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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Geriatrics. Author manuscript; available in PMC 2010 August 11.
Published in final edited form as:
Geriatrics. 2008 December; 63(12): 14–18.
PMCID: PMC2920045

The autopsy and the elderly patient in the hospital and the nursing home: Enhancing the quality of life


The autopsy is the ultimate “peer review.” Yet the autopsy has nearly disappeared from hospitals in the United States and around the world. It is rarely performed in the nursing home or other long-term care (LTC) setting. As a result, all of society has lost much, in terms of quality of health care, the skills of physicians, and insights gained through autopsy-based research. The elderly have the lowest rate of autopsies of any age group. This is a paradox, since the greatest quality and quantity of knowledge would accrue from the often surprising findings revealed at autopsy that reflect the acknowledged ‘multiple simultaneous illnesses’ occurring in older persons. This review and analysis describe why autopsy rates have fallen in hospitals and offer rationales and solutions for reversing this trend in the nursing home and other LTC settings.

Keywords: autopsy, pathology

The autopsy has nearly disappeared from US hospitals and from the hospitals of all nations.1 As a result, society has lost much in the quality of health care, the skills of physicians, and the insights gained through research. The elderly have the lowest rate of autopsies of any age group.2,3 This is a paradox, since the greatest quality and quantity of knowledge would accrue from the often surprising findings revealed at autopsy that reflect the acknowledged “multiple simultaneous illnesses” occurring in older persons.

In a vague way, the common rationale for not performing autopsies in the elderly relates to a supposed “kindness” on the part of families and clinicians reluctant to inflict further “discomfort” upon the deceased. Even more powerful as a deterrent to autopsy is the often unstated bias against learning more about an older person’s illnesses and the normal changes that come with age, both of which are dismissed as unimportant. Of course many other factors contribute to the decrease in autopsies; some of the most common are noted in Table 1 (page 15).

Table 1
Factors in the decline of the autopsy rate in older patients and those of all ages

The autopsy is the ultimate “peer review” method. Through autopsy we discover our errors of omission and commission, noting unacknowledged diseases and normal though often unexpected age-related changes, while confirming insightful diagnoses. We learn causes of death or are humbled, perhaps, to see that the cause of death is so often less clear than we had concluded.

Beyond the anatomic insights that enhance knowledge and al low us to do better for all patients, are the established effective medical education programs based almost entirely on the revelations from the autopsy. The most widely acknowledged thinking process is the well-known “Clinical Pathological Conference” (CPC), which in past decades occurred at most teaching hospitals and at many community hospitals. Here the expert clinician attempts to correlate the clinical observations with the soon-to-be-revealed autopsy findings. The CPC has been a magnetic component of the weekly New England Journal of Medicine, helping to educate generations of physicians.

In a recent survey of resident physicians in internal medicine and in pathology at the Massachusetts General Hospital,2 the authors reported that of the more than 200 resident surveyed, most strongly agreed about the importance of the autopsy to their education and to the public health.

Surprisingly, these physicians in internal medicine reported that they were comfortable with requesting autopsies, but they emphasized the insufficiency of guidelines available from their mentors and from the hospital administration. Consequently the residents felt unable to answer many questions from family members about the procedure itself, about religious values, and about the regulations governing the autopsy.

There was not much concern by these resident physicians about malpractice implications or about costs to the hospital of the autopsy procedure.

This study made evident the need to strengthen the collaboration between internists and pathologists.

