In Reply

In Reply.—Thank you for the opportunity to respond to this letter to the editor. We feel the author makes some valid points that contribute to the debate on the role/value of communication and the autopsy. We also feel the author has misinterpreted some of our statements. In particular, our sentence, “[a] failure of communication among families, physicians, and pathologists is recognized as a major cause of declining autopsy rates and may be involved in increased litigation,” appears to have caused some confusion.1 First, we do not state that a decline in autopsy rates may be involved in increased litigation but that a failure of communication may be involved in increased litigation. Second, we did not intend to imply that pathologists are not physicians, although we agree that the wording we chose was somewhat ambiguous. In retrospect, it would have been more precise if we had qualified “physicians” in that sentence by saying “treating (or primary care) physicians” to differentiate their role from that of the pathologist.The author of the letter raises a substantive criticism in his last paragraph, that is, that we “do not present or cite any data that indicate that poor communication involving families has led to the decline in autopsies.” He also points out that the decline of the autopsy is multifactorial. We agree with the latter opinion. We also agree that there is limited direct evidence that poor communication with families has contributed to the decline in autopsy rates. However, several studies have shown that the major factor for low autopsy rates is a failure to ask for consent.23 This is surely a breakdown in communication. There is also much indirect evidence for our opinion that better communication with families leads to higher autopsy rates.We have identified several studies that address the indirect evidence that good communication with families is an effective way to increase autopsy rates. In one of these, McPhee4 states that improving communication with clinicians and families is an important requirement for maximizing autopsy benefits. In addition to improving direct communication with families, the author also recommended “educating both medical professionals and public citizens about the value of autopsy (eg, featuring autopsy results in medical conferences, distributing educational materials, and using print and electronic media).” 4 Resident internists reported insufficient guidance and difficulty with answering technical questions with respect to autopsies and expressed interest in developing better communication skills with families by improving communication and support from pathology residents.5 Lack of training in communication is not restricted to internists; 48% of surgeons reported a lack of competence in gaining consent for autopsy and could benefit from formal training in communication.6 The next of kin's perceptions of the autopsy are also an important factor to consider when requesting consent for an autopsy.7 When families' concerns and questions were addressed in a formalized setting, 62% of parents consented to an autopsy for their child.7In conclusion, we feel it is reasonable to suggest that good communication between pathologists, primary care physicians, and families about the role and benefits of autopsies would increase autopsy rates.

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