

We Need More Autopsies, to Help Save the Living - dnetesn
http://nautil.us/blog/we-need-more-autopsies-to-help-save-the-living

======
mapt
"Not really; not always; and sometimes not even with causes of death you’d
think would show up easily in a good scan. Doctors take far too much
confidence in scan results, feeling they see everything with certainty. They
don’t. As a Florida coroner told me a few years ago, “We get this all the
time. The doctors get our report and call and say, ‘But there can’t be a
lacerated aorta. We did a whole set of scans.’"

I would note that _postmortem_ scans, done once the patient is deceased, can
be substantially higher fidelity, because there is no concern about radiation
exposure in X-ray tomography of arbitrary contrast and number of slices, and
after that metal bits can be removed at will for MRI of arbitrary strength,
duration, and confinement on a nonmoving subject. Blood tests can be run in
standard panels. DNA tests can reveal CoD correlations.

All of this, streamlined, without a surgical autopsy & reporting being
performed, seems like a tractable middle ground.

~~~
fragsworth
Wow, that would be an incredible source of data and a boon to the world.
Imagine if it were 1) required by all deaths, and 2) freely released to
researchers (for research purposes).

~~~
infogulch
Even better if it included doctors' notes, diagnosis, prognosis, and treatment
before death.

------
gwern
"Discrepancies between clinical and autopsy diagnosis and the value of post
mortem histology; a meta-analysis and review"
[http://www.pathkids.com/autopsy/hasleton%20on%20discrepancie...](http://www.pathkids.com/autopsy/hasleton%20on%20discrepancies.pdf)
, Roulson et al 2005 (excerpts:
[https://plus.google.com/103530621949492999968/posts/e983tqSE...](https://plus.google.com/103530621949492999968/posts/e983tqSEHYE)
)

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goodcanadian
I find this thought provoking. When my father-in-law died, the coroner
declined to do an autopsy as he was over 70. Essentially, for anyone old
enough, an autopsy is considered unnecessary as death isn't all that unlikely.
In some respects, that is a sensible position. However, my father-in-law's
death was slightly mysterious (in the medical sense; no suspicion of foul
play) as he was extremely healthy and HIS father is still alive at 100.

~~~
niels_olson
The coroner may have decided it was better for the family's closure to let it
go. Particularly if a physician had already signed the death certificate.

~~~
goodcanadian
No, the decision was based entirely on his age (and standard department
policy); the coroner was not subtle about it. He died at home.

------
ams6110
Statistically, there is no reason to autopsy all deaths or even most of them
and to do so would be a fantastic waste of resources. A random sampling would
suffice. What we do now is probably not random, and not sure it ever could be
given the need to defer to family wishes, religious requirements, etc. in
cases where no foul play is suspected.

------
starving_coder
"In the United States, we usually don’t autopsy people unless the cause of
death is mysterious or foul play is suspected."

In any case, health insurance doesn't cover autopsy. Turns out its classified
as postmortem to deny insurance coverage. there was an hour long special on
NPR sometime in 2014.

~~~
sokoloff
Why _should_ health insurance cover autopsy?

Given no chance of "recovery" from the condition, there's no health interest
to the subscriber, right?

~~~
kinghajj
Not to the subscriber that has passed, but insurance companies may benefit
from the knowledge acquired from autopsies. Analysis could reveal that if the
company covered some drug/procedure, the overall usage rate per subscribe
decreases, saving them money in the long run.

~~~
Terr_
In an amoral economic sense, insurance companies don't profit by helping
people eke out their problem-prone later years, versus helping generally-
healthy people avoid death and stay customers.

There are probably scenarios where their best-case scenario is to say: "Oh
well, I guess it was his time to go" and move on.

------
zxcvcxz
I'm donating my body to science. I don't see much use in having a death
ceremony involving my body. Will probably be much cheaper for my family too.

