The final chapter

Shortly after lunch on a midsummer’s day, Charles Slater felt ill. (His name and identifying details have been altered.) Complaining of indigestion, the 55-year-old administrator at a New Haven-area social services center headed home. Soon after, though, the pain became unbearable. He called for emergency medical service and paramedics arrived within five minutes, but he had already collapsed. The paramedics could find no pulse and tried to restart his heart and breathing. In the Yale-New Haven Hospital (YNHH) Emergency Department, physicians continued efforts to restore a heartbeat, but gained no more than a slight systolic fluttering. An hour after Slater telephoned for help, the doctor in charge declared him dead.

In most respects, the end of Slater’s life, although sudden and unexpected, was identical to that of all others. A biological event of catastrophic proportions overwhelmed his body. In reviewing the medical records, John H. Sinard, M.D., Ph.D., HS ’93, FW ’94, director of the autopsy service at YNHH, says that Slater had no serious apparent health problems before that day and kept himself in decent physical shape. A heart attack seemed the likely culprit, but the body holds many secrets. His family agreed to an autopsy. In this, the end of Slater’s life stands out.

While every death is ultimately the same, in the eyes of those who deal with death for a living, “each death is different,” says Sinard, an associate professor of pathology and of ophthalmology and visual science. Every time a patient dies at YNHH, the family is asked to consider an autopsy, even when the cause of death is apparent. Very few consent. About 20 percent of patients who die at YNHH are autopsied. As in most teaching hospitals, that rate is significantly above the average for private and community hospitals, which is typically below 10 percent—and half of those are required for forensic or legal reasons. (In Connecticut, forensic autopsies are performed at the Office of the Chief Medical Examiner and, in the case of crime-related deaths, are often attended by representatives from the state police.)

Pathologists at Yale worry that even the hospital’s comparatively high rate of autopsies is barely sufficient—in the 1960s, more than 70 percent of YNHH patients were autopsied at death. (The Mayo Clinic, which has one of the highest rates in the nation, autopsies more than 35 percent of patients who die in its care.) “Around the 20 percent level is the minimum to provide a reasonable statistical basis for what is seen in the hospital,” contends Raymond Yesner, M.D., a professor emeritus of pathology who, at 91, continues to serve as a research scientist in the department. “Below that level, a hospital may not be monitoring care sufficiently, and you may see problems in quality control.”

Adds Rosemarie L. Fisher, M.D., HS ’75, professor of medicine and associate dean for graduate medical education, “From an internist’s point of view, I would like to see the rate higher, although we are probably higher than a lot of other institutions. Autopsies should be performed because they often contribute to knowledge about other illnesses that may be important for the care providers or the family to know about.”

With such low rates nationally, many pathologists are concerned that medical practices may be suffering. “If you get in the range of 10 to 15 percent these days, a hospital is doing very well,” says Kim A. Collins, M.D., who chairs the autopsy committee of the College of American Pathologists, the world’s largest organization of board-certified pathologists.

“Many people think we can diagnose everything before death,” says Collins, a professor of pathology and laboratory medicine at the Medical University of South Carolina. “But studies show that in close to half the cases, autopsies find something contributory or that the whole cause of death was different than physicians believed beforehand.” With investment in health care and biomedical research based in part on mortality statistics, the evidentiary basis for that investment may now be distorted or even false. “Without enough autopsies,” Collins contends, “we really can’t be accurate with our epidemiological facts.”

In the age of genetic studies and imaging technologies, autopsies still provide a unique means for studying certain diseases and identifying previously unknown public health issues. Jon S. Morrow, Ph.D., M.D. ’76, HS ’79, FW ’81, the Raymond Yesner Professor of Pathology, chair of pathology and professor of molecular, cellular and developmental biology, says: “Even to this day, autopsies are essential to the identification of a number of our latest scourges, like SARS, much of AIDS and other new diseases.” Moreover, he notes that even when no questions about cause of death may remain, an autopsy still provides a unique picture of a patient’s health and health care, which otherwise remains incomplete. “A patient is served by many different physicians,” he says. “The pathologist’s evaluation is where the data come together.” Those data can serve to improve teaching, research and medical care. He worries that the decline in the rate of autopsies may undermine the entire system. “We’re in danger of losing a critical piece of infrastructure.”

Nothing routine about death

Less than a day after Slater’s death, I don a head-to-toe jumpsuit and enter the autopsy room in the morgue in an extension to the Brady Memorial Laboratory. Half a dozen people cluster around Slater’s body, which lies on a long aluminum tray. Water flows continuously along a trough beneath the tray. A loud and powerful fan evacuates the air in the brightly lit room. With masks muffling our mouths and surgical caps pulled down over our ears, the echoing fan and splashing of the water make hearing difficult. Perhaps it is my own expectation, but all of us in the room seem intensely alert and attentive. There may be as many as five more autopsies performed this day, but the awesome presence of the dead and the seriousness of the investigation of death make nothing routine about any individual case.

