Journal of Religion and Health, Vol. 25, No. 2, Summer 1986
The Therapeutic Value in the Autopsy Request MAURICE E. ROBERTS and E D W A R D P. FODY A B S T R A C T : Recently the number of autopsies performed in the United States has declined. Although the benefits of the autopsy for physicians are many, we maintain, based on our own experiences, t h a t the request for autopsy is of benefit to the surviving family members as well, in that it helps them accept the reality of loss of a loved one and enables them to begin the process of "letting go." Realization of the therapeutic value of the autopsy request should enable those who work with the recently bereaved, such as physicians and clergy, to fulfill more effective roles.
Introduction
The autopsy is the final medical procedure. Although autopsies are performed on patients of any age, most are elderly. For the last several decades in the United States, the number of autopsies has declined. A striking decline in autopsy rates among geriatric patients has been documented. 1 The usefulness of the autopsy in medical practice has been thoroughly established. However, it is our contention, based on our experience in a large Veterans Administration teaching hospital, t h a t there is, as well, a therapeutic value in the request for autopsy permission from the deceased's family. This value extends to the family, the physician, and to other allied health personnel.
The incidence of autopsy consent in the United States and other countries
A literature review of the percentage of hospital deaths coming to autopsy reveals a downward trend. Roberts gives a history of the decline of autopsy consent over the last forty years: The hospital autopsy rate shortly after World War II was 50 per cent. By 1964 the mean autopsy rate in all U.S. hospitals was 41 per cent; by 1970, 29 per cent; and by 1973, 22.2 per cent; and by 1975, 21.7 per cent . . . . 2 In 1982, the autopsy rate for all Chicago hospitals was 19 per cent. 3 Even this figure is probably higher than the true national average, since it includes several maj or teaching hospitals with relatively high percentages of autopsies. Anderson's study focused on large teaching hospitals which historically Edward P. Fody, M.D., is Chief of Laboratory Service at John L. McClellan Memorial Veterans Hospital in Little Rock, Arkansas, and Associate Professor in the D e p a r t m e n t s of Pathology and Pharmacology at the University of Arkansas for Medical Sciences in Little Rock. Maurice E. Roberts, M. Div., M.A., is Chief of Chaplain Service at the Veterans Administration Medical Center in Fayetteville, Arkansas. 161
(z)1986 Institutesof Religionand Health
162
Journal of Religion and Health
have enjoyed the highest percentage of autopsy consent in the United States. Of the ten largest "charity-type" of hospitals which are principal teaching hospitals of major medical schools, Anderson found t h a t five had consent rates below 50 per cent and four had averages below 40 per cent. In a companion study, he found a substantially higher rate ranging between 50 and 80 per cent in teaching hospitals t h a t are basically private in nature. 4 A comparison of U.S. autopsy rates with other countries is interesting. Switzerland has an autopsy rate of 80 per cent, and the U.S.S.R.'s is 100 per cent. 5 Russia's political philosophy, which maintains that all bodies belong to the state, accounts for its high percentage. When an individual in the Soviet Union is pronounced dead, physicians can perform an autopsy or remove an organ immediately and without consent of the next of kin. Albeit such a policy removes all "problems" connected with obtaining autopsy permission, the deprivation of the freedom of choice is a price that most Americans are unwilling to pay. A consideration of the statistics raises questions concerning the autopsy consent in the United States, the most fundamental being, " W h y an autopsy?"
