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Context: Fear that damaging information from autopsy may be introduced as evidence in lawsuits alleging medical malpractice is often cited as one factor contributing to the decline in autopsy rates., Objective: To determine how autopsy information influences the outcome of medical malpractice litigation., Design: We studied state court records in 99 cases of medical malpractice adjudicated from 1970 to the present to assess the role of information from autopsies in the outcomes., Results: The 3 largest groups defined by cause of death at autopsy were acute pulmonary embolism, acute cardiovascular disease, and drug overdose/interaction. Findings for defendant physicians outnumbered medical negligence in the original trial proceedings by a 3:1 margin. The appellate courts affirmed 51 acquittals and 19 findings of negligence, and reversed the original trial court decision in 29 cases for technical reasons. We found no significant relationship between accuracy of clinical diagnosis (using the autopsy standard) and outcome of a suit charging medical negligence. Even when a major discrepancy existed between the autopsy diagnosis and the clinical diagnosis, and the unrecognized condition was deemed treatable, defendant physicians were usually exonerated. Moreover, major diagnostic discrepancies were relatively uncommon in suits in which a physician was found to be negligent. Conversely, in about 20% of cases, autopsy findings were helpful to defendant physicians., Conclusions: Our study confirms that a finding of medical negligence is based on standard-of-care issues rather than accuracy of clinical diagnosis. Autopsy findings may appear to be neutral or favorable to either the plaintiff or the defendant, but are typically not the crux of a successful legal argument for either side in a malpractice action. We conclude that fear of autopsy findings has no rational basis and is an important obstacle to uninhibited outcomes analysis.

Context: We studied 99 appellate court records in cases of alleged medical malpractice and found no relationship between discrepant clinical and autopsy findings and outcome of litigation. Standard-of-care issues and not diagnostic accuracy were at the heart of every case., Objective: To characterize and discuss issues related to the autopsy and/or pathologist behavior that were raised in court records of medical malpractice litigation., Design: In 18 appellate court records, issues were raised about quality of autopsy performance and reporting or about death certification. The details of these controversies are succinctly reported here in a manner intended to be instructive to pathologists who perform autopsies in a hospital setting or on a private fee-for-service basis., Conclusion: Autopsy reports are intended to provide objective medical information in a coherent format to the patient's medical record, to the attending physician and other concerned staff physicians, to other health care professionals, and to the families of the deceased. Inevitably, occasions arise that require legal counsel to be added to this list of parties with a legitimate interest. Our findings emphasize that incomplete, incoherent, obfuscated, or delayed reporting of autopsy findings do not meet professional standards, are unethical if intentional, and may be counterproductive.

The downward trend in the rate of clinical autopsies has been extensively documented in the literature. This decline is of concern when the benefits of the clinical autopsy are considered. In contrast, the rate of medicolegal autopsies has not been studied in such detail. What little reference there is to medicolegal autopsy rates suggests an absence of the same downward trend. A retrospective review of autopsy data over a 13-year period from the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, and from the Office of the Chief Medical Examiner of Nova Scotia was conducted. This review showed a difference between the rates of clinical and medicolegal autopsies for the metro Halifax area. The clinical autopsy rate was consistently less than 30% and declined to 15% in 1999, while the medicolegal autopsy rate was consistently greater than 40% and rose to 62% in 1999. The literature proposes many reasons for the decline in the clinical autopsy rate, but none for this difference between rates. The explanation proposed here is the changing and currently uncertain purpose of the clinical autopsy versus the clear, and consistent over time, purpose of the medicolegal autopsy.

