22 dec 2008--Leslie S. Libow, MD, an icon in academic geriatrics and long-term care, and an esteemed member of our Editorial Board for many years, and his longtime colleague Richard R. Neufeld, MD, have written a thoughtful and thought-provoking article on autopsies in the elderly1 for this edition of Geriatrics. Drawing on more than 40 years of clinical experience in academic geriatrics and long-term care, they describe both the benefits of autopsies in hospitals and nursing homes, and the burdens and risks of obtaining them. They address their arguments to clinicians, medical educators, researchers, administrators, legislators, and most importantly, to elderly patients and their families.
The autopsy rate in hospitals in this country is abysmally low—less than 5%.2 Ask any primary care physician when he or she has had an autopsy done on a nursing home patient and the answer is "never." Drs. Libow and Neufeld attribute this low rate of autopsies to negative physician attitudes because of the extra time involved, fear of malpractice suits, and a misunderstood desire to limit suffering. In addition, they cite the cost (about $1000 per case) and the over-reliance on imaging studies, which give a false sense of diagnostic security, ie, that these non-invasive studies yield definitive answers and nothing can be learned from the autopsy.
Drawing on their experience in establishing successful nursing home autopsy programs, the authors propose two additions to the typical panoply of advance directives that could lead to increasing the number of autopsies:
1) "Advance Consent to Grant Autopsy" or permission for autopsy in the standard advance directives, is a state and/or federally legislated procedure, which would formally allow the elderly individual with capacity to agree to an autopsy; and
2) "Advance Intent to Grant Autopsy," a discussion initiated by the physician to determine and document the wishes of the older patient regarding autopsy in states with no formal procedures. Upon death, the family of the deceased will know the wishes of their relative, thus removing the difficult decision-making that takes place when the family has no idea about their loved one's wishes.
To these two innovative ideas, I would add another legal vehicle, an "Advance Payment for Autopsy" clause in the older adult's will. Such a clause would stipulate that the autopsy be paid for by money from the deceased's estate, a clear directive that the deceased wanted an autopsy. The "Advance Payment for Autopsy" clause would relieve the family of any decision-making and financial burden at the time of death.
In addition to the clinical and educational values of autopsies, Drs. Libow and Neufeld emphasize the proven value of nursing home autopsy programs in advancing research, citing specific contributions in Alzheimer's and Parkinson's disease, macular degeneration, and cardiovascular and neoplastic diseases.
While I hope that the authors' calls for increasing the autopsy rate in both nursing homes and hospitals are heard, I remain concerned about the negative impact of both the managed-care penetration into nursing homes and the hospitalist movement.
And now a little bit of history! In 1975, Dr. Libow gave me my first job. He hired a young, newly trained internist with an interest and enthusiasm for the burgeoning field of geriatrics but little knowledge. As an attending and teacher in one of the first "teaching nursing homes" in the country, I quickly learned the principles of clinical care of the elderly under his tutelage.
Like hundreds of other academic geriatricians in this country, I have been taught many things by Dr. Libow. Here are three educational experiences that are etched in my mind:
First, his bedside teaching rounds where he demonstrates the art and science of interviewing the elderly patient, elicits a host of geriatric physical findings, and leads a dynamic discussion about aging, disease, disability and hope with students, fellows and faculty;
Second, his leadership of a weekly interdisciplinary conference that he calls "The struggle of the ill elderly." 3 Here, after presentations by multiple disciplines, he interviews both the older nursing home patient, who is struggling to return to their own home after a subacute, or less likely, long term nursing home stay, and their caregivers. In front of the interdisciplinary team, geriatric fellows, and medical students, he asks probing questions that allow the team to assess the benefits and burdens of leaving the nursing home, the strengths and weaknesses of the patient-caregiver dyad, and the safety of the transitional care plan; and
Third, his pursuit of autopsies on nursing home patients. I remember him walking with us to the autopsy room where he stood at the head of the OR table, commenting on the clinical issues as the elderly patient's history was presented and then questioning the pathologist about the subtle differences between a geriatric autopsy and that of middle-aged and younger adults.
It's now almost three and half decades later and his insights about autopsies in the elderly are more important then ever.
Dr Sherman is professor of geriatrics and medicine, The Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, and medical director for Senior Health Partners, New York, NY. He won the 2008 Jesse H. Neal award for opinion columns from American Business Media.
Send comments to Dr Sherman at fsherman@advanstar.com
References
1. Libow LS, Neufeld RR. The autopsy and the elderly patient in the hospital and the nursing home: Enhancing the quality of life. Geriatrics. 2008;63(12):14-18, 26.
2. Nemetz PN, Tanglos E, Sands LP, et al. Attitudes toward the autopsy — an eight state survey. MedGenMed. 2006;8(3):80.
3. Libow LS. A geriatric medical residency program. A four-year experience. Ann Intern Med. 1976;85(5):641-7.
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