From chaos to order—and compassion—in autopsies

Anne Ford

November 2014—Pathology resident Beth Ellen Frost, DO, has at times taken an uncommon step to put family members at ease when they are asked to consent, or have consented, to an autopsy for a loved one: She’s providing her cell phone number.

Simple but purposeful, and it’s one part of a new initiative to improve the University of Kentucky HealthCare system’s autopsy process, which has other pathology staff handing out numbers too.

Efforts underway include not only making pathology staff more available to the families of the deceased, but also making autopsy results more readily available in the electronic health record, revising the autopsy consent form, and helping clinicians answer the families’ questions when they seek that consent.

Why the move to bring more order? Because clinicians today are less familiar with autopsy procedures and requirements than were clinicians in past years. Television shows have given unrealistic impressions of what an autopsy entails. And few institutions have a dedicated decedent affairs office to handle end-of-life care.

“All of a sudden, these grieving relatives have thrust upon them decisions that have to be made fairly rapidly,” says Gregory J. Davis, MD, professor of pathology and laboratory medicine in the UK College of Medicine, co-director of UK HealthCare’s autopsy service, director of its Division of Forensic Consultation Service, and vice chair of the CAP Forensic Pathology Committee. “‘Should we get an autopsy? What is an autopsy? How do I give permission for an autopsy? Will it delay the funeral? Can we still show the body at the funeral home?’ If you don’t have a system in place, all of a sudden the chaos of activity around the death is just that—chaos.”

Preventing chaos is what’s behind the autopsy efforts underway at UK HealthCare. Heading up the changes is a new autopsy committee co-chaired by Dr. Frost and another pathology resident, Grace Dukes, MD, a member of the CAP Forensic Pathology Committee. “Early in our residency,” Dr. Dukes says, “we thought improvements could be made to the autopsy service in terms of streamlining and helping clinicians with our diagnoses. So we set up a meeting with the director of the autopsy service and made our suggestions, and we were then asked to be co-chairs of an autopsy committee focused on improving the service.”

One of the committee’s most pressing tasks: Clarifying and streamlining the autopsy consent form. The existing document was so confusing that clinicians frequently filled it out incorrectly, says UK College of Medicine professor and UK HealthCare autopsy service director William O’Connor, MD. This meant that the laboratory then had to chase the clinicians down, have them contact the family again, and get a new form completed. “Up to 75 percent of the time, the permission needed to be revised,” he says.

He adds that in the distant past, autopsies were so numerous that UK HealthCare, along with many other institutions, employed dedicated autopsy technicians whose duties included reviewing consent forms for errors. “There were these two full-time employees who could troubleshoot the permit and tell the admitting person, ‘This isn’t going to fly; you need to get that information right away.’ All that’s gone.” Hence the need for a consent form that is as simple and straightforward as possible.

The existing form was not either of those. “As to which family member was allowed to sign, some of that needed to be clarified,” Dr. Dukes says. “Also, we had spaces for the signatures of the resident obtaining consent and the attending obtaining consent, and we would usually get one or the other, but not both. We wanted to emphasize that we wanted as many names there as possible.” The major source of confusion was the section that described the retention and eventual disposal of organs. “We had a statement saying we would retain some organs for educational purposes, and then a separate statement saying they would eventually be disposed of as medical waste, and the family had to initial both, and sometimes they didn’t. So we clarified that into one statement.”

They added a line for a printed name and a pager number for each clinician, Dr. Frost says. “Because sometimes we were getting consents scribbled down at 3 am,” resulting in handwriting that proved difficult to decipher the next day. “Now we can track someone down if we need to.” The new form has been presented at UK’s morbidity and mortality conference for internal medicine, introduced at all nursing stations, and made available on the pathology department’s website.

In addition, the committee has been working to sync UK HealthCare’s EHR with the CoPath system the pathologists use to enter their autopsy diagnoses. As it stands, “sometimes clinicians don’t know where to get the autopsy results, and the results aren’t there as soon as the family would like,” Dr. Dukes explains. They are working to change the process so the clinicians can access autopsy results just as they would any other test result. “Right now, when the final autopsy result comes out, someone in our office will print it and take it to medical records, and it will get scanned in, and eventually the clinician can find the report on the EMR. But that takes more time than a lot of clinicians or families are comfortable with, in some cases. Syncing the two systems will require some work, but it’s something we definitely have the capability to do. It just hasn’t been done.”

