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Communications to the Editor |

Clinical Cause of Death and Autopsy Results Clinical Cause of Death and Autopsy Results FREE TO VIEW

Cyril H. Wecht, MD, JD
Author and Funding Information

Affiliations: Office of the Coroner Pittsburgh, PA,  The Cleveland Clinic Foundation Cleveland, Ohio

Correspondence to: Cyril H. Wecht, MD, JD, Coroner, 542 Fourth Ave, Pittsburgh, PA 15219



Chest. 2001;120(6):2113-2114. doi:10.1378/chest.120.6.2113
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To the Editor:

I should like to commend Dr. Tai and his coauthors for their excellent article (February 2001).1 They have done a great service in bringing to the attention of your readers just how important autopsies are and how much valuable and, frequently, critical information is missed by competent clinicians in the treatment of their patients. Therein lies the indisputable and unique value of postmortem examinations.

Over the past 45 years of my professional involvement as a pathologist, I have witnessed the incredible decline in autopsy rates. I would concur completely with the reasons set forth by the authors for such a decline. They are right on the money.

I wish that this article could be made compulsory reading for all physicians, hospital administrators, and other health-care providers in America.

Tai, DYH, El-Bilbeisi, H, Tewari, S, et al (2001) A study of consecutive autopsies in a medical ICU; a comparison of clinical cause of death and autopsy diagnosis.Chest119,530-536
 

Clinical Cause of Death and Autopsy Results

To the Editor:

We thank Dr. Wecht for the positive comments about our report.1 We agree that postmortem examination has unique value for the teaching of young and even experienced physicians.

Dr. Sheikh, in his letter, makes several important comments. Since publication of our study, other authors have addressed, in retrospective and prospective studies, the utility of autopsies in patients who died in the ICU. All of these studies24 report that, for a significant percentage of patients, a new diagnosis is made during the autopsy. Roosen et al2reported a retrospective study of patients who had died in 1996 in their medical ICU. Their rate of autopsy was very high (93%), and in 19% of their 100 patients studied, the autopsies revealed major diagnoses that were not suspected prior to death. Twigg et al3recently reported a study of 97 patients in the medical surgical ICU who had postmortem studies. The rate of autopsy was 40%, and the rate of discrepancies was 23%. Finally, Mokhtari et al,4 in a recent prospective study reported in abstract form, found that postmortem studies revealed major diagnostic discrepancies in up to 27% of their patients. This latest report was conducted over 3 years; the autopsy rate was 53%, and at the time of death of the patients, the physicians taking care of the patient had listed the major premortem diagnoses. During the postmortem studies, a senior physician had been present, and in later academic sessions, the cases were discussed and the discrepancies were analyzed.

We think that these three recent studies, together with our report and the articles referenced in our article,1 consistently showed that, in spite of significant improvements in diagnostic modalities, postmortem studies performed on patients who have died in the ICU show 19% to 30% discordance between premortem and postmortem diagnosis. Furthermore, there is an extensive body of literature in the previous decades that suggest very strongly that postmortem studies are useful and effective tools for discovering clinicopathologic correlations and for returning the lessons learned to the bedside.5 Ignoring these lessons may have a negative impact for new generations of physicians.

Inoue et al,6 in their letter, make valid points, but the objective of our report was to review the role of the autopsy in patients who died in the ICU. The focus of our report was not undiagnosed malignancies—we think that Inoue et al6 and others have already explored that area extensively.

Our goal was to emphasize the usefulness of autopsy in patients who had been critically ill before death. We believe that the autopsy study is still very useful for uncovering discrepancies in diagnoses. That does not mean that knowledge of these diagnoses will change the prognosis or even decrease the mortality of the patient. However, postmortem studies still have an educational role, and they probably have a role in assessing the quality of service that these critically ill patients received.

References
Tai, DYH, El-Bilbeisi, H, Tewari, S, et al A study of consecutive autopsies in a medical ICU: a comparison of clinical cause of death and autopsy diagnosis.Chest2001;119,530-536
 
Roosen, HJ, Frans, E, Wilmer, A, et al Comparison of premortem clinical diagnoses in critically ill patients and subsequent autopsy findings.Mayo Clin Proc2000;75,562-567
 
Twigg, SJ, McCrirrick, A, Sanderson, PM A comparison of postmortem findings with post hoc estimated clinical diagnoses of patients who die in a United Kingdom intensive care unit.Intensive Care Med2001;27,706-710
 
Mokhtari, M, Couvelard, A, Combes, A, et al Do autopsies of ICU patients reveal clinically undetected findings [abstract]? Am J Respir Crit Care Med. 2001;;163 ,.:A801
 
Moore, GW, Hutchins, GM The persistent importance of autopsies [editorial].Mayo Clin Proc2000;75,557-558
 
Inoue, K, Yoshioka, K, Kawahito, Y Is the discordance rate of malignancy still high? Arch Intern Med. 1999;;159 ,.:1013
 

Figures

Tables

References

Tai, DYH, El-Bilbeisi, H, Tewari, S, et al (2001) A study of consecutive autopsies in a medical ICU; a comparison of clinical cause of death and autopsy diagnosis.Chest119,530-536
 
Tai, DYH, El-Bilbeisi, H, Tewari, S, et al A study of consecutive autopsies in a medical ICU: a comparison of clinical cause of death and autopsy diagnosis.Chest2001;119,530-536
 
Roosen, HJ, Frans, E, Wilmer, A, et al Comparison of premortem clinical diagnoses in critically ill patients and subsequent autopsy findings.Mayo Clin Proc2000;75,562-567
 
Twigg, SJ, McCrirrick, A, Sanderson, PM A comparison of postmortem findings with post hoc estimated clinical diagnoses of patients who die in a United Kingdom intensive care unit.Intensive Care Med2001;27,706-710
 
Mokhtari, M, Couvelard, A, Combes, A, et al Do autopsies of ICU patients reveal clinically undetected findings [abstract]? Am J Respir Crit Care Med. 2001;;163 ,.:A801
 
Moore, GW, Hutchins, GM The persistent importance of autopsies [editorial].Mayo Clin Proc2000;75,557-558
 
Inoue, K, Yoshioka, K, Kawahito, Y Is the discordance rate of malignancy still high? Arch Intern Med. 1999;;159 ,.:1013
 
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