The European Critical Care Foundation is sufficiently concerned about this to have organised a one-day meeting on the subject, hosted by the Nuffield Council on Bioethics in London on 6th March. It was a fascinating meeting, with lots of unexpected conclusions.
Although medico-legal post-mortems for the coroner continue to be performed in large numbers, the number of post-mortem examinations carried out with the consent of relatives has shown a progressive decline across Europe. The UK is leading the way; less than 0.1% of deaths in the UK are now followed by a consented post-mortem.
Many would be surprised that critical care doctors are bothered about this; aren’t their patients investigated enough during life to be sure what caused death? Not so, and the European Critical Care Foundation recognises this. Different studies produce different numbers, but a post-mortem typically identifies something that, if known during life, would have altered the care given in about 20% of intensive care unit deaths.
Many would think that modern scanning techniques will make conventional autopsies redundant. Not so; such scans can certainly help in unexpected sudden deaths, but it was pointed out that patients in intensive care have usually had all the scans that modern medicine can provide; yet post-mortem examinations still generate numerous unexpected findings.
Many would think that the decline is because society has changed and relatives are less willing to give consent. Not so; there is actually little evidence of such a change in attitudes, but there is abundant evidence that doctors have stopped asking for consent for post-mortem examinations. Long ago when I was a junior doctor, the consultants I was supervised by all told me that whenever a patient died under their care I was to ask for consent for a post-mortem. That doesn’t happen now. Not asking for consent is the main reason for the decline in numbers. Doctors’ explanations of this include an incorrect assumption that relatives will refuse, an incorrect belief that no useful information will be gained, and the large amount of time taken to obtain appropriately informed consent. And perhaps a worry that finding the unexpected could trigger litigation – but again, there’s no evidence for it.
Consent, of course, has a lot to do with why the Nuffield Council on Bioethics is interested in this subject. But if you don’t ever ask for consent, you’re not doing much to empower individual autonomy! Surely an ethical doctor should be more open with the relatives when what is being put on the death certificate is actually no more than a ‘best guess’ as to the cause of death? In such cases, surely we should be talking about offering the relatives the opportunity of finding out, and offering them the opportunity to do something for the benefit of the rest of society, rather than suggesting that the consent process involves them doing the doctors a favour?
Ethical issues also arise in assessing how best to investigate each death. Any investigation costs money. Is a ‘good’ post mortem examination one that obtains the most possible information, as the Royal College of Pathologists has always assumed? Or is it actually the most cost-effective investigation?
If we favour the cost-effective answer, a standard protocol won’t do; we have difficult decisions to make in every case. This isn’t helped by the current situation, where pathologists conduct dissections and radiologists look at scanned images. Shouldn’t we have a new medical specialty of death investigation, with practitioners trained in all the available methods, so that they can decide objectively how best to investigate each death?
Allocating resources reminded me of an ethical dilemma that surfaced at a similar meeting I attended some months ago in North America. A doctor from Texas proudly explained how MRI imaging had allowed him to identify congenital cardiac abnormalities in dead children, avoiding the need for post-mortem dissection. But the abnormalities he described would have been amenable to surgical correction. So I asked the dumb question from the other side of the Atlantic. “If you can diagnose these conditions using MRI after death, why did no-one do that before the children died?”
That generated an embarrassed silence. Finally the lecturer explained the obvious, in just four words. “The parents were poor”. Only after death is the state willing to pay.