The why of an autopsy Observation of the physician's request for autopsy during the notification-ofdeath interview leads to an appreciation t h a t the doctor must have reasons for asking such a difficult question at t h a t time. In fact, one learns that the request for autopsy is a clinician's prerogative based on a belief that the autopsy is beneficial and desirable for the family, the institution, the clinician, and other patients. The value of the autopsy, according to Corrigan, is t h a t it is "the final informational device of known scientific calibre, which helps him [the physician] correlate the patient's disease with the care given. ''6 What he seems to be saying is t h a t the physician's scientific role as a searcher for t r u t h requires his use of this tool. Katz and Gardner suggest another rationale for use of the autopsy. They refer to the therapeutic value for family survivors by the raising of the autopsy question: By using this interview to allow the family to ventilate its feelings of hurt and anger without rebuke, indeed, actually supporting the appropriateness of such feelings, and to convey a sense of concern for the family that goes beyond the immediate situation, for example by offering to call the family to discuss the autopsy findings when they become available, the physician can make the family more comfortable as the mourning process begins . . . . 7 In short, the autopsy request can serve an important role in helping the survivor family deal with their grief. Corrigan appears to concur in his reference to the educational aspect of the autopsy request. "We physicians," he states, "can teach a rational approach
Maurice E. Roberts and E d w a r d P. Fody
163
to death and disease through the autopsy. ''s The therapeutic and educational aspect of the autopsy request is perhaps overlooked by the requesting physician as well. An often-repeated response to a physician's request for autopsy consent is, "No autopsy; he's suffered enough." In our experience, at this point most request physicians accept such a response as the family's final decision and all discussion concerning the autopsy ceases. However, if the autopsy request is viewed as having therapeutic value and as a means to encourage an acceptance of death, there is every justification in carrying on the discussion, albeit using another tactic. As counselors are aware, there is value in leaving a subject for the time being and returning to it later at the client's pace. Without an acceptance of the reality of death, the process of a family working through their bereavement cannot begin. We have come to appreciate t h a t the physician's request for autopsy, when properly handled, can be an encouragement for the family to accept the death of a family member and t h a t they have a need to begin "to let go." In conclusion, there is more than meets the eye when the physician asks, " M a y we perform an autopsy?"
Factors affecting the therapeutic value of the autopsy request It has been proposed in this paper and in the literature cited t h a t there is a therapeutic value to the family when they are asked for consent to an autopsy. The therapeutic value, however, is often a missing element in the physician's interview with the family. The question is " w h y . " A basic factor appears to be t h a t the physician himself or herself does not view the autopsy interview as therapeutic. Katz and Gardner, who studied interns on the subject of autopsy request, concluded: Only a rare intern contemplated the possibility that this interview might actually be beneficial to the bereaved relatives, at the very least in permitting them to ventilate their acute feelings of anger, guilt, and so forth . . . . Most interns clearly see this meeting [the notification-of-death interview with the family when an autopsy is requested] as completely void of any therapeutic value. They generally conceive it as one more "painful blow" inflicted on relatives and come to it with considerable anxiety because of their own conflicts. . . . 9 The physician's unresolved conflicts on the subject of death have also been found to be a factor contributing to not viewing the autopsy request as therapeutic. Hendon found the doctors t h o u g h t less about death than did two control groups t h a t he studied, one of patients and one of professionals. 10This factor would seem to account for the almost mechanical approach t h a t characterizes m a n y physician-family interviews in which the physician apologetically asks, " I ' m sorry to have to ask you this, but the hospital requires it. Will you give consent to an autopsy?" Without the appreciation of the therapeutic
Journal of Religion and Health
164
potential to the family of the interview and with the physician's lack of selfawareness, autopsy requests become repetitive, "gradually numbing and desensitizing him to his own feelings and those of bereaved families."'1 Another factor preventing the interview from becoming therapeutic is the physician's acknowledgement of feelings of awkwardness and unpreparedness for conducting such interviews: While all interviewed interns acknowledged that increasing experience eventually exerts a beneficial effect, five recalled their awkwardness . . . in dealing with the specific arguments put forth by families. But more unfortunate than the sense of inadequacy in attempting to deal rationally with the resistances thrown up by the family was the tendency of at least half of the interns to react defensively themselves if the family expressed hostility over the autopsy matters. Rather than seeing this as a symptom of and defense against the acute grief and likely guilt of the bereaved family, these interns tended to respond concretely and aggressively in turn . . . . 12 It is apparent t h a t there is a lack of medical school and internship preparation for autopsy issues at the present time. Physicians have expressed through questionnaires and interviews considerable interest in the subject and a desire for further information and discussion in this area. Katz found t h a t the physicians he interviewed wished there could be some ongoing outlet in which they could discuss their feelings, family resistances, unpleasant encounters, and mechanical obstacles t h a t were constantly arising regarding autopsy during the house year. 13 It does appear t h a t a forum, be it a seminar or ward conferences, needs to be provided to assist physicians in an area where by their own admission they are ill-trained. The topics for such sessions could, and should, cover the spectrum, from the seemingly mundane to the profound. Communication specialists have learned t h a t in interpersonal relations even the mundane and common have significant consequence. For example, the place where the physician interviews the family can have a positive or negative effect on decision making. If the setting is the hospital corridor or a cramped room with insufficient chairs for all the family members, the physician immediately has two strikes against him or her in obraining autopsy consent. Likewise, the physician can be helped in dealing with those occasions when the family are hostile and angry. The teaching technique of "role-playing" has been found to be effective in such situations. Through this technique, common family statements of refusal can be understood as symptoms of acute grief, guilt, anger, and not cause for defensiveness or hostile reactions. Such statements include: Autopsy is against our religion. He's suffered enough. Don't make him suffer more. An autopsy won't bring him back. You did him no good and you still want to hurt him.
