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Autopsy, a new era When a death raises questions

The procedure, once standard, often must be arranged today. Families do so for answers -- and peace of mind.

April 21, 2008|Christie Aschwanden | Special to The Times

When a relative discovered Sharon Waldorf's 64-year-old mother dead in her Paramount home, Waldorf asked her mom's physician about an autopsy. "The doctor didn't want us to do it," she recalls.

Waldorf's mother had been in and out of the hospital that year with a series of strokes and seizures, and the doctor was confident that a stroke had killed her. Besides, the doctor said, an autopsy would cost several thousand dollars and insurance wouldn't pay.

For The Record
Los Angeles Times Monday, April 28, 2008 Home Edition Health Part F Page 4 Features Desk 2 inches; 87 words Type of Material: Correction
Autopsies: An April 21 Health section article about arranging a private autopsy said that after the procedure, incisions are closed in a manner that renders them nearly invisible. In fact, after an autopsy larger sutures are often used to close an incision. The embalmer later closes the incision with smaller stitches, but these are still visible. Incisions are made in areas that are hidden by clothes, however, and incisions in the head are generally made in the back and can be concealed by hair or a pillow.

Waldorf and her two sisters insisted. "We wanted to know what it was that took our mom from us," she says. "Mom would have wanted us to know."

Autopsies were once standard procedure in U.S. hospitals. A few decades ago, doctors would recommend one even when the cause of death seemed certain, because it allowed them to gauge the effects of treatments and find out to what degree a disease had progressed, says Dr. Harry Bonnell, a fellow of the American Society for Clinical Pathology and a pathologist in private practice in San Diego.

But today, fewer than one in 10 deaths in the U.S. is followed by an autopsy, in part because of its high cost (which Medicare and most insurance companies won't cover) and because many doctors believe -- erroneously -- that modern imaging techniques such as the MRI have rendered the autopsy obsolete.

Yet autopsies still provide one of the best ways for doctors to learn how to improve their practice of medicine. "Autopsies could reveal that, unbeknownst to practitioners, a certain disease presents differently than people think," says Dr. Kaveh Shojania, a physician at the University of Ottawa who coauthored a Feb. 28 paper in the New England Journal of Medicine expressing concerns about the vanishing autopsy. For instance, a tear in the wall of the aorta -- known as an aortic dissection -- can easily be mistaken for a heart attack, as was the case for actor John Ritter. Though a jury found that his doctors were not to blame for Ritter's death, the case drew new attention to the condition's warning signs.

An autopsy, Shojania says, might also show that a medical device or procedure did not work as well as the doctors had thought, as occurred recently when autopsy studies helped reveal that drug-eluting stents, used to keep arteries open after blockages, were not performing as expected. They can offer clues about the spread of disease. In 2004, autopsies showed that four transplant patients at Baylor University Medical Center in Texas had caught rabies from the same infected organ donor.

In the case of Waldorf's mother, the autopsy revealed that she hadn't died of a stroke at all. A massive heart attack had claimed her life. "The main artery leading to her heart was 100% blocked," Waldorf says. "It was probably genetic, which means it could happen to us."

Waldorf and her sisters had known that their mother had high cholesterol and that it didn't respond well to drugs. But proof that heart disease killed their mom has motivated the sisters to go the extra mile to control their cholesterol.

"Now we know we need to be extremely aggressive with our diet and exercise or we're going to die at 64 like our mother," Waldorf says.

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Making the request

Today, the few autopsies that take place usually occur because the coroner has required them. Deaths that are unexplained, unnatural, or happen during surgery or shortly after admission to the hospital must be reported to the coroner or medical examiner, who then decides whether to require an autopsy. Autopsies are rarely ordered if the person is older than 60 and there's no evidence of foul play, Bonnell says.

With few doctors pushing for autopsies, it's up to the family to request them -- and Dr. Elizabeth Burton, a pathologist at the Institute for Health Care Research and Improvement at Baylor University Medical Center, says she's seeing more and more families do just that. Hard statistics are difficult to come by, but pathologists who perform private autopsies say that demand is growing, partly because popular television shows such as "CSI" have raised awareness about the kind of information that an autopsy can provide.

Learning a parent's true cause of death might teach survivors more about their own medical risks, as was the case for Waldorf and her sisters.

Even when the cause of death seems obvious, an autopsy can also reveal previously undetected underlying health problems that weren't the primary cause of death -- conditions that family members too might inherit.

"Study after study has shown that about 20% to 30% of autopsies will come up with a significant medical condition that was not known during life," says Dr. Michael Dobersen, coroner/medical examiner for Arapahoe County, Colo., and a member of the College of American Pathologists' Autopsy Committee.

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