An odor of bowels, cleansers and preservative chemicals—not quite sickening but enough to make a shower afterward a must—filters through the mask. Slater’s body extends straight except for his head, which is braced by a block beneath the neck and cocked upward. A white man, his skin is yellow, waxy and splotched with patches of purple, except for the lower third of his back, which is bruised a deep burgundy. As I soon see, his blood has pooled there. He is tall, almost as long as the table, and appears to have been in pretty good shape for his age, with little fat bunched around his waist.

He still has most of his auburn hair, which is swept back from his forehead. His brown-green eyes stare straight into the harsh overhead spotlights. His elbows, bent rigidly, hold his forearms and hands a few inches off the table, as if he died while reaching for something with both hands.

He looks alive enough that it appears he could bend his elbows and push himself off the table when Arthur J. Belanger III, M.H.S., manager of the autopsy service, approaches Slater’s body and announces the present time, shortly after 1 p.m. Belanger is a jovial man with black-rim glasses and dark hair and a Navy tattoo on his thick forearm. He likes his work, enjoys explaining what he is doing and talks about it freely. With practiced swiftness, he picks up a scalpel and inserts the blade into Slater’s chest just beneath the top of the left collarbone. No blood flows from the wound.

A young college student considering a future as a pathology assistant flees the room. The others—two pathology residents and an aide—watch intently. Belanger swiftly slices downward and toward the center of the chest, cutting into the rib cage. He cuts at the tip of the right collarbone and continues down until the wound intersects with the other slice. In one swift, practiced cut, he sweeps straight down the abdomen to the top of the pelvic bone. With a pair of heavy-duty snips, he snaps the last resisting bones in the rib cage and hinges open Slater’s chest, exposing a sunken tangle of bluish gray, green and red organs. Belanger reaches inside Slater’s body cavity. He calls out his actions as he feels with his knife to cut all the central organs free of the arteries, muscle, thorax, bone, nerves and connective tissue holding them in place.

Much to learn from the dead

Death was once the greatest biological mystery, other than life itself. No longer. Medicine and health care have progressed to the point that, when a person dies, the physiological reasons are usually apparent. In some cases, the actual time of death becomes a matter of when the switch on the life-support machinery gets turned off.

The decline in autopsy rates reflects many factors, including costs (not borne by families of patients) of up to $3,000 per autopsy and advances in diagnostic imaging and testing methods, endoscopic exploration and surgical interventions that make cause of death all but certain in most cases. Nonetheless, “As good as those ancillary studies are, we can’t diagnose everything pre-mortem,” insists Collins. “Even if you know the accurate cause of death, there’s still so much you can learn.” According to Sinard, who serves with Collins as vice chair of the College of American Pathologists’ autopsy committee, “It is one of the very few times you consider the whole patient and the whole disease process. It shows the physicians the extent of the disease process and the effectiveness of therapy for a patient. We may discover things that are entirely unexpected.” For the family and the doctor, it will usually answer any outstanding questions.

Given that so much is already known about a patient’s poor health and the causes of death, families often fail to grasp why an autopsy is needed at all. Many families resist what they perceive as a violation of the body after an often- arduous end of life. Perhaps as a result of all the forensic medicine series on television, many also think autopsies serve only to solve mysteries or to demonstrate a failure in their loved one’s health care. They worry that the request for an autopsy indicates a problem. Yet even when it reveals no surprises, says Sinard, an autopsy can be reassuring to the family. “We’re not policemen,” says Morrow. “We’re not looking for bad practices. We’re looking for accuracy and the quality of care. An autopsy almost always substantiates that the hospital and the physician did nothing wrong.”

How the news about a death is communicated can affect a family’s willingness to “help” medicine. “It’s the way it’s presented that matters,” Morrow says. “Physicians are often uncomfortable around death. They would often rather move on. The rates of autopsies, though, are higher when families are asked appropriately.” Few physicians ever bother to ask; most know little about autopsies or their value and have never attended one. And few medical schools require that their students attend autopsies. At Yale, medical students attend autopsies as part of the second-year pathology course, but as with all courses in the first two years, attendance is not mandatory. “It should be a routine part of a student’s education,” says Collins. “Everyone needs to know about it.”

Fisher, who directs Yale’s residency programs, notes that residents are less likely to observe an autopsy than in years past. “There used to be a 15 percent autopsy rate required for internal medicine residency program accreditation purposes,” she says. “That has just disappeared. Some programs now see only one or two autopsies a year. That’s a concern.”

Writing the last chapter

Even though all outward signs pointed to acute myocardial infarction—a sudden, devastating heart attack—as the cause of death, Charles Slater’s family agreed to an autopsy.