Maurice E. Roberts and Edward P. Fody
165
Equally important, such forums could provide: an outlet for the week to week feelings, conflicts, problems, and frustrations that the intern will invariably still experience in relation to the autopsy request . . . . 14 9
Implicit in this argument for an awareness of the therapeutic value in the autopsy request and a recognition of the need to assist the physician in conducting the family interview is the assumption t h a t an increase in incidence of autopsy consent would result. Such an expectation is based on more than hope.
Conclusion Our conviction, confirmed by this study, is t h a t there is a therapeutic value to the family in the request for autopsy. When handled properly, the autopsy request can be the first step in the survivors' acceptance of the reality of death. Thanatologists confirm t h a t grief work is thwarted when re-attachment sets in.15 An appropriate response by the physician to a family member's protest, "No autopsy; he's suffered enough," can prevent re-attachment and begin the process of "letting go." Erich Lindemann identifies three primary tasks necessary for satisfactory grief management: 1. Letting go of the deceased; accepting the fact of loss. 2. Adjusting to a life without the deceased. 3. Forming new relationships, is The physician in the family interview enjoys the unique opportunity to help family survivors begin the process of working through their grief. There is ampie evidence t h a t the physician has the desire as well.
References 1. Ahronheim J. C.; Bernhole A. C.; and Clark W. D., "Age Trends in Autopsy Rates: Striking Decline in Late Life," J. Amer. Medical Association, 1983, 250, 1182-1186. 2. Roberts W. C., "The Autopsy: Its Decline and a Suggestion for Its Revival," New E n g l a n d J. Medicine, 1978, 299, 332-338. 3. Lundberg G. D., "Medicine W i t h o u t the Autopsy," Archives o f Pathology and Laboratory Medicine, 1984, 108, 449-454. 4. Anderson M. N., "The Problem of Autopsy Consent in a Teaching Hospital," J. Medical Education, 1964, 39, 518-521. 5. Hendon D., Death as a Fact o f Life. New York, W. W. Norton & Co., 1973. 6. Corrigan G. C., "The Clinician's Prerogative to Request an A u t o p s y , " Texas Medicine, 1976, 72, 92-94. 7. Katz J. L., and Gardner R., " R e q u e s t for Autopsy Consent: Conflict and Challenge," N e w York StateJ. Medicine, 1973, 2592-2596.
166
Journal of Religion and Health
8. Corrigan, 019. cit., 92-94. 9. Katz J. L., and Gardner R., "The I n t e r n ' s Dilemma: The Request for Autopsy Consent," Psychiatry in Medicine, 1972, 3, 197-203. 10. Hendon, op. cit. 11. Katz, op. cit., 197-203. 12. Ibid. 13. Ibid. 14. Katz, op. cit., 2592-2596. 15. Morgan R. L., "Cremation," The Christian Ministry, 1984, 15, 3, 13-15. 16. Despeller L., The Last Dance: Encountering Death and Dying. Palo Alto, Mayfield Publishing Co., 1983.