~~~
stephengillie
Your family will likely want ceremonies to help them grieve and deal with your
loss. Maybe just bury an empty casket.

~~~
Devthrowaway80
Exactly. Funerals are for the living, not the dead.

------
sampo
_" In fact, we [USA] autopsy less than 5 percent of all deaths."_

Coming from a country (Finland) where about 25% of all deaths are autopsied,
this was a surprise, that not all developed countries have a similar level.

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maaku
How do I _prevent_ an autopsy from being performed on me?

As a cryonicist, I find what is being advocated for very scary...

~~~
peter303
It is no longer "you" when your body is dead.

~~~
ivank
You brain still has all of "you" when you're legally dead though, at least for
a few hours, probably longer if cooled properly. See
[http://en.wikipedia.org/wiki/Information-
theoretic_death](http://en.wikipedia.org/wiki/Information-theoretic_death)

------
gmarx
former pathology resident here- disagree. The main reason we do fewer
autopsies is because of better diagnostics while the patient is alive. The
numbers they provide for significant changes in diagnosis based on autopsy
seem pretty high (based only on my own experience). Even the examples they
pick for the article are kind of lame- it wasn't St. louis encephalitis, it
was west nile! Um...so? Do we have a treatment now for West Nile? Would they
have done something different knowing that it was west nile (honestly I don't
know; I've been out of the medical biz for years)

~~~
sampo
> The main reason we do fewer autopsies is because of better diagnostics while
> the patient is alive.

The article claims that _" About 15 to 30 percent of the time, the diagnoses
at time of death are wrong"_.

~~~
gmarx
Maybe, I haven't read the study, but there is a huge selective pressure here.
That is, these days you tend to order autopsies only when there was something
mysterious about the death.

~~~
jacquesm
> Maybe, I haven't read the study

I don't get that. If you haven't read the study, how can you comment on it?

I understand that you'd have your opinion canned and ready in the normal case
but this study supposedly moves the needle and I'd be very interested on what
it does to your position _after_ you read the study, but without that it's as
if you are rejecting out of hand any evidence the study might provide.

~~~
gmarx
I can comment based on my observation (lately shared by many) that most of the
medical literature is bunk and my experience participating in more than 100
autopsies which tells me that 30% is absurdly high, 15% is too high and the
range reported is bizarrely large. In those over 100 autopsies I recall only
two surprises. Mostly we learned nothing the clinicians didn't know.
Occasionally we found something unknown that wouldn't have altered treatment
or course. My experience was that the autopsies were overwhelmingly
uninformative.

------
morekozhambu
Load of BS!

This means we need more people dead (considering autopsy is done on every
body), so that we get a chance to look at more bodies and hopefully reduce the
death rate in the future!!??. Is it not same as having less people die now?

~~~
arundelo
From the article, which you apparently didn't read:

 _In the United States, we usually don’t autopsy people unless the cause of
death is mysterious or foul play is suspected. In fact, we autopsy less than 5
percent of all deaths._

~~~
morekozhambu
From my comment, which you apparently didn't read:

> considering autopsy is done on every body

what I meant was, even if every body is autopsied, it wouldn't make sense

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ars
The United States is quite large. Even 1 out of 50 is still a very large
number. We have plenty of opportunities to learn everything necessary.

~~~
andyakb
If that 1 out of 50 was picked by random, then that _might_ be correct, but
the article makes it seem as though that isn't the case.

Since most of these autopsies are conducted when foul play is suspected or
when the cause of death is unknown, that doesn't help doctors improve in the
cases where they thought they knew the cause of death but were wrong.

------
MichaelCrawford
I understand that there are 1400 different brands of over-the-counter
medication that contain acetaminophen.

That's what destroyed my father's liver.

~~~
MichaelCrawford
Is there some rational reason you downvoted this?

He was taking tylenol for neuralgia. It harmed his liver so bad he had severe
jaundice. He was barely able to walk and was completely unable to speak.

He died at the age of 68.

~~~
mikeash
Maybe because it's completely off topic?

~~~
niels_olson
It isn't really off-topic, but he didn't show the connection. I'm starting to
think a lot of what gets perceived as trolling is people trying to make a
contribution but failing to show the connection from where the group is to
where they are. Then the group comes down hard and then the "troll" gets
defensive.

