Clinical autopsies
Clinical autopsies are becoming less common—and that’s a bad thing. Marshall Allen explains in ProPublica:
When Renee Royak-Schaler unexpectedly collapsed and died on May 22, no one ordered an autopsy.
Not the doctors at Howard County General Hospital in Columbia, Md., where the 64-year-old professor and cancer researcher was pronounced dead.
Not the Maryland Office of the Chief Medical Examiner, which passed on the case because no foul play was involved.
And not Royak-Schaler’s physicians at Johns Hopkins University School of Medicine who had diagnosed cancer in her hip two days beforehand but acknowledged they didn’t know what had caused her unforeseen death.
A half-century ago, an autopsy would have been routine. Autopsies, sometimes called the ultimate medical audit, were an integral part of American health care, performed on roughly half of all patients who died in hospitals. Today, data from the Centers for Disease Control and Prevention show, they are conducted on about 5 percent of such patients.
As Royak-Schaler’s husband, Jeffrey Schaler, discovered, even sudden unexpected deaths do not trigger postmortem reviews. Hospitals are not required to offer or perform autopsies. Insurers don’t pay for them. Some facilities and doctors shy away from them, fearing they may reveal malpractice. The downward trend is well-known — it’s been studied for years.
What has not been appreciated, pathologists and public health officials say, are the far-reaching consequences for U.S. health care of minuscule autopsy rates.
Diagnostic errors, which studies show are common, go undiscovered, allowing physicians to practice on other patients with a false sense of security. Opportunities are lost to learn about the effectiveness of medical treatments and the progression of diseases. Inaccurate information winds up on death certificates, undermining the reliability of crucial health statistics.
It was only because of Royak-Schaler’s connections that her case ended differently. Her colleagues at the University of Maryland School of Medicine urged her husband to authorize an autopsy and volunteered to conduct it for free.
In her case, as in so many, the autopsy revealed a surprise: Royak-Schaler, the renowned cancer researcher, had cancer ravaging her body — in her lungs, kidneys, abdomen and the marrow of her bones. A blood clot, likely related to the tumors, caused her sudden death.
Jeffrey Schaler has wrestled with anger that his wife wasn’t diagnosed sooner but said knowing how she died was better than not.
“There’s a sense of peace that accompanies that knowledge,” he said.
For the last year, ProPublica, PBS “Frontline” and NPR have probed America’s deeply flawed system of death investigation, focusing primarily on forensic autopsies, which are conducted by coroners’ offices and medical examiners when there is suspicion of an unnatural death. State laws vary, but the preponderance of deaths that occur in hospitals are considered natural. When deaths are unexplained, unobserved or within 24 hours of admission, hospitals may be required to report them to local coroners or medical examiners, but such agencies rarely take hospital cases.
Hospital physicians, with consent from patients’ next of kin, may . . .
Continue reading. And even when autopsies are authorized, problems may ensue. Marshall Allen also reports on a case in Texas:
“Your husband is dead,” the doctor told Linda Carswell.
This was not supposed to happen. Jerry Carswell had been admitted to Christus St. Catherine Hospital in Katy, Texas, with kidney stones. The previous night, he’d been walking around his room, talking about basketball and the upcoming presidential election with his son, Jordan. The plan was for the 61-year-old to be discharged that morning.
Instead, at about 5 a.m., a phlebotomist entered Jerry’s room to draw blood and found him lying across the bottom of his bed, not breathing, mottled and blue, without a pulse. Staffers performed CPR for 25 minutes to no avail. Carswell was pronounced dead at5:30 a.m. on Jan. 22, 2004.
Upon learning the news, Linda and Jordan Carswell rushed to Jerry’s bedside. Lying there, sheets and blankets folded halfway up his chest, he looked as if he could be dozing, except for the tubes running out of his mouth — remnants of the failed resuscitation effort. Linda shrieked and grabbed her husband’s cold hands, trying in vain to stir him.
The on-call doctor suggested that the Carswells authorize an autopsy, launching the family on a traumatic journey that still isn’t over.
Clinical autopsies, once commonplace in American hospitals, have become an increasing rarity and are conducted in just 5 percent of hospital deaths. Grief-stricken families like the Carswells desperately want the answers that an autopsy can provide. But they often do not know their rights in dealing with either coroners or medical examiners, who investigate unnatural deaths, or health-care providers, who delve into natural ones.
For the last year, ProPublica, PBS “Frontline” and NPR have examined flaws in the U.S. system of death investigation, finding that mistakes in America’s morgues have sometimes helped convict the innocent and allowed the guilty to go free.
The Carswells’ experience illustrates a different kind of injustice. Their case would play out in pathology labs, lawyers’ offices and courtrooms for more than seven years. It led to a rare $2 million fraud judgment against Christus St. Catherine, which was found by a jury to have deceived Linda Carswell about Jerry’s autopsy. It also led to state legislation designed to strengthen families’ entitlement to comprehensive, independent postmortem reviews.It has not, however, led to closure or accountability. Thanks to an incomplete autopsy, Jerry Carswell’s cause of death remains unknown. He also has not been laid fully to rest. His heart, retained by the pathologist who conducted his postmortem examination, sits in a refrigerated cabinetin a hospital lab to this day.
None of the hospital employees involved in the Carswell case would answer questions from . . .
