nearby hospital. There is no charge to patients for the procedure, or for transporting the body to Stanford from within the Bay Area. The required autopsy consent form is located in the Decedent Care packet used by clinical teams after a patient’s death, and the form should be transported to the Autopsy Service after being signed by the next of kin. For questions, contact the Autopsy Service at 650-723-6265 during business hours, or page the on-call autopsy pathologist at other times.

A complete autopsy includes the removal, examination and retention of organs, tissues, devices and fluids, and the procedure itself takes less than two hours. In a complete autopsy, the pathologist will retain internal organs to achieve maximum benefits. However, a family may restrict the scope of the autopsy, such as examining only the chest and abdomen, or returning the organs to the body except for portions needed for microscopy and laboratory testing. Cultural preferences are respected and the autopsy service works with families to ensure that funerals are not delayed.

"Physicians and other caregivers should feel confident in assuring family members that the autopsy service is committed to treating each body with dignity and respect during the procedure," said Regula, professor of pathology. Once an autopsy is complete, physicians can view the autopsy report in the patient’s electronic medical record, filed under the Media tab in the Chart Review section.