May 1, 2009

Tying up loose ends

There is an urgent need for establishing the relevance of medical autopsy
By Dr Arif Rasheed Malik and Khayal Khalil
The concept and scope of health care in this part of the world is thought to terminate with the life of the patient. In case doctors fail to establish the cause of death during the life of that patient, the quest is abandoned as soon as the patient is lost. The doctors -- as scientists -- must enquire into such a 'mystery' and solve it to avoid encountering it again. However, despite the acknowledged role of medical autopsies in the prevention of medical errors, they are not carried out in Pakistan. This is an irresponsible attitude, because by not trying to learn we deliberately ensure the repetition of our mistakes, costing no less than somebody's life.
Medical (also called hospital or clinical) autopsy, a surgical procedure performed on a recently deceased patient, is the last and most complete diagnostic procedure. Carefully performed by a thoughtful, interested and experienced individual, it should reveal much of the truth about the health of the deceased patient and the mechanism of death. On the other hand, in Pakistan mostly only medico-legal or forensic autopsies -- which are performed with the aim of providing answers to questions about the identity of the patient, cause of death, time of death, circumstances of death, etc -- are carried out, and that too to help the law-enforcing agencies in solving a crime.
In short, medico-legal or forensic autopsy is performed when there is suspicion of a criminal activity; while medical autopsy is usually carried out in case of hospital deaths with the consent of the patient's relatives. Medical autopsy is rarely performed in Pakistan, except in the army's medical institutes, and that too in only high profile cases. The pathologists who carry out medical autopsies try to figure out exactly what caused the death of an undiagnosed patient or a patient for whom a treatment for an established diagnosis failed resulting in his/her death. As part of this procedure, there is a systematic analysis of the patient's body, especially the organ systems.
The external scrutiny of body and examination of clothes, in this case, is of lesser significance, because no foul play is suspected. Further examination may require a team of professionals who can carry out histological and biochemical examinations. The medical records registering the course of treatment undertaken and the complete medical history of the patient is very important to reach a verdict about the exact medical cause of his/her death. This knowledge can be used to educate practising physicians and students, and even help the patient's family to come to terms with the tragedy.
Different beliefs among health professionals in particular and people in general create a certain hesitation to performing a medical autopsy. Some believe that due to advanced diagnostic medical procedures, there is little room for error and autopsy is unlikely to reveal anything other than that what is already known. Moreover, hesitation may result from defensiveness of doctors apprehending blame for diagnostic complications.
Medical autopsy, however, remains the most comprehensive and final method 'when one sees for oneself' in case a death has occurred, especially considering everything that was done was by the book. After all, we must not forget in our complacency that a new disease might have appeared to endanger us all. So, the role of medical autopsy is well acknowledged and established throughout the world. Unfortunately, however, we in Pakistan have failed to adopt it. Medical autopsy is especially important in clinical medicine, because it can identify medical error and assist continuous improvement.
For example, a study focussing on myocardial infarction (MI) or heart attack as a cause of death found significant errors of omission and commission: a sizeable number of cases ascribed to MIs were not MIs and a significant number of non-MIs were actually MIs. Similarly, a review calculated that in about 25 percent of autopsies a major diagnostic error will be revealed. In another contemporary US institution, 8.4-24.4 percent of autopsies will detect major diagnostic errors.
At some hospitals abroad, the rate of autopsy was astonishingly high, demonstrating the emphasis laid on the relationship between the quality of health care and the rate of autopsy in the past. In Cuba, for instance, a hospital having 520 beds, and more than 15,000 admissions and about 1,100 deaths per year, claims to have performed autopsy on more than 80 percent of the cases since its opening 24 years ago. However, autopsy rates are now on the decline even in developed countries. For example, in US hospitals, the autopsy rate was about 50 percent before World War II; it reached about 60 percent in the 1960s; and then rapidly declined to its current level of 5-10 percent.
It is noteworthy that despite the increased use of advanced imaging techniques (considered as invaluable for diagnosis), the frequency of medical errors, diagnostic or therapeutic, has not reduced significantly. In US hospitals, studies have shown findings suggesting that major clinical diagnosis can be wrong. Beginning in the 1970s, 21-43 percent of autopsies discovered at least one clinically undetected error contributing to the patient's death, and 10 percent to 13 percent discovered a condition, which if known before the patient's death, would likely have changed ongoing treatment.
One study found 55 percent major diagnostic errors (Class I and Class II), documenting its findings as: "Autopsies revealed 171 missed diagnosis, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli and 9 endocarditis, among others." Focussing on intubated patients, another study found abdominal pathologic conditions -- such as abscesses, bowel perforations or infarctions -- were as frequent as pulmonary emboli as a cause of Class I errors. While patients with abdominal pathologic conditions generally complained of abdominal pain, results of examination of the abdomen were considered unremarkable in most patients and the symptom was not pursued.
A large meta-analysis suggested that approximately one third of death certificates are incorrect and that half of the autopsies performed produced finding that were not suspected before the person died. Moreover, it is thought that over one fifth of unexpected findings can only be diagnosed histologically – by biopsy or autopsy – and that approximately one quarter of unexpected findings, or 5 percent of all findings, are major and can only be diagnosed from tissue by biopsy or autopsy.
These facts and figures reflect the existence of a considerable number of medical cases that should have been approached differently. Moreover, they portray possible medical errors and missed diagnosis even at centres that are considered as first class. We have no data to speak of that might make us aware of how mistaken we have been in the past; hence, there is little promise that we will be able to correct these mistakes. Therefore, it is suggested that medical autopsies should be carried out in Pakistan, at least in teaching and tertiary medical institutes.
(Dr Arif Rasheed Malik is associate professor and head of the Department of Forensic Medicine and Toxicology, Services Institute of Medical Sciences, Lahore. Khayal Khalil is an MBBS student at the same institute.)

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