Autopsies are becoming a dying practice

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http://www.seattletimes.com/news/local/html98/auto_19990707.html

Wednesday, July 7, 1999

Autopsies are becoming a dying practice

by Kim Barker

Seattle Times staff reporter

Darlyne Kestler died the morning after hip surgery, so suddenly that her

daughter couldn't make it to the hospital to say goodbye, so quickly that

her family was suspicious.

Kestler, 67, had a triple heart bypass three years earlier. She stayed

active, fishing or hosting friends at her Camas, County, home. The hip

replacement was supposed to keep her going.

But her family wondered if it killed her.

Louise Walcott, Kestler's daughter, wanted an autopsy to find out for sure.

The hospital sent her mother's body to a funeral home without one, but

Walcott kept pushing.

" We wanted to know, " she said. " We really had to fight to get the autopsy. "

The autopsy, a post-mortem research function performed for 2,300 years, has

become a dying practice. Except in cases of murder or mysterious death, it

is increasingly difficult to have one done.

That's mainly because health insurers don't cover them. Insurance companies

say they have a tough enough time paying to care for the living, let alone

to study the dead.

But doctors and researchers say autopsies are an important tool in

identifying disease, and they worry that valuable scientific information is

being ignored.

Since the 1950s, the autopsy rate has dropped steadily nationwide, from

1-in-2 deaths to 1-in-10 or 1-in-20. In Washington state, autopsies were

done for only 1-in-10 deaths in 1997.

Most of those autopsies - 87 percent statewide in 1997 - are performed in

hospitals by medical pathologists, not through the better-known offices of

county medical examiners and coroners, where autopsies are handled by more

specialized forensic pathologists.

Training on the wane, too

Even in cases of suspicious or questionable deaths, the coroner or medical

examiner has discretion to decide whether an autopsy is warranted.

As demand for the service drops, so does training - a cycle that leaves

fewer people able to perform the procedure. Many medical students no longer

are required to view autopsies as part of their overall training. And

budding pathologists perform fewer autopsies to become certified than ever

before. Some hospitals no longer even feature autopsy suites.

But the dead can teach a lot about the living. Autopsies can determine how

well surgeries and drugs work. They can show how disease spreads. They can

sniff out incompetent doctors. And sometimes they can find nothing - which

is actually something in the world of medicine.

Autopsies ferret out toxic-shock syndrome, hantavirus and congenital heart

disease. They are the only way to determine whether an elderly patient had

Alzheimer's disease or a baby died of sudden-infant-death syndrome.

Autopsies, and accurate death certificates, can paint a picture of a

community's health and signal public-health problems. For a family, an

autopsy can be a gift, giving children and grandchildren a genetic map.

" It's a shame, a major mistake, " said Dr. Hackman, the director of

the clinical laboratories at the Fred Hutchinson Cancer Research Center in

Seattle. " It represents a loss of a great deal of information and

information that would really help speed our process of understanding

disease better. "

A full-body autopsy costs about $2,500. But insurance companies don't put

dead clients on the top of their coverage list.

In Washington state, insurers rarely cover autopsies. Regence Blue Shield

and Premera Blue Cross, the state's two largest insurers, don't pay for any.

" It's not medically necessary as a treatment of an illness or an injury, and

it's not preventive, " said Robin Valaitis-Heflin, a spokeswoman for Premera.

Group Health ative, the state's largest health-maintenance

organization, will authorize autopsies only if a Group Health doctor

requests one. But last year, only about 35 autopsies were performed -

slightly more than 1 percent of the subscribers who died.

" We have to spend all medical funds in the best way, " said Andes, an

accountant who helped study declining autopsy rates for the Institute of

Medicine of Chicago. " We can't say that every death should be autopsied. We

have to make choices. "

Families pay out of pocket

In some cases, families are paying to have autopsies performed in funeral

homes by for-profit companies.

Hospitals and pathology departments, strapped for cash themselves, usually

absorb the cost of autopsies if patients die in a hospital and autopsies are

granted.

But fewer people die in the hospital these days, meaning their access to

autopsies is even more limited. Thirty-three percent of Washington deaths in

1997 happened in a hospital, compared with 51 percent in 1980.

As hospital deaths have decreased, deaths in nursing homes and private

residences have increased. And in those cases, autopsies are rare.

