ORANGE COUNTY VOICES : Patients Should Demand the Right to an Autopsy : Post-mortem examinations are the definitive measure of assurance of quality of care. They also have a value in signaling hereditary tendencies.

For 87 years Martha lived a full, healthy, active life. At age 85 she managed a round-the-world cruise by herself and enjoyed every minute of it. But just two weeks shy of her 90th birthday, after two years of a mysterious wasting malady, she died.

Those two last years--during which she gradually shrank from 130 pounds to 79 and her white blood count dropped to dangerous levels--were associated with three hospitalizations for progressive weakness, recurrent accumulations of abnormal abdominal fluid, and gastrointestinal hemorrhages. She endured it all stoically until near the end, when her mind mercifully began to fail. And despite bone marrow sampling, CAT scans, blood studies and the ministrations of a compassionate internist and a dedicated and attentive oncologist, she died without a diagnosis.

Although in those last two years of her life she had been hospitalized several times, she died at home. As her concerned primary care doctor (and with the concurrence of her family), I tried to arrange to have her returned to the hospital for an autopsy. At first I naively assumed that all that I would have to do for a post-mortem examination would be to obtain the family’s consent, which was readily granted. The hospital refused to accept her.

With mounting frustration, then real anger, I went up the administrative ladder to obtain the autopsy, which I thought would yield a bonus for a hospital’s professional reputation. First, the admitting department refused; so I called the oncologist who had treated her last. He called the hospital administrator and pleaded with him--in vain. Then I called the administrator and the chief of pathology. I found that there is no way to get the body of a patient who dies at home back into the hospital for an autopsy. My cynical belief as to the reason is that an autopsy costs the hospital about $3,000 and no third-party payer and certainly not Medicare will reimburse one single cent for that service.

The patient lived in and was treated and hospitalized in Los Angeles County. Surely, I thought, it couldn’t be this way in Orange County. It is. I called the CEOs and chief pathologists in half a dozen of the largest and most prestigious local hospitals. The administrative reactions varied from no interest to indignation. The pathologists were much more sympathetic--for, after all, their entire training involves the examination of tissue to determine pathology. But the bottom line is that once the patient is at home, there is no way in this world any hospital is going to accept him or her back for post-mortem examination.

I was shocked to learn from an empathetic pathologist in one of our most prestigious teaching hospitals that its autopsy rate is below 15%. When I was a resident, we were excoriated if the rate fell below 75%. But this is the era of Medicare and third-party reimbursements. Once the patient dies of “natural causes,” who cares why?

Do we still need autopsies?

Well, after two years of receiving marvelous care, Martha died with there being only the unsubstantiated suspicion that what she probably had was cancer. Where and of what? No one knew. No one knows now, neither I nor her family. A post-mortem examination is the ultimate teaching experience for the physician. I can still remember the twinge of apprehension I always felt before one of my cases went to a post-mortem. Had I missed something? Was my diagnosis wrong? Could I somehow have prevented death? Despite remarkable advances in diagnosis, autopsies remain the definitive measure of assurance of quality of care. They should not only be encouraged, they should be demanded.

Autopsy information can often forewarn families of hereditary tendencies, and by allowing for timely intervention, may actually prevent illness. Even if the knowledge gained cannot be used today, the awareness of potential future illness may be of inestimable value after the research of one or two more decades.

Despite the financial straits hospitals are in now, they should be required to perform autopsies. I believe that the Medical Board of California should demand that any patient who dies at home or in a nursing facility within 120 days of having been hospitalized should be allowed the privilege of an autopsy in the hospital where he or she was treated. If insurance laws and Medicare regulations can be altered to make the financial burden less, so much the better. But for the hospital, autopsies should be part of the cost of doing business.