Perhaps one of the committee’s largest accomplishments has been making pathology residents available to help clinicians answer the questions of family members about a loved one’s potential autopsy. As autopsy rates have dropped over the years, so too has many clinicians’ familiarity with the procedure, making it more difficult for them to walk the decedent’s family through the process. “In the late ’70s, we did in excess of 350 autopsies a year,” Dr. O’Connor recalls. “Gradually, it got to be less and less. Right now we do a little over 100 university hospital autopsies a year.” Adds Dr. Davis, “A lot of medical students and nursing students, unlike when I was a med student in the 1980s, now get through their training and their degree without ever having seen an autopsy.”

Perhaps it was no wonder, then, that Dr. Frost received a phone call one day from one of the hospital’s risk management lawyers, asking her to work with a clinician who had never before obtained an autopsy consent. “I met with the clinician, and we went over what was going to happen,” she says. He handed the form to Dr. Frost. “But I didn’t want to take over,” she says, “because he had already established rapport with the family. I said, ‘Why don’t you go in and start the conversation with the family, and if you have any questions about what the autopsy entails, just give me a nod, and I’m happy to jump in and help you.’

“We met with the family for a little while,” she continues, “and then, because he wasn’t familiar with what was going to be happening, he gave me a look, and I was able to explain: ‘This is what we will do. Here is the material we will keep so we can examine it.’ I answered their questions: ‘Will we be able to have an open casket? Where will the incisions be made?’ We do tend to keep a lot of tissue—we can sometimes keep whole organs, because it is a teaching hospital—so I explained that we could keep the organs for a period of time, or we could put the organs back in if the family wished.”

But what the family really wanted to know was: Who can I call if I have more questions about this? The decedent’s daughter went so far as to tell Dr. Frost, “When I leave here, I want to be able to pick up the phone and call somebody and get answers. I don’t want to be put on hold three times or leave a message and then find out that doctor is off service.” That’s when Dr. Frost offered her cell number, “so she could ask questions at any time,” she says. “It was just better communication overall.” And Dr. Frost realized the number, or at least a pager number, could and should be provided routinely.

“Now that we meet the families up front during the consent process,” she says, “our ultimate goal is for families to feel comfortable contacting us—the pathologist—directly.”

Members of the autopsy committee agreed. “We are working on getting the word out that we would like to be involved in this process,” Dr. Dukes says. “We definitely don’t want to force ourselves into the situation; we just want to be available when someone needs help. And we don’t want to obtain the consent for the clinicians, because they have the relationship with the family, and we think it’s important they’re there to start the conversation. But we would like to be there to answer either their questions or the family’s questions.”

In the future, the autopsy committee hopes to establish an office, or at least a full-time employee, dedicated to decedent affairs—that is, to tracking the deceased from the hospital to the morgue, from the morgue to the autopsy, and from the autopsy to the funeral home. “In most areas of the U.S., including Kentucky, there’s never been a dedicated division within hospitals assisting families with these matters,” Dr. Davis says. “Right now what we have is a patchwork of interested clinical physicians, interested nurses, and a person in our admitting office who is interested and helpful when she’s here; of course she’s not here at night or on the weekends. And then we use our capacity command department, which consists of nursing personnel who essentially help after hours with triage and disposition of patients and discharge to the funeral home.” While these staff members are dedicated and helpful, he says, he’d like to see a more streamlined system in place.

“We have great systems for entering you into the hospital database and registering you and calling you back to see your doctor, but we drop the ball after a patient dies,” he says. “There’s a conscious or unconscious tendency in American medicine, once a patient dies, to think that that’s the end of the story and there’s nothing left to be done. I think the paradigm is: you say, ‘We’ve lost him,’ and you look at the clock, and you say, ‘Time of death is 4:15 am,’ and you walk away. And what I want to say is: ‘You don’t just walk away. There’s more to be done.’”
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Anne Ford is a writer in Evanston, Ill.