Autopsy rates in the Netherlands: 35 years of decline

<div><p>Objective</p><p>Although the autopsy still is a valuable tool in health statistics, health care quality control, medical education, and biomedical research, autopsy rates have been declining worldwide. The aim of this study was to examine trends of overall, clinical and forensic autopsy rates among adults in the Netherlands over the last four decades, and trends per sex, age (groups), and hospital type.</p><p>Methods</p><p>We performed a retrospective study covering 35 years of Dutch national death counts (1977–2011), the number of in-hospital deceased patients, the number of deaths due to external causes, and the proportion of autopsies performed in these populations. The effects of sex, age and hospital category were analysed by linear and logistic regression and differences were evaluated by chi-square tests.</p><p>Results</p><p>Overall autopsy rates declined by 0.3% per calendar year, clinical autopsy rates by 0.7% per calendar year (from 31.4% to 7.7%), and forensic autopsy rates did not decline. Per calendar year the fraction of in-hospital deceased patients decreased by 0.2%. Autopsy rates were highest among men and younger patients; clinical autopsy rates were highest for patients dying in academic hospitals.</p><p>Conclusions</p><p>In the Netherlands clinical autopsy rates have rapidly declined while at the same time the fraction of in-hospital deaths decreased, both contributing to the overall reduced absolute number of autopsies performed. It is important to improve awareness among both clinicians and general practitioners of the significance of the clinical autopsy.</p></div

Available patient characteristics and clinical aspects.

<p>Available patient characteristics and clinical aspects.</p

Autopsy of Adult Patients Deceased in an Academic Hospital: Considerations of Doctors and Next-of-Kin in the Consent Process

<div><p>Introduction</p><p>Hospital autopsies, vanishing worldwide, need to be requested by clinicians and consented to by next-of-kin. The aim of this prospective observational study was to examine how often and why clinicians do not request an autopsy, and for what reasons next-of-kin allow, or refuse it.</p><p>Methods</p><p>Clinicians at the Erasmus University Medical Centre were asked to complete a questionnaire when an adult patient had died. Questionnaires on 1000 consecutive naturally deceased adults were collected. If possible, missing data in the questionnaires were retrieved from the electronic patient record.</p><p>Results</p><p>Data from 958 (96%) questionnaires was available for analysis. In 167/958 (17·4%) cases clinicians did not request an autopsy, and in 641/791 (81·0%) cases next-of-kin did not give consent. The most important reason for both clinicians (51·5%) and next-of-kin (51·0%) to not request or consent to an autopsy was an assumed known cause of death. Their second reason was that the deceased had gone through a long illness (9·6% and 29·5%). The third reason for next-of-kin was mutilation of the deceased’s body by the autopsy procedure (16·1%). Autopsy rates were highest among patients aged 30–39 years, Europeans, suddenly and/or unexpectedly deceased patients, and tissue and/or organ donors. The intensive care and emergency units achieved the highest autopsy rates, and surgical wards the lowest.</p><p>Conclusion</p><p>The main reason for not requesting or allowing an autopsy is the assumption that the cause of death is known. This is a dangerous premise, because it is a self-fulfilling prophecy. Clinicians should be aware, and communicate with the next of kin, that autopsies not infrequently disclose unexpected findings, which might have changed patient management.</p><p>Mutilation of the deceased’s body seems a minor consideration of next-of-kin, though how it really affects autopsy rates, should be studied by offering minimally or non-invasive autopsy methods.</p></div

National autopsy rates of Western European countries according to the World Health Organization (European Health Information Gateway).

<p>National autopsy rates of Western European countries according to the World Health Organization (European Health Information Gateway).</p

Autopsy requests and consents per hospital ward.

<p>For some of the deceased patients it is unknown whether the clinicians had requested consent for autopsy: from the Intensive Care Units (ICUs) 10, Thoracic surgery/Cardiology and its ICU 7, Neurology/Neurosurgery 2, Medical and Surgical Oncology 3, Internal Medicine 5, Surgery (general and all subspecialties) 2, the Emergency Room 3, Pulmonology 7, Haematology (including haemato-oncology) 1, and the other wards 2. For the overall rates of performed autopsies per ward we divided the number of autopsies actually performed by the total number of deceased patients. Autopsies had to include at least examination of thorax and abdomen. Two autopsies, respectively from the ICU and Cardiology were restricted to a single organ. One autopsy on a case of the emergency room was cancelled, because the next-of-kin were unable to sign the consent form.</p

4-year moving averages of clinical autopsy rates per sex (A), age group (B) and hospital category (C).

<p>4-year moving averages of clinical autopsy rates per sex (A), age group (B) and hospital category (C).</p

Linear regression analyses of clinical autopsy rates, per time period per variable.

<p>Linear regression analyses of clinical autopsy rates, per time period per variable.</p

Deaths and autopsy rates per year: Overall in the Netherlands (A), clinical (B) and forensic (C).

<p>Deaths and autopsy rates per year: Overall in the Netherlands (A), clinical (B) and forensic (C).</p

Linear regression analyses of autopsy rates, per time period per variable.

<p>Linear regression analyses of autopsy rates, per time period per variable.</p

Flowchart survey.

<p>Based on the mortuary logbook 1000 consecutive cases of adult patients who had died in our academic hospital were included in this prospective observational study using a questionnaire. Information was deemed insufficient for further analyses if the clinician had neither reported in the questionnaire, nor in the electronic patient record, whether or not they had discussed autopsy with the next-of-kin and requested consent. Three consent procedures had to be discarded: two on restricted autopsies, and one because the next-of-kin were unable to sign the consent form.</p