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Consent to autopsy is usually obtained by a doctor other than the one who will perform the procedure. There is an argument that, for proper informed consent, a pathologist should participate. We ascertained the views of consultant pathologists in south-east England.
53 (87%) of 61 consultants responded, of whom 50 currently do autopsies. Only 2 at present participate directly in obtaining consent, and 10 of the remaining 48 expressed willingness to do so. The general view was that consent is best obtained by a senior clinician from the team that has looked after the patient.
Pathologists see their primary role as to provide guidance to clinicians. Few see it as their function to obtain consent for autopsy.
Public and professional confidence in the autopsy service has been undermined by recent events, many of which have reflected poor communication between pathologists, clinicians, the coronial service and patients' families1. In the medical press there have been repeated suggestions from clinicians that pathologists should participate actively in gaining consent for autopsies2,3. The autopsy is unusual in medical practice in that, customarily, consent is obtained by a doctor who will not perform the procedure4. We have surveyed practising histopathologists in south-east England to determine the extent to which they participate in gaining consent for hospital autopsy and how they would feel about increasing their involvement. At present, direct consent from the family is not required for a coronial autopsy.
A postal questionnaire was sent to all 61 consultant pathologists working at sixteen hospitals within the South Eastern region, including two teaching and fourteen district general hospitals. Replies were received from 53 (87%), 50 of whom currently perform autopsies. Only 2 respondents participate directly in obtaining informed consent from next of kin whilst 13 are indirectly involved (by offering advice to clinicians who will be seeking consent). Of the 48 not directly involved, only 10 indicated that they would be willing to become directly involved in the consent process. Further questions sought to establish the pathologists' attitudes towards consent, both as it is now obtained and with regard to the possibility of direct contact with patients' families (Table 1).
Space was provided for specific comments (received from 25 respondents) and these expanded on the reasons for pathologists' reluctance to participate in gaining consent. Among these respondents the majority view was that consent is best obtained through the clinical team who have been looking after the patient, since the family will know the doctors and they will be able to explain most clearly the clinical reasons for an autopsy. One added that, in the aftermath of Alder Hey, direct participation in the consent process would be regarded by the relatives as ‘distasteful eagerness on my part’. Several suggested that the most appropriate time for the pathologists to meet the family would be in a next-of-kin clinic in which relatives could meet clinicians and pathologists to discuss autopsy findings and their implications. Many mentioned the explicit autopsy consent forms that have been widely adopted in response to guidelines from the Royal College of Pathologists5, although not all clinicians like the candour of these forms3. The importance of continuing education of clinicians concerning the nature and value of the autopsy was stressed by several respondents. When asked which grades of clinicians were appropriate for seeking informal consent only 1 of the 50 said preregistration house officer and 4 said senior house officer; 15 thought a staff grade or registrar was appropriate and all 50 a consultant.
The majority view among our respondents is that responsibility for gaining consent should rest with the consulting clinician, and that the discussion is best conducted without the pathologist in attendance. Pathologists see their primary role as providing guidance to clinicians. Few believe either families or clinicians wish them to be present. Nevertheless, respondents did share the concern of some clinicians that, without the participation of a pathologist, consent is not fully informed. The introduction of more explicit consent forms has not been welcomed by all clinicians. The preferences of the families in this process are paramount and clearly neither clinicians nor pathologists wish to increase their distress. Public expectations are likely to have been changed by the widespread media coverage of autopsy practice, and in future pathologists and clinicans will need to be responsive to family preferences, after local discussions including all interested parties.