Factors that limit performance of autopsy

In Table 1 we see many of the key factors contributing to the decline of autopsy to its present level of about 5%.1

  1. The nursing home has in recent decades become a major site of death for elderly patients, who are now transferred quickly from hospitals to the nursing home. Autopsies are rarely performed upon nursing-home-residing patients who die either in the nursing home or at the acute hospital.
  2. Society-wide attitudes and denial of death are self-defeating.
  3. Physician attitudes are generally negative toward autopsy, in part because of an age bias and in part because of the additional time and work involved in obtaining the autopsy.
  4. Cost of the autopsy: The hospital is not reimbursed for the autopsy procedure, which is estimated to cost $1000 per case. The remedy is obvious. It is important for the Center for Medicare and Medicaid as well as for private insurers to address this cost.
  5. A false belief exists that the many imaging techniques (CT, MRI, PET scan, SPECT, ultrasound) provide all of the answers.
  6. Some practitioners hold a misbelief that supposed “kindness” is shown in preventing “more suffering” by the deceased. This attitude is generally agreed to be an inappropriate rationale for negating the need for the autopsy.
  7. Medico-legal fears: Understandable concern about lawsuits is a huge deterrent to autopsy in spite of the obvious potential for educational, clinical, and research gains.
  8. A cultural gap exists between patients, families, and physicians. This undoubted challenge in our multicultural society calls for an educational intervention.
  9. The language barrier between physician and patients and/or families adds to the difficulty related to cultural issues.
  10. Fear and denial of death are widespread in our society, and rejection of the autopsy is an understandable consequence of these attitudes.

Benefits of autopsy

It is obvious that we improve the life of our citizens through the knowledge gained from autopsy. The gains noted above — strengthened medical skills, enlarged body of knowledge, advances in public health with containment of infections, and major scientific advances — often are only possible through study of the tissue within which a mysterious disease is occurring. The best examples of medical mysteries requiring study of tissue are Alzheimer’s disease and Parkinson’s disease, for which the causes and mechanisms are yet to be discovered within the tissues of the human brain.

In addition, families often benefit from autopsy; it yields new knowledge of hereditary illnesses that may then be prevented or slowed as a result of findings discovered at autopsy.

Methods for increasing the practice of autopsy

As seen in Table 2 (page 16), there are several approaches likely to improve the autopsy rate.

Table 2
Methods to increase the autopsy rate in older patients and those of all ages
  1. Hospital leadership. Obviously most autopsies are done at hospitals and the hospital leadership has been distracted from supporting autopsy for many of the reasons stated above. To encourage and embrace the reinstitution of the autopsy procedure will necessitate leadership by hospital administrations and academic centers.
  2. Cost. It is a cost-effective move for the nation to support payment to hospitals for performance of autopsy because the knowledge gained is likely to improve the quality of health care and thereby diminish overall cost.
  3. Education. It is essential to educate clinical and administrative staff about guidelines and procedures to follow in obtaining and performing the autopsy.
  4. Advance consent. Create a new legality for ‘advance consent for autopsy’ somewhat analagous to the legality now existing to give ‘advance consent’ to removing organs such as the eyes upon one’s death. Also create a section on ‘Advance Consent to Grant Autopsy’ in the standard advance directive. The time to address the question of autopsy consent and/or intent to permit autopsy is during the lifetime of the patient, and the best moment to do this is when we are encouraging that patient to create an advance directive.
    This represents a significant change in our medical and legal structure, but it is appropriately linked to patients’ choices about their lives, end-of-life-care, and now the examination of their physical remains for the good of society and perhaps specifically for the good of their own family. This will call for a major program of educational outreach, but the potential benefit to society is also great.
  5. Advance intent. While governmental bodies address the question of advance consent, we can immediately institute ‘Advance Intent to Grant Autopsy’ to assist the redevelopment of autopsy programs. It is often the case that when physicians seek autopsy permission from families, families do not know what the deceased would have wanted. Advance intent will help this situation. Though advance intent is now not legally binding, it is meant to have a guidance impact upon the family, At our program we have found "advance intent" to have a positive though modest impact on obtaining consent for autopsy from families.
    Advance intent is a major departure from the usual approach in our culture to discussions of death and/or autopsy and understandably is immediately unnerving to many clinicians, administrators, some patients and families. Yet many older persons see the positives contained in contributing to the greater good of the society and making such impact beyond their living years. Also compelling is the realistic possibility in selected cases of the autopsy in helping to improve the quality of life of family members if hereditary factors are discovered and if these factors lead to some amelioration of the biologic destiny contained within the genetics.
    Each institution and their leadership need to create the approach to seeking an “Advance Intent" to autopsy that is compatible with the demography and general culture of their environment.
  6. Religion/clergy. When families or clinicians are puzzled by questions arising from religious beliefs, it is important to call upon the assistance of clergy who can address family concerns and help move the decision forward.