The Therapeutic Value in the Autopsy Request MAURICE E. ROBERTS and E D W A R D P. FODY A B S T R A C T : Recently the number of autopsies performed in the United States has declined. Although the benefits of the autopsy for physicians are many, we maintain, based on our own experiences, t h a t the request for autopsy is of benefit to the surviving family members as well, in that it helps them accept the reality of loss of a loved one and enables them to begin the process of "letting go." Realization of the therapeutic value of the autopsy request should enable those who work with the recently bereaved, such as physicians and clergy, to fulfill more effective roles.
Introduction
The autopsy is the final medical procedure. Although autopsies are performed on patients of any age, most are elderly. For the last several decades in the United States, the number of autopsies has declined. A striking decline in autopsy rates among geriatric patients has been documented. 1 The usefulness of the autopsy in medical practice has been thoroughly established. However, it is our contention, based on our experience in a large Veterans Administration teaching hospital, t h a t there is, as well, a therapeutic value in the request for autopsy permission from the deceased's family. This value extends to the family, the physician, and to other allied health personnel.
The incidence of autopsy consent in the United States and other countries
A literature review of the percentage of hospital deaths coming to autopsy reveals a downward trend. Roberts gives a history of the decline of autopsy consent over the last forty years: The hospital autopsy rate shortly after World War II was 50 per cent. By 1964 the mean autopsy rate in all U.S. hospitals was 41 per cent; by 1970, 29 per cent; and by 1973, 22.2 per cent; and by 1975, 21.7 per cent . . . . 2 In 1982, the autopsy rate for all Chicago hospitals was 19 per cent. 3 Even this figure is probably higher than the true national average, since it includes several maj or teaching hospitals with relatively high percentages of autopsies. Anderson's study focused on large teaching hospitals which historically Edward P. Fody, M.D., is Chief of Laboratory Service at John L. McClellan Memorial Veterans Hospital in Little Rock, Arkansas, and Associate Professor in the D e p a r t m e n t s of Pathology and Pharmacology at the University of Arkansas for Medical Sciences in Little Rock. Maurice E. Roberts, M. Div., M.A., is Chief of Chaplain Service at the Veterans Administration Medical Center in Fayetteville, Arkansas. 161
(z)1986 Institutesof Religionand Health
162
Journal of Religion and Health
have enjoyed the highest percentage of autopsy consent in the United States. Of the ten largest "charity-type" of hospitals which are principal teaching hospitals of major medical schools, Anderson found t h a t five had consent rates below 50 per cent and four had averages below 40 per cent. In a companion study, he found a substantially higher rate ranging between 50 and 80 per cent in teaching hospitals t h a t are basically private in nature. 4 A comparison of U.S. autopsy rates with other countries is interesting. Switzerland has an autopsy rate of 80 per cent, and the U.S.S.R.'s is 100 per cent. 5 Russia's political philosophy, which maintains that all bodies belong to the state, accounts for its high percentage. When an individual in the Soviet Union is pronounced dead, physicians can perform an autopsy or remove an organ immediately and without consent of the next of kin. Albeit such a policy removes all "problems" connected with obtaining autopsy permission, the deprivation of the freedom of choice is a price that most Americans are unwilling to pay. A consideration of the statistics raises questions concerning the autopsy consent in the United States, the most fundamental being, " W h y an autopsy?"
