General practitioners and necropsies

Abstract

The clinical picture during life and necropsy findings are two sides of the same coin. To look at one without the other is to see only half the picture. Proof of that assertion comes from the known discrepancy between the clinical and necropsy findings-for example, Cameron et al found that 15% of the main diagnoses and 42% of causes of death were not confirmed at necropsy and Hartveit reported that one in five diagnoses thought to be certain were found to be erroneous.1 2In this issue Berlin et al report that only 20% of deaths in the community are followed by necropsies and that three quarters of those are requested by coroners for legal and not for medical reasons (p 1080).3 Why, then, do general practitioners so rarely request necropsies when they sign about one quarter of all death certificates? Berlin et al found that in the main they favour the performance ofnecropsies and want to be sent the reports. They were not asked about their reluctance to request necropsies.During discussion with small groups of general practitioners we have found two main deterrents: a belief that "I only need a postmortem if I don't know the cause of death" and anxiety about the reaction of relatives. Doctors believed that unless the relatives recognised that there are important reasons for a necropsy permission might be difficult to obtain. Indeed, Cameron et al failed to obtain permission in 35% of deaths because of the resistance by relatives or the inadequate approach by medical staff.' They found that female relatives were more likely to give permission than male relatives.Berlin et al argue that more communication between general practitioners and pathologists might help.3 Initial fruitful discussions could review the number of necropsies requested by general practitioners in each hospital area, the availability of the service (which should be universal), and the resource implications. A necropsy costs roughly £200, which would presumably come from fundholding general practitioners and health commissions. If the number of necropsies rose, more staff and facilities might be needed. The next stage would be agreement on firm objectives to satisfy the needs of continuing medical education, audit, and quality control in general practice; again this should come from discussions between general practitioners and pathologists, opening up a climate of investigation and inquiry.One issue raised by Berlin et al could be resolved quickly and easily. At present pathologists and coroners do not always send necropsy reports to general practitioners. In Southampton the coroner permits the routine distribution of these reports to general practitioners, but this is not always the case-indeed, coroners have the power to prevent the dissemination of reports. The questionnaire showed a strong demand from practitioners for these reports, and a distribution scheme organised by the family health services authority could be an important first step toward achieving collaboration between pathologists and general practitioners.For most of us the necro...

Sectie op initiatief van de huisarts

“…To look at one without the other is to see only half the picture.' 11 Een onverwacht overlijden wordt wel aangeduid met het acroniem SUDA (sudden unexpected death in adults) 10 , naar analogie van SIDS (sudden infant death syndrome). Sinds wiegendood als zodanig benoemd is en er nader onderzoek naar is verricht, is het aantal overlijdensgevallen door deze doodsoorzaak sterk gedaald.…”

“…en obductie uit de weg gaan uit angst voor de reacties van de nabestaanden. Die angst is echter ongegrond 11 , want als de arts zich toetsbaar opstelt door sectie voor te stellen en zich onderwerpt aan de kwaliteitsborging die dat inhoudt, schept dat juist mogelijkheden om de eventuele onvrede te bespreken en te verhelderen. 13 De 'opbrengst' van een sectie bij overlijden na een ziekbed is voor de huisarts vooral dat er meer inzicht verkregen wordt in het beloop van een onvoldoende begrepen ziekte.…”

General practioners and necropsies General practioners are welcome at necropsies

“…The comment that a deterrent to general practitioners requesting necropsies is their belief that a necropsy is needed only if the cause of death is not known1 is wrong. When the cause of death is unknown the case is referred to the coroner and a request from the general practitioner for a necropsy is redundant.…”