Attitudes of hospital administrators toward autopsy

A survey of hospital administrators in eight US states reveals the distressing finding that with a median autopsy rate in hospitals of 2.4% and a cost of $852 per autopsy, 66% of hospital administrators agree that “current autopsy rates were adequate.”4 Of course, the median autopsy rate in teaching hospitals is somewhat higher than the rate in non-teaching hospitals, but it is still at a most moderate level. Most of these administrators believe that improved diagnostic tests significantly reduce the need for autopsy. They also agree that payment to pathologistis for performance of autopsies might lead to an increase in autopsies.

The most distressing aspect of this study4 is the belief by hospital administrators that improved diagnostic technology makes the autopsy redundant and unimportant. Equally distressing is the link in the minds of administrators between predictable concerns about cost control and continued restriction of autopsy.

Nursing homes and the autopsy rate

There are approximately 7000 skilled nursing facilities in the United States and about 13,000 other facilities for long-term care. As stated earlier, the deaths of older people now occur much more frequently in nursing homes; some studies have estimated that 33% of all elder deaths occur in these settings.5 This remarkable increase is primarily attributable to the US government’s DRG program, which clearly encourages rapid transfer of elderly patients from hospitals to nursing homes. With rare exceptions, nursing homes are not capable of providing autopsies, nor is this expected of them when even their community hospitals are not performing these procedures. Thus, by regulation, we have set the autopsy rate to move toward zero. Many other nations show similar rapid transfer of patients from hospital to nursing home.3

Since we will not be reverting to a system under which older persons die in hospitals, we will have to create autopsy programs for the elderly who die in nursing homes.

One such autopsy program conducted at Jewish Home LifeCare, a teaching nursing home formerly known as the Jewish Home and Hospital for the Aged of New York, has contributed to the strong quality of clinical care at that facility. In addition, the active training programs for medical students and postgraduate fellows and residents at that facility are bolstered by ongoing pathology conferences that interface with the autopsy program.

Along with the clinical insights and educational benefits derived from this nursing-home autopsy program, it has produced research insights in several subject areas, including the neurodegenerative disease so frequent in older persons. This research has placed particular emphasis on Alzheimer’s disease,6,14 Parkinson’s disease,15 and the processes of normal aging.

Autopsy studies also are providing insight into many other disease processes, including pulmonary embolism, 16 macular degeneration,17 gender differences in illness, and many other cardiovascular and neoplastic illnesses.

Autopsy essential to diagnosis

Most autopsies are performed as full autopsies and include a study of most vital organs. At times, autopsies are restricted to one organ holding great interest for the clinician, researcher, and family. The best example of this is the brain; brain autopsy has resulted in a significant percentage of the advances made in study of Alzheimer’s disease and Parkinson’s disease.

Members of the lay public are surprised to discover that many diseases — including Alzheimer’s disease — cannot be diagnosed accurately without an autopsy. Even with an autopsy, the cause of death in older persons is demonstrable in only about 70% of cases.

Additionally, information derived from autopsies often benefits the patient’s relatives. In one survey of family members of approximately 100 patients who had died in a teaching hospital in the United Stales, most responded that they considered the autopsy beneficial, that they found some comfort in knowing the cause of death, and that it reassured them to know that the clinical care was appropriate and that their relative’s autopsy contributed to the growth of knowledge.1

Communication between physicians, hospital administrators, and families concerned with the autopsy is essential to the growth of the autopsy program. As stated above, families appreciate knowing the specific details of their relatives’ illnesses, rather than being left in the dark about deaths from unexplained causes.