For instance, 30 percent of people died in nursing homes in 1997. But only 1

percent of those people received autopsies, most likely because their deaths

were considered the result of old age.

Yet autopsies are the only way to check whether something bad happened at

the nursing home or to definitively check genetic illnesses, researchers

say.

" Why do people die in nursing homes? " asks Dr. Corinne Fligner, the

pathologist in charge of autopsy services at the University of Washington

Medical Center. " Nobody knows. "

No major regulatory body requires autopsies to be performed.

In 1970, the Joint Commission on Accreditation of Healthcare Organizations

dropped its standards for autopsies. Previously, it required 20 percent of

deaths in community hospitals to be autopsied, and 25 percent of deaths in

teaching hospitals.

In 1986, Medicare dropped its previously required minimum autopsy rates.

Why? Some say the autopsy has fallen out of favor because it seems obsolete,

an ancient technology amid new-fangled diagnostic tools.

New tests allow doctors to see inside the body without cutting it open. A CT

(computerized tomography) scan can spot a tumor mass, for instance; and if

it looks like a tumor and acts like a tumor, it's probably a tumor.

Some doctors are reluctant to ask for autopsies because it seems a morbid

request for a family already grieving over a death.

Some doctors also don't ask because they fear they will be caught in a

mistake; they don't want to be sued for malpractice.

That's what happened in Walcott's case. An autopsy showed that her mother

died after a catheter inserted into her pulmonary artery to monitor her

heart during surgery had punctured the artery.

Walcott credits the autopsy with providing evidence that allowed her to sue

four doctors and the hospital for alleged malpractice. That suit is still in

court.

Target: disease

But the value of most autopsies is to show disease.

There was never any question that Amy Dye died, not from her cancer, but

from its cure.

Dye died at age 22, on her 52nd day after receiving a stem-cell transplant

at the Fred Hutchinson center. Her doctor asked for an autopsy, and Dye's

parents agreed. The results were predictable. The chemotherapy was too much.

Her gastrointestinal system shut down.

" It was just too many toxins, " said Marilyn Dye, her mother. " Her body just

couldn't take it. "

But the autopsy showed just how this happened, a road map of her cure and

disease. Dye hopes the autopsy on her daughter might be helpful in the

future, when doctors treat other patients fighting the same kind of cancer.

Autopsies also can show a person's death isn't as obvious as it might seem,

even when cancer is involved.

An elderly man who came to a community hospital in Louisiana had flu

symptoms. Scans and screens showed pneumonia and cirrhosis. Then the man

died.

Dr. Burton did the autopsy, one of her first. She found a liver

tumor that had spread to the man's lungs. The pneumonia and the cirrhosis

had masked the cancer.

Burton and several colleagues started looking at autopsies done through

Louisiana State University Medical Center.

Their study, published in October's Journal of the American Medical

Association, indicated that 44 percent of the cancers in patients who

received autopsies at the university had been undiagnosed or misdiagnosed.

" Autopsies are not obsolete, " Burton said. " There's a lot of information we

can gain from them. One of the fallacies is we think our diagnostic

technology is so good that we don't have a need for autopsies anymore.

That's simply not true. "

A 25 percent goal

Now, more people are calling for a new look at the dead. Many pathologists

say at least 25 percent of all people who die should get autopsies as a way

to keep an up-to-date scientific bank.

The U.S. Department of Veterans Affairs, in a ruling issued in February,

wants all of its hospitals to have a 30 percent autopsy rate by next year,

double their most recent rate.

And a report to Congress last month from the Medicare Payment Advisory

Commission says the Department of Health and Human Services should pay to

research autopsies: when they should be performed and how to use the autopsy

information to improve health-care quality and reduce medical errors.

Louise Walcott didn't necessarily care about the big picture of medical

research. She just wanted answers about her mother.

Then Walcott's husband died, at age 52, an hour after complaining of chest

pains while chopping wood.

Walcott had no health problems, and he rode his bike to work.

His widow demanded, and got, an autopsy. It showed that Walcott

suffered from congenital heart problems and a grossly swollen heart. His

mother had also had heart problems.

The knowledge was a small gift to the couple's two children, now adults.

They can take precautions, watching their diets or perhaps taking folic

acid.

" I'm so thankful I had the autopsy, " Louise Walcott said. " His death wasn't

a mystery any longer. "

Copyright © 1999 Seattle Times Company