Half a century ago, 60 percent of all patients who died at the Hospital of the University of Pennsylvania received autopsies.
Today, that figure has fallen drastically — to less than 15 percent.
This steep decline mirrors a drop in autopsy rates across the nation, although academic hospitals have fared better than their non-academic counterparts.
The national autopsy rate fell from 19.3 percent in 1972 to just 8.5 percent in 2007, according to a report published by the Centers for Disease Control and Prevention last year.
There are several reasons for this precipitous decline, which is indicative of the changing role autopsies play in medicine, the evolution of the healthcare system and the meaning of death in American society.
The end of a mandate
Hospital care was very different in the mid-20th century, explained Leslie Litzky, professor of Pathology and Laboratory Medicine and Director of the Section of Medical Pathology at Penn.
“It was generally the norm to have autopsies,” she said. They were an internal “quality-assurance mechanism” for hospitals to detect errors in diagnosis and patient care, and hospitals were also mandated to perform a certain rate of autopsies to remain accredited.
Before the early 1970s, a non-profit organization called The Joint Commission — known then as the Joint Commission on Accreditation of Hospitals — “required hospitals to have an autopsy rate of at least 20 percent,” TJC spokesperson Bret Coons wrote in an email. That figure was 25 percent for teaching hospitals, like HUP.
The mandate was abolished in 1971, and the organization “does not currently require that accredited hospitals perform a specific number of autopsies.”
TJC’s decision “was probably an acknowledgement of reality,” said Gregory Davis, professor of Pathology & Laboratory Medicine at the University of Kentucky College of Medicine. Many hospitals, especially smaller ones, were having trouble meeting TJC’s requirement.
Changing trends and practices
Autopsy rates had already been in decline when TJC eliminated its mandate, and they went in a free fall afterward.
One significant reason for the drop is the costliness of the procedure.
The cost of an average autopsy varies from $1,500 to $3,500, Litzky estimated, with the upper end reaching $5,000. Penn, like other teaching hospitals, doesn’t charge for the procedure.
Because of the high costs associated with autopsies, many smaller hospitals are outsourcing their autopsies to larger ones. Many new medical centers are even being built without morgues or autopsy suites.
The consolidation is evident here at Penn; families of patients who die at the Penn Presbyterian Medical Center must travel to HUP, where the procedure is performed.
Academic medical centers are becoming “regional autopsy centers,” Davis said. “It’s a trend that’s been going on for some time because of the teaching mandate of [academic] hospitals and because of the resident training program,” both of which lead to higher autopsy rates than at non-academic hospitals.
But this consolidation has some potential pitfalls, Litzky said. “Families don’t know which way to turn because [their hospitals] don’t have the availability.”
Litzky added that most families do not request autopsies, and those that do seek them for “very specific reasons.”
Another reason for the decline of autopsies may be a more hubristic one — the advancement of technology.
Because of breakthroughs in imaging technologies and other medical advances, “there’s still a general attitude that we know everything that went on” related to the patient’s death, Litzky said.
Computed tomography scans and magnetic resonance imaging are increasingly being used in post-mortem examinations.
There is “a good faith but misguided thought that imaging technologies make autopsies a moot point,” Davis said. But autopsies are unparalleled for “directly visualizing, both internally and externally, the human body.”
Indeed, there are some types of diseases that can only be diagnosed by autopsies, including Alzheimer’s and some cases of mesothelioma.
“Who knows what new and emerging diseases … are going to be discovered [because of autopsies]?” Davis asked.
‘Stronger push’ at HUP
At Penn, as well as at other academic medical centers, autopsy rates have stabilized over the past two decades.
The exact rate at HUP is difficult to calculate because the total number of deaths at the hospital is hard to pin down, but Litzky estimates that the rate is around 12 to 15 percent.
The number of autopsies hasn’t changed much over the past decade; there were 274 autopsies performed in both 2001 and in 2011.
“We bump up a little bit here and there,” Litzky said. Still, she said she has to “work hard to make sure” the current rate is maintained.
Although TJC no longer has an autopsy mandate, “they still say that autopsies are very important,” Litzky said.
The organization “requires a hospital’s organized medical staff to have a leadership role in performance improvement activities to improve quality of care, treatment and services in the use of developed criteria for autopsies,” Coons wrote. “Hospitals may choose to set specific requirements for conducting autopsies as part of their required continuing performance improvement plans.”
But Litzky believes that Penn has a responsibility to go beyond the guidelines set by TJC.
“At an institution like Penn, there is a much stronger push for maintaining” higher rates, especially because “we do a lot of new procedures, clinical trials, experimental therapies,” she said.
She considers declining rates a threat to medical education.
“I do see it as a national problem … something that compromises the general education of clinicians and trainees,” she said. “[But] I’m less concerned about it here.”
She said Penn’s current autopsy rate “is such that I have adequate numbers to educate the residents” and that, “considering all the forces against autopsies, we do very well.”
But for Davis, the decline is a problem of deep social and moral consequence.
“We live in a death-denying society,” he said. “People don’t like to think about it. [But] those of our loved ones who have passed on still have a lot to teach us.”