With two pathology residents looking on and occasionally assisting, Belanger cuts Slater’s organs—from the trachea to the testes—free of connective tissue and bone. Grasping the innards as a single mass in his arms, Belanger lifts the shiny, wet, shifting clump out of Slater’s body and sets it on a large white plastic surface that covers the other leg of the L-shaped autopsy table. The pathology residents then dissect the mass of organs, paring away the connective tissue, viscera and fat. Soon, the major organs are revealed. One by one those organs and major arteries are cut free.

Belanger and an assistant turn their attention to the head. After opening Slater’s skull cap with a vibrating saw, the gray brain is removed by cutting it loose from the brain-stem and other soft-tissue attachments.

Meanwhile, the residents separate the removed organs, slicing the larger ones and examining the cut surfaces carefully for any signs of pathology. These are then placed on display trays for presentation to the attending pathologist. Some of the tissues, such as calcified coronary arteries, must be further prepared before they can be completely dissected.

Sinard enters the room and, with the pathology residents, reviews tissue from the organs. A resident presents the deceased’s clinical story, which is then discussed in the context of the pathological findings. Sinard and the residents select tissue for further, microscopic examination. Finally, the attending and the residents will review the case and determine the most likely sequence of events that led to Slater’s death. Slater, the deceased, has provided a valuable teaching tool. The residents participating in his autopsy would never otherwise have the chance to view a body’s organs whole, fresh and in context. They have also benefited from viewing the consequences of biological and medical processes.

Their inspection shows that Slater’s lungs were congested with blood, a telltale sign of heart failure. The heart itself had a slight grayish discoloration in the left ventricle wall, evidence of a sudden, devastating thirst for blood. To the touch, the pinkish white coronary arteries were brittle. Although it would take later decalcification to allow them to be sliced open, that appeared to be the “smoking gun,” a single factor capable of causing death. Arteriosclerosis, by far the most common cause of sudden death in middle-aged men, was clearly present.

Belanger returns the remaining viscera to Slater’s body cavity and replaces the crown of his skull. His assistant sews both shut. The pathology residents remain in the room, examining the organs and helping to catalog them for preservation. They have witnessed the conclusion of a life, from within a profession that pays special respect to the patient who has died.

“I tell my residents to handle with care,” says Yesner. “What you are doing is writing the last chapter in somebody’s life.”

The death certificate is filled out, and Slater’s body is released in condition for an open-casket funeral. A veteran, he will be buried three days later with military honors in a cemetery outside New Haven.

Help for the living

Two weeks later, the laboratory report is ready. In fact, one of the arteries had been entirely blocked by a fatty plaque that had dislodged from the artery wall, starving the heart of blood and sending it into lethal spasms as it strained for oxygen. The report also shows benign tumors developing in Slater’s adrenal glands and intestine. The tumors had yet to cause symptoms, but had Slater lived, he would have encountered medical difficulties within a few years. They had not contributed to his death, but, says Sinard, “We are trying to catalog all of the disease processes in the patient.” Armed with the report, his family members, who could themselves face similar conditions, will be in a position to take action. Such findings remind Collins that “there’s so much you can learn about your own health by having an autopsy done on a deceased family member.”

At Yale, tissue samples from every autopsy are frozen, placed in fixative solution or embedded in paraffin blocks for permanent storage. If questions should arise, tissue will be there for study—potentially avoiding exhuming a body. Longer term, the tissue may be used for teaching or research purposes. Yale possesses millions of tissue samples dating back to 1917, many of which have proven valuable for research, even decades after first being cataloged and stored. Autopsy-based research at Yale has led to a greater understanding of the worldwide flu pandemic of 1918-1919, resulted in descriptions of new forms of liver cancer and various pneumonias and expanded insights into the way blood reaches tumors. Today’s research on Alzheimer’s disease and other central nervous system disorders, which in most cases cannot be directly studied during a patient’s lifetime, depends on autopsy material. “The speed of collecting and preserving the material is critical to the value of the specimen,” says Morrow.

The national rate of autopsies has been in decline for decades. Since 1970 the Joint Commission on Accreditation of Healthcare Organizations has no longer required an autopsy rate of 20 percent to maintain accreditation. Morrow, Sinard, Collins and other autopsy pathologists have been trying to educate the medical community and the wider public about the need to reverse the trend. While there is no rate of autopsies considered minimally necessary by any national organization, “100 percent would be ideal,” says Collins. “I wish we could have at least 20 percent nationally. Every family ought to be approached for the opportunity an autopsy offers them.”

One day, a genetic factor may be found to underlie sudden cardiac death. Tissue collected in autopsies from patients such as Slater will almost certainly prove crucial in the development of new diagnostic methods and preventive therapies. The post-mortem picture of Slater’s health may also prove directly beneficial to his own children and other relatives. “All of us will die,” says Sinard. “That doesn’t end what we can do for the living.” YM