Context: Autopsy rates have been declining throughout the world, although preservation of the autopsy is considered a fundamental principle of medical care. In France, the 1994 bioethics law requires physicians to inform relatives before performing an autopsy., Objective: To analyze the following factors that potentially influence hospital autopsy rates: legal constraints, autopsy reporting times, opinions of physicians requesting autopsies and pathologists regarding the usefulness of autopsy in patient care, and use of autopsy material in research publications., Design: Record of the annual numbers of deaths and autopsies during a 10-year period (1988-1997). Record of the delays for transmission of final autopsy report to the requesting physician. Questionnaire analyzing the possible factors influencing autopsy rate. Categorization of articles published by pathologists according to the use of autopsy material., Setting: A 1000-bed, university teaching hospital in the Paris, France, area., Participants: Questionnaire addressed to physicians, head nurses, and mortuary staff., Results: A total of 1454 autopsies were reviewed. The autopsy rate declined from 15.4% in 1988 to 3.7% in 1997. This decline was marked after 1994 and tended to be slower for neurologic indications than for other indications. The final report had not been communicated within 180 days in 620 (42.6%) of 1454 autopsies. Fifty-five of 105 respondents considered that the bioethics law was one cause of the recent decrease of autopsy rate. Considering the contribution of autopsy to medical research, 94 (81%) of 116 articles dealing with central nervous system but only 28 (6%) of 464 articles dealing with other organs used autopsy-derived material., Conclusions: The 1994 bioethics law seems to contribute to the decline of autopsy. Inadequate delays for communicating autopsy results are frequent. Except for neuropathologists, autopsy is a minor source of research material.

The guideline for forensic pathology was prepared by the Forensic Pathology Committee of the College of American Pathologists. The definitional criteria for forensic pathology included in this guideline have been approved both by the House of Delegates and the Board of Governors of the College of American Pathologists. The guideline presents an overview of forensic pathology and an approach to the forensic autopsy and medicolegal death investigation. Emphasis is placed on the role of forensic pathology in maintaining public health, welfare, and safety. The guideline is intended to serve as an educational tool, and its use should be determined by the individual circumstances and settings of specific cases.

Objective: Identification of factors that contribute to a high autopsy rate at our institution., Design: An objective analysis of the Autopsy Service's organization, functions, and process flow to identify factors that impact the autopsy rate., Setting: The University of Texas Medical Branch at Galveston, Tex., Methods: Statistics were collected using the autopsy log book and computerized data bank. The events starting at the time of a patient's death through the completion of the autopsy report were reviewed. The role of each significant event was analyzed., Results and Conclusions: The annual autopsy rates between 1981 and 1995 ranged between 45% and 59%. The largest number of nonmedicolegal autopsies were received from the Department of Internal Medicine. The Texas Department of Criminal Justice Hospital contributed the largest number of medicolegal autopsies. We conclude that the following key factors contribute to our high autopsy rates: (1) the organization and multiple functions of the Autopsy Service, particularly the presence of a Decedent Affairs Office, dedicated resident assignments, and internal and external quality control of the autopsies; (2) close interactions with clinicians, including timely communication of autopsy results to clinicians and a fostering of positive attitude among clinical residents and faculty; and (3) other factors such as the contributions to hospital risk management, disproving the idea that there may be increased litigation related to high autopsy rates, and support by the hospital administration.

The Autopsy Committee of the College of American Pathologists has prepared this guideline in conjunction with representatives of other organizations to assist pathologists in the performance of autopsies. The guideline is to be regarded as being primarily an educational tool. Application of these recommendations on autopsy performance is to be made on the basis of the judgment of the pathologist engaged in a specific case.

Autopsy studies have provided the foundation of our knowledge of clinical medicine. Despite the acknowledged value of this postmortem procedure, hospital autopsy rates have fallen to only 10% of deaths. New diseases and therapeutic modalities are in danger of not being properly evaluated. A number of proposals have been made to increase autopsy rates. While many of these proposals are excellent, the key to increasing autopsy rates is direct reimbursement by third-party payers.

Information concerning autopsy laws, regulations, rates, and practice was collected from 29 industrialized countries. In many countries, laws have been revised in recent years, introducing more restrictive rules, with consent required from the next-of-kin. With one exception (Finland), introduction of a requirement for consent was followed by a decline in the autopsy rate. Experiences in various countries are discussed. It is apparent that the problem of decreasing autopsy rates is an international one. Efforts to inform and educate the public about the benefits of autopsy are necessary, if the decision whether to perform autopsy is to remain their responsibility.