As shown in Figure 1 (page 17), the autopsy rate at the teaching nursing home with which the authors are affiliated (Jewish Home LifeCare of New York) is remarkable. Over the course of many years our rate has exceeded the autopsy rate of most teaching hospitals in the United States (Figure 2, above). The autopsy rate (12% to 20%) at this nursing home reflects the efforts made by its clinical and research staff, along with support from the leaders of the administrative staff and board of directors. In existence for more than 50 years, the autopsy program was strengthened and the autopsy rate accelerated when the nursing home developed a partnership with Mount Sinai’s Department of Geriatrics and Adult Development in 1982,18,19,20 as well as a linkage to the Departments of Pathology and Psychiatry at Mount Sinai School of Medicine.

Figure 1
Jewish Home and Hospital for Aged* of New York City
Figure 2
Rate of autopsies in the nursing home

This autopsy program has contributed to the education of more than 2500 medical students who have trained at the nursing home as well as to the education of 125 fellows in geriatric medicine. It has also served the educational growth of primary care physicians and nurses who have been part of the Jewish Home LifeCare system.

Building the nursing-home autopsy program

It is remarkable that patients, families, friends, nursing-home clinicians, administrators, boards of directors, and affiliated hospitals all have come to support the autopsy program at Jewish Home LifeCare. The autopsy program is linked to the quality of care, which helps to make this teaching nursing home a respected entity in the community. While there have been elements of resistance to the autopsy program, as one would expect, time and performance have nurtured trust in the program and its society-wide goals to do good.

The Mount Sinai School of Medicine Brain Bank, under direction of V. Haroutunian, has certainly helped catalyze the success of the autopsy program at the Jewish Home LifeCare. The partnership of the Brain Bank, the Mount Sinai School of Medicine, and the Jewish Home LifeCare has benefited all three participants through the program’s level of quality and its advancement of knowledge and care. Indeed, the presence of approximately 500 of the brains at the MS Brain Bank —about 35% of the specimens at this vigorous and productive brain bank —results from the willingness of JHL patients and families to contribute to the advancement of knowledge and scientific insight.

The studies have not only provided insights into brain diseases such as Alzheimer’s disease and Parkinson’s disease; they also have allowed us to study the processes of normal human aging and compare their changes to those of the neurodegenerative diseases. Thus a recent study highlighted the discovery that in the very old (those beyond 80 to 85 years of age) the density of plaques and tangles in patients with Alzheimer’s disease was significantly reduced compared to those of the young old (65 to 75 years) Alzheimer’s patients. This report from the collaboration strongly suggests a reconsideration of the role of plaques and tangles and of the normal aging of the human brain and mind.21


The autopsy needs to be restored to the health care system in order to achieve improved cost-effective and human-effective goals. The approach to enhancing the autopsy rate in the United States is described in detail.


The authors gratefully acknowledge the active participation in this autopsy program of the Jewish Home LifeCare’s entire primary care clinical staff with particular appreciation of Drs. P. Toledo, M. Camargo and P. Sharma. We also thank the nursing department, the medical records department, and Ms. Violet Derrick for her assistance with preparation of the manuscript.

We appreciate the Leir Foundation for their support, in part, of the autopsy program and the support of grants NIH-AG02219 and NIH-AG05138.


Disclosure: The authors declare that they have nothing to disclose.

Contributor Information

Leslie S. Libow, Distinguished Clinical Professor, Jewish Home LifeCare, and Clinical Professor, Department of Geriatrics and Adult Development and Department of Medicine, Mount Sinai School of Medicine. New York City.

Richard R. Neufeld, Medical Director of the Manhattan Campus-Jewish Home LifeCare, and Associate Clinical Professor, Department of Geriatrics and Adult Development, Mount Sinai School of Medicine.


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