The why of an autopsy Observation of the physician's request for autopsy during the notification-ofdeath interview leads to an appreciation t h a t the doctor must have reasons for asking such a difficult question at t h a t time. In fact, one learns that the request for autopsy is a clinician's prerogative based on a belief that the autopsy is beneficial and desirable for the family, the institution, the clinician, and other patients. The value of the autopsy, according to Corrigan, is t h a t it is "the final informational device of known scientific calibre, which helps him [the physician] correlate the patient's disease with the care given. ''6 What he seems to be saying is t h a t the physician's scientific role as a searcher for t r u t h requires his use of this tool. Katz and Gardner suggest another rationale for use of the autopsy. They refer to the therapeutic value for family survivors by the raising of the autopsy question: By using this interview to allow the family to ventilate its feelings of hurt and anger without rebuke, indeed, actually supporting the appropriateness of such feelings, and to convey a sense of concern for the family that goes beyond the immediate situation, for example by offering to call the family to discuss the autopsy findings when they become available, the physician can make the family more comfortable as the mourning process begins . . . . 7 In short, the autopsy request can serve an important role in helping the survivor family deal with their grief. Corrigan appears to concur in his reference to the educational aspect of the autopsy request. "We physicians," he states, "can teach a rational approach
Maurice E. Roberts and E d w a r d P. Fody
163
to death and disease through the autopsy. ''s The therapeutic and educational aspect of the autopsy request is perhaps overlooked by the requesting physician as well. An often-repeated response to a physician's request for autopsy consent is, "No autopsy; he's suffered enough." In our experience, at this point most request physicians accept such a response as the family's final decision and all discussion concerning the autopsy ceases. However, if the autopsy request is viewed as having therapeutic value and as a means to encourage an acceptance of death, there is every justification in carrying on the discussion, albeit using another tactic. As counselors are aware, there is value in leaving a subject for the time being and returning to it later at the client's pace. Without an acceptance of the reality of death, the process of a family working through their bereavement cannot begin. We have come to appreciate t h a t the physician's request for autopsy, when properly handled, can be an encouragement for the family to accept the death of a family member and t h a t they have a need to begin "to let go." In conclusion, there is more than meets the eye when the physician asks, " M a y we perform an autopsy?"
Factors affecting the therapeutic value of the autopsy request It has been proposed in this paper and in the literature cited t h a t there is a therapeutic value to the family when they are asked for consent to an autopsy. The therapeutic value, however, is often a missing element in the physician's interview with the family. The question is " w h y . " A basic factor appears to be t h a t the physician himself or herself does not view the autopsy interview as therapeutic. Katz and Gardner, who studied interns on the subject of autopsy request, concluded: Only a rare intern contemplated the possibility that this interview might actually be beneficial to the bereaved relatives, at the very least in permitting them to ventilate their acute feelings of anger, guilt, and so forth . . . . Most interns clearly see this meeting [the notification-of-death interview with the family when an autopsy is requested] as completely void of any therapeutic value. They generally conceive it as one more "painful blow" inflicted on relatives and come to it with considerable anxiety because of their own conflicts. . . . 9 The physician's unresolved conflicts on the subject of death have also been found to be a factor contributing to not viewing the autopsy request as therapeutic. Hendon found the doctors t h o u g h t less about death than did two control groups t h a t he studied, one of patients and one of professionals. 10This factor would seem to account for the almost mechanical approach t h a t characterizes m a n y physician-family interviews in which the physician apologetically asks, " I ' m sorry to have to ask you this, but the hospital requires it. Will you give consent to an autopsy?" Without the appreciation of the therapeutic
Journal of Religion and Health
164
potential to the family of the interview and with the physician's lack of selfawareness, autopsy requests become repetitive, "gradually numbing and desensitizing him to his own feelings and those of bereaved families."'1 Another factor preventing the interview from becoming therapeutic is the physician's acknowledgement of feelings of awkwardness and unpreparedness for conducting such interviews: While all interviewed interns acknowledged that increasing experience eventually exerts a beneficial effect, five recalled their awkwardness . . . in dealing with the specific arguments put forth by families. But more unfortunate than the sense of inadequacy in attempting to deal rationally with the resistances thrown up by the family was the tendency of at least half of the interns to react defensively themselves if the family expressed hostility over the autopsy matters. Rather than seeing this as a symptom of and defense against the acute grief and likely guilt of the bereaved family, these interns tended to respond concretely and aggressively in turn . . . . 12 It is apparent t h a t there is a lack of medical school and internship preparation for autopsy issues at the present time. Physicians have expressed through questionnaires and interviews considerable interest in the subject and a desire for further information and discussion in this area. Katz found t h a t the physicians he interviewed wished there could be some ongoing outlet in which they could discuss their feelings, family resistances, unpleasant encounters, and mechanical obstacles t h a t were constantly arising regarding autopsy during the house year. 13 It does appear t h a t a forum, be it a seminar or ward conferences, needs to be provided to assist physicians in an area where by their own admission they are ill-trained. The topics for such sessions could, and should, cover the spectrum, from the seemingly mundane to the profound. Communication specialists have learned t h a t in interpersonal relations even the mundane and common have significant consequence. For example, the place where the physician interviews the family can have a positive or negative effect on decision making. If the setting is the hospital corridor or a cramped room with insufficient chairs for all the family members, the physician immediately has two strikes against him or her in obraining autopsy consent. Likewise, the physician can be helped in dealing with those occasions when the family are hostile and angry. The teaching technique of "role-playing" has been found to be effective in such situations. Through this technique, common family statements of refusal can be understood as symptoms of acute grief, guilt, anger, and not cause for defensiveness or hostile reactions. Such statements include: Autopsy is against our religion. He's suffered enough. Don't make him suffer more. An autopsy won't bring him back. You did him no good and you still want to hurt him.
