We Need More Autopsies, to Help Save the Living | Hacker News Reader

We Need More Autopsies, to Help Save the Living

nautil.us

72 pointsdnetesn60 comments

"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.

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).

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

We do postmortem scans of all autopsies at our hospital. We still do the actual autopsy too. Lots of stuff is still required such as toxicology specimens (including toxicology of solid organ tissue like liver), There's also a fair amount of artifact in autopsy scans due to lack of blood flow, medical interventions (CPR-induced lung contusions, broken ribs, hemorrhages, etc)

"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... , Roulson et al 2005 (excerpts: https://plus.google.com/103530621949492999968/posts/e983tqSE... )

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.

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.

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

However, the pyramid of ages shows that our generation had 95% chances of being alive at 70. Followed by a sharp decline.

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.

"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.

Why should health insurance cover autopsy?

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

If it's for the public good then it ought to be paid from taxes. If it's just to satisfy the curiosity of friends and family then maybe they could pay for it themselves. Unless it'll somehow bring the deceased back to life, it would be weird for health insurance to cover an autopsy.

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.

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.

If you believe that subscribers don't have an interest in improving medicine, then yes. But medical care and the health care industry as a whole are more complicated than this.

An autopsy could reveal medical malpractice. As such, I could see that there might be a benefit for a life insurance company to cover a more detailed examination of the cause of death.

After all, the insurer has been harmed to the extent that between the actual demise of the insured and the statistically predicted time of death, they can no longer collect premiums and interest. And the insured has been harmed by being deprived of life during that same span.

But given that many doctors are covered by malpractice insurance from the same company or family of companies, that would be a case of taking from Peter to pay Paul. And it would probably line the pockets of lawyers and medical examiners to a greater extent than those who suffered the harm.

Well, it is postmortem by definition. I don't get the argument in favor of it being treated otherwise.

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.

You may still get autopsied. If you die of an accident, unexpectedly, or as the result of a homicide, suicide, or just because you're physician won't sign a death certificate or hasn't seen you in the last year.

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

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

"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.

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

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

Why would you?

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

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

Legal death is not the same as biological death.

You may not remember, but part of the cryo signup process involves declaring a religious objection to autopsy.[1] (No state has an irreligious objection to autopsy, but they don't ask for specifics.) In California, a court order is required to override it. I don't think that has ever happened. A medical examiner would only go to the courts if you were patient zero in some sort of outbreak.

1. http://www.alcor.org/Library/html/certificateofreligiousbeli...

Using a religious objection for this seems appropriate. The belief that you can live forever by if your body is frozen after death is more or less the same as the belief that you can live forever if your body is intact and you worshipped the right deity.

I don't want to stray too far from the original topic, but your equivocation is unwarranted. Unlike religions, cryonics actually has evidence behind it. Modern cryoprotectants allow for accurate preservation of brain nanostructure. Axons and even synaptic vesicles are kept intact. In fact, Alcor's cryopreservation protocols have already been used successfully on small mammal organs, such as rabbit kidneys.[1] Kidneys are harder to preserve than brains, as they have less vasculature to allow saturation with cryoprotectants.

Does all this mean that pumping a brain full of cryoprotectants and cooling it to -196°C will preserve its memories? Possibly, but we don't know. Cryobiologists and cryonics researchers readily admit this, and they're working to find the answer.[2] If that sort of thinking is religious, then call me a zealot.

1. http://www.21cm.com/pdfs/12FahyORG5-3%5B1%5D.pdf

2. https://vimeo.com/22766034 Starting around 33:05, Dr. Brian Wowk talks about memory preservation. He's quite frank about the fact that there's not proof, just a good likelihood that current methods preserve memory and personality. Then he outlines some next steps for research.

There's not yet evidence in favour of brain function being preserved though, even if the structure seems somewhat intact.

Anyway, many electron microscopy studies show that even in ideal laboratory conditions, cryoprotected tissue always has some amount of freeze damage to its structure, despite some areas being beautifully preserved. Humans have it even worse than the average lab rat, as there is always going to be a greater amount of post-mortem delay - during which the brain is undergoing ischaemic damage.

Cryonics is an interesting area of research, but the claims of being able to preserve memory and personality are really quite unfounded at this point.

May I respectfully suggest that if the capability to revive a cryonically preserved human does not currently exist, then current proponents of the practice are placing their faith in the possibility that the capability will exist in the future?

Not a religion in the traditional sense, but as humanity currently lacks the ability to reproduce the intended result, the practice relies highly on belief.

Regardless, if claiming a religious exemption from autopsy allows one to "hack" the legal system to achieve ones goal ... why not do it? I have a hard time finding a possible victim in such a circumstance.

Tell your family not to consent to it

You need to die a natural death and have been seen by your physician within the last year and they have to be willing to sign the death certificate. All other bodies become the coroner's jurisdiction. They can waive them, or they may do an external examination only, but once they have jurisdiction, it's out of your hands. Even then, at least in San Diego, the medical examiner reviews all death certificates and they occasionally pull one in due to something sounding fishy.

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)

> Would they have done something different knowing that it was west nile

Considering it reinforced the value proposition of county, state, and federal epidemiology units, all of whom are now monitoring crow populations, and it has launched a significant amount of research, and every primary care and ER doctor now looks for symptoms, yes, I do believe something is different.

>> former pathology resident here

The implication being that you did not complete your training. I'm curious -- if you don't mind the derailment -- why not?

Completed it. Never practiced as an attending. Went into the computers instead

> 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".

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.

> 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.

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.

As far as I understood, an "autopsy study" means a study where the researchers decide to perform an autopsy to all of patients in their sample. A quick googling seems to support this meaning, links below.

If this is the case, then the results do not contain the bias you are suggesting.

http://www.ncbi.nlm.nih.gov/pubmed/10877491

http://www.ncbi.nlm.nih.gov/pubmed/18288887

http://journals.plos.org/plosone/article?id=10.1371/journal....

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?

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.

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

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.

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.

1. Many of them are natural causes, third party (murder, suicide, accidents), and so on that are not necessarily caused by diseases or unexpected pathogens of which the doctors want to learn about. Remember the early autopsy reasons in the article: "In the United States, we usually don’t autopsy people unless the cause of death is mysterious or foul play is suspected." 2. What about races, gender, blood types, ages, and so on? The progression of the disease is different in each combination, so when factoring these factors in, 1 out of 50 really isn't that big of a number.

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

That's what destroyed my father's liver.

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.

Maybe because it's completely off topic?

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.

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-...)

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

Was this discovered by an autopsy?

"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".

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?

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...

The rate of suicide among physicians is mainly due to their higher success rate. They have a lower attempt rate compared to the population at large.

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