We need to talk about post-mortem exams
Post-mortems are a vital medical tool to identify exact causes of death, promote medical innovation and help train junior doctors and pathologists. Mike Osborn, pathologist at Imperial College Healthcare NHS Trust, suggests that more families should be encouraged to allow post-mortems to be carried out on their loved ones in order to aid this process.
It can be difficult to talk about post-mortem exams. We’re more likely to associate them with news scandals and television crime dramas than with any real medical benefit, which may be why many families don’t consider them for their loved ones, and why some medical professionals avoid the discussion altogether. Overall, roughly 20 per cent of deaths result in post-mortem exams – at our Trust, around two per cent of deaths result in hospital-consented post mortems. But a sensitively performed post-mortem exam can support vital medical research and offer peace of mind to families. Research indicates that if families are asked about post-mortems in an appropriate and sensitive way, often utilising specially trained staff, over half of them would agree to one.
The medical knowledge that can be gained from post-mortems can be hugely beneficial clinically. Death certificates put the cause of death in general terms, and often despite knowing this general cause of death specific details relating to the cause of death remain unclear. A post-mortem can often provide these very specific, in-depth answers which are invaluable to clinicians and in developing the medical practice of the future. Recent research has shown that 28 per cent of death certificates showed one major misdiagnosis. Research also suggests that eight per cent of death certificates have a class 1 diagnostic error, meaning had the diagnosis been made before the patient died there would likely have been alterations to the treatment plan, which would have potentially increased their survival chances.
It is only through a post-mortem that clinicians can find out the full medical story and pinpoint the reason behind an individual’s death. They act as a gold standard for finding an accurate cause of death. It allows clinicians to learn more from these difficult cases, and apply these lessons to future clinical care.
There have been a number of examples in our Trust where post-mortems have proven to be a great way to increase medical learning. Recently, after a patient died, that person’s death was attributed to cancer. However, after a post-mortem we found that though the patient had had cancer, their true cause of death was actually heart disease, which had not been identified despite in-depth investigations before surgery. These instances have a direct effect on the clinical care we can offer at the Trust. Now we are adapting our preoperative studies on a patient’s heart, ensuring that patients in a similar situation have the best chances of survival.
Post-mortem examinations allow us to delve more deeply into the cause of death. Sometimes a chest infection or a complicated lung infection can mean that cancers cannot be spotted – a post-mortem can allow us to identify tumors. In such cases this gives us an opportunity to proceed differently in subsequent similar cases and alter the treatment given.
For particular types of cancer such as breast cancer, there can be immeasurable medical benefits in analysing tumor tissue taken from a deceased patient. One particular study that we are involved with here at our Trust is the LEGACY study which will enable people with metastatic breast cancer to donate their cancerous tissues to research shortly after their death. Accessing each participating patient’s detailed medical treatment history and scans can help us to understand why their cancer progressed in the way it did. Using post-mortems and tissue donations helps us an incredible amount to understand how breast cancer spreads around the body and why it eventually stops responding to treatment. Participation in the study is entirely voluntary, and we know from speaking to patients with secondary breast cancer that many care passionately about making sure other women don’t have to suffer as they have done.
It is important not to forget the peace of mind that post-mortems can bring to families. Having full knowledge about why their loved one died can help to bring a certain level of closure. Any post-mortem will be firmly based on the wishes of the family and wouldn’t stop someone from having an open casket at their funeral. Most suturing takes place behind the hairline or is covered by a shroud or clothing and wouldn’t be noticed without fairly close inspection.
It is a common misconception that post-mortems delay funerals. In fact this is rarely the case – the post-mortem itself is generally a relatively short process, normally taking no longer than one working day, so has little impact on the timings of the funeral. The process can be much quicker if needs be and so wouldn’t necessarily have to impact on Muslim or Jewish funerals either, which traditionally take place very soon after death.
We need to speak openly and sensitively about this tough subject. Post-mortem exams are clinically significant and can do much to improve the care we deliver at our Trust and across our wider community. We should make an effort to discuss them with our patients and their families, so they understand that through a post-mortem exam, a loved one has the opportunity to impact many lives, even after their death.