Maurice E. Roberts and Edward P. Fody
165
Equally important, such forums could provide: an outlet for the week to week feelings, conflicts, problems, and frustrations that the intern will invariably still experience in relation to the autopsy request . . . . 14 9
Implicit in this argument for an awareness of the therapeutic value in the autopsy request and a recognition of the need to assist the physician in conducting the family interview is the assumption t h a t an increase in incidence of autopsy consent would result. Such an expectation is based on more than hope.
Conclusion Our conviction, confirmed by this study, is t h a t there is a therapeutic value to the family in the request for autopsy. When handled properly, the autopsy request can be the first step in the survivors' acceptance of the reality of death. Thanatologists confirm t h a t grief work is thwarted when re-attachment sets in.15 An appropriate response by the physician to a family member's protest, "No autopsy; he's suffered enough," can prevent re-attachment and begin the process of "letting go." Erich Lindemann identifies three primary tasks necessary for satisfactory grief management: 1. Letting go of the deceased; accepting the fact of loss. 2. Adjusting to a life without the deceased. 3. Forming new relationships, is The physician in the family interview enjoys the unique opportunity to help family survivors begin the process of working through their grief. There is ampie evidence t h a t the physician has the desire as well.
References 1. Ahronheim J. C.; Bernhole A. C.; and Clark W. D., "Age Trends in Autopsy Rates: Striking Decline in Late Life," J. Amer. Medical Association, 1983, 250, 1182-1186. 2. Roberts W. C., "The Autopsy: Its Decline and a Suggestion for Its Revival," New E n g l a n d J. Medicine, 1978, 299, 332-338. 3. Lundberg G. D., "Medicine W i t h o u t the Autopsy," Archives o f Pathology and Laboratory Medicine, 1984, 108, 449-454. 4. Anderson M. N., "The Problem of Autopsy Consent in a Teaching Hospital," J. Medical Education, 1964, 39, 518-521. 5. Hendon D., Death as a Fact o f Life. New York, W. W. Norton & Co., 1973. 6. Corrigan G. C., "The Clinician's Prerogative to Request an A u t o p s y , " Texas Medicine, 1976, 72, 92-94. 7. Katz J. L., and Gardner R., " R e q u e s t for Autopsy Consent: Conflict and Challenge," N e w York StateJ. Medicine, 1973, 2592-2596.
166
Journal of Religion and Health
8. Corrigan, 019. cit., 92-94. 9. Katz J. L., and Gardner R., "The I n t e r n ' s Dilemma: The Request for Autopsy Consent," Psychiatry in Medicine, 1972, 3, 197-203. 10. Hendon, op. cit. 11. Katz, op. cit., 197-203. 12. Ibid. 13. Ibid. 14. Katz, op. cit., 2592-2596. 15. Morgan R. L., "Cremation," The Christian Ministry, 1984, 15, 3, 13-15. 16. Despeller L., The Last Dance: Encountering Death and Dying. Palo Alto, Mayfield Publishing Co., 1983.