~~~
jkha78fnc
Thank you for taking the time to state this. I read what you wrote, then what
OP wrote, and realized that you were very correct in my case. Have an upvote
for both of you :).

@Michael - I suspect the downvoting is a reaction to your tone. The certainty
with which you prevented your statement, along with its (on-the-surface)
appearance of being unrelated to the conversation made it appear as if you had
an axe to grind. The downvotes (I hope) were a (misguided) attempt to rectify
this behavior.

I bet that a lot of people who downvoted you would have supported your comment
if your words were changed a little so the tone came across more clearly.
Something like, "I wish there had been an autopsy done on my father, who died
of renal failure. He had been advised to take XYZ medication, much of which
contained acetaminophen. His autopsy could have supported science that brought
awareness of cumulative acetaminophen ingestion."

I am sorry for your loss. Thank you for sharing your experience -- it led me
to research acetaminophen toxicity, where I found out that the deaths caused
may be greatly underreported due to a variety of factors.
([http://www.propublica.org/article/tylenol-mcneil-fda-
behind-...](http://www.propublica.org/article/tylenol-mcneil-fda-behind-the-
numbers))

Better post-mortem data from autopsies in cases like your fathers would go a
long ways towards understanding the scope of the problem.

------
trevdarc
"Doctors, meanwhile, learned humility. If you’re a doctor, it’s one thing to
know, as an abstract fact, that 10 or 20 percent of patients who seemed to die
of heart attack actually died from pulmonary embolism. It is quite another to
have a pathologist dissect one of your patients and tell you No, this woman
you took care for 25 years, and whose husband you pass on the street each day,
did not die of heart attack; she died of a pulmonary embolism, and that’s
probably why she complained of shortness of breath when you examined her three
months ago. An angiogram might have spotted it."

If we increase the rate of autopsies, the higher degree of accountability for
doctors will lead to higher stress levels in the profession. The rate of
suicide in physicians is already far above average. The US should be doing
more autopsies, but we should increase them in a way that supports the
profession, rather than giving our culture another way to point fingers at
doctors and say "your mistake killed that person".

~~~
stephengillie
In software development and system administration - automation, variables, and
copy-paste (instead of retyping) can be used to remove the possibility for
human error to occur. Instead of seeing the number "0x80007003" and
accidentally retyping it as "0x80070003", we can just copy it, and paste it
into the other system. Or have the systems talk to each other and take us out
of the loop.

How do we remove opportunities for human error in medicine and health care?

~~~
logfromblammo
I worked for a medical software company for a couple of years a little while
ago. One of the major ingredients in the mandatory corporate beverage was the
concept of "patient safety".

As a severe simplification, you can think of the transition from older medical
processes to newer ones as like pulling all the string parameters, string
parsing, and string building out of old code and replacing it with strictly
typed data. In doing so, you remove all errors generated by improperly
formatted strings.

That, and barcoding every damned thing in the hospital.

For instance, you barcode the patient's wrist tag, and you barcode everything
going out of the hospital pharmacy. When the nurses go into a room to
administer a patient's meds, they scan the patient, and scan the medication.
The scanner bleeps either a "yes, proceed" or a "WHOA WHOA WHOA, RIGHT THERE!
WRONG MED OR WRONG PATIENT!"

That last measure alone saves thousands of lives every year.[0]

[0] This statistic is entirely made up, but sounds about right.[1]

[1] Fine. Sort through it yourself. This ought to get you started:

[https://scholar.google.com/citations?view_op=view_citation&h...](https://scholar.google.com/citations?view_op=view_citation&hl=en&user=ZQ6VX_oAAAAJ&citation_for_view=ZQ6VX_oAAAAJ:d1gkVwhDpl0C)

[https://scholar.google.com/citations?view_op=view_citation&h...](https://scholar.google.com/citations?view_op=view_citation&hl=en&user=Q3v-FPAAAAAJ&citation_for_view=Q3v-FPAAAAAJ:u-x6o8ySG0sC)

