Post-Mortem Examination of an Adult
Further Information Leaflet
1 -Post-mortem examination
2 -Tissue samples, blocks and slides
3 -Uses of the medical record
4 -Genetic testing
5 -Organ retention
6 -Conditions and requests
8 -Disagreement about post-mortem examination
9 -Further information
This booklet is intended to be read along with the basic information leaflet (1) and contains more information about the post-mortem examination itself, retention of organs and tissue blocks and slides and the uses of the medical record (see index).
1 What happens in a post-mortem examination?
A post-mortem examination is not just an internal examination, but includes the clinical history, photography, X-rays and external examination as well as many possible tests including virology (the study of viruses), bacteriology (the study of bacteria) and genetic investigations (which can vary from chromosome examination to identification of a specific gene). Some of these tests are only very rarely done during a post-mortem examination on an adult.
The body will have a careful external examination. There will then be two openings made to examine the internal organs, one in the chest and abdomen and one on the back of the head. This allows the pathologist to remove the organs from the body and examine each organ in detail. Small tissue samples will be taken from each organ to be examined under the microscope. Swabs, fluids or very small tissue samples may be taken for other tests such as virology, microbiology, biochemistry and genetics if indicated. (See What are tissue samples, blocks and slides.)
In some rare cases it may also be felt that small samples should be stored frozen, for later studies using biochemical or genetic tests.
Usually genetic tests would be undertaken to make a specific diagnosis in the deceased, but occasionally they may have implications for the whole family. If this is the case, you will be consulted and the implications discussed with you. (See Genetic testing.)
The organs are all returned to the body unless the deceased (or you) has given authorisation for their retention, and after the examination, the body is carefully restored, usually by a mortuary technician in such a way that when fully clothed you cannot see the incisions. You should be able to see the body after the examination if you wish.
2 What are tissue samples, blocks and slides?
Tissue samples are a very small part of an organ. These tissue samples are placed in formalin (called fixation) and are often placed directly into plastic cassettes. The tissue is then chemically treated to remove water, which is replaced by wax. This produces a tissue block, which is a hard block attached to the cassette and from which a very thin section can be cut by a biomedical scientist. This thin section (10 times thinner than a human hair) is mounted on a glass slide before being stained. A very large number of sections can be cut from one tissue block, and a number of different stains can be used to show different features. Tissue blocks and glass slides are stored in special cabinets and are kept securely in laboratories that keep very good records and control access to the laboratory. These techniques are the same as those used to examine tissue from living patients.
After tissue blocks have been prepared, there are sometimes slivers or small samples of tissue remaining. These will be disposed of by the hospital.
3 Uses of the medical record
What can be done with the medical record?
If authorisation for a post-mortem examination has been given, then the tissue blocks and slides become part of the medical record of the deceased. The medical record also consists of the case notes, photographs and X-rays.
It is an important part of ensuring the quality of medicine that work is routinely audited, as recommended by the General Medical Council in their booklet Good Medical Practice. This means that checks are made to ensure that the work of medical staff is as accurate as possible by comparing it against recognised standards.
In addition to audit, the photographs, and X-rays taken may have useful lessons or may relate to rare conditions that other doctors could learn about. Examining tissue is one of the most important ways in which doctors learn about illness and how to treat it. Students training to be doctors need to watch and learn about post-mortem examinations, and discuss the findings with an experienced doctor. In the same way, glass slides can be used to teach other doctors or as part of a test in a scheme such as the national Scottish pathology external quality assurance scheme which regularly tests pathologists' knowledge.
Sharing information between doctors and hospitals is also very important for public health surveillance - making sure that infectious diseases do not spread throughout the local or national population.
If the deceased's medical records were to be used in this manner, they would be used anonymously and any identifying features removed.
What about research?
Research is a valuable part of medicine and is how new understanding of disease processes can help in the search for new treatments. Research can vary from a simple study reviewing diagnoses already made to see if there is a new pattern to more complex tests involving gene probes that have only recently been discovered. All research is governed by research ethics committees which might be in the local area (research ethics committees - RECs) or that cover a number of areas (multicentre research ethics committee - MRECs). Both RECs and MRECs have members of the public on the committee.
You can ask if you might see the results of any research that the person's organs or tissue were involved in, but it may not be possible to identify an individual's contribution to a research study. The research institution will have records of its publications, and may have a website giving details of the sort of research it carries out. You should be able to obtain details of the sort of research carried out by the lead researcher and the institution.
4 Genetic testing
Genetic tests vary from the examination of chromosomes (often from a blood or skin sample) to those involving specific probes looking for a particular gene linked to a known disease. Simple tests for diagnosis will be done if necessary as part of the post-mortem examination, but a test that might have major implications for the whole family will only be done after discussion with you. Genetic testing is rarely carried out in post-mortem examination of adults.
5 Organ retention
The body contains many organs, such as the brain, heart, lungs and liver. Each organ carries out many different functions and is composed of different tissues. The brain is extremely soft and in order to examine it thoroughly it has to be hardened in fixative often for several weeks. Neuropathologists are doctors who specialise in the study of disorders of the brain and spinal cord. They may not be in the same hospital as the post-mortem is carried out and it may take some time to get the results of a neuropathological examination.
What happens after the retention and examination of an organ?
If the person left instructions authorising the retention of organs for further examination or gifted them for research, the wishes of the deceased will be followed, as will any instructions concerning disposal.
If you authorise the retention of an organ for further examination, you need to consider how it might be dealt with after the examination is complete. If the examination or a preliminary examination can be completed before the funeral, the organ can be returned to the body, and you might wish to consider delaying the funeral to allow this to happen. You should discuss with the hospital how long the funeral would need to be delayed.
If you do not feel you need to have the organs returned to the body before the funeral, you can ask the funeral director who is making the funeral arrangements to arrange for the later disposal of organs. Alternatively, the hospital can arrange this for you and you may wish to ask for more details about what the hospital's arrangements for disposal are.
You may feel that you would like more use to be made of any organ that you authorise to be retained for diagnosis. There are many research studies in different areas of medicine that could benefit from a donation, and a gift such as this would be appreciated and could help in research or education of future doctors. Please discuss this with the person who is explaining the post-mortem, and they should know who to ask about what can be done.
If you authorise the retention of an organ for education, audit or research it will usually not be returned and will be disposed of by the hospital or researcher once the purpose for which it has been retained has been completed.
6 Conditions and requests
What sort of conditions and requests can I make?
You may have specific religious requirements about the timing of the funeral or washing of the body. If you do, please tell the hospital staff and ask them to note these in section 3 of the form.
If there is specific research that you would like the person's organs and tissue to be donated to, or if there are specific types of research that you would object to, then the authorisation form is the place to record those wishes.
You may want the organs to be held for only a limited period of time. Again, if so, please say so on the authorisation form.
How do I know that only what has been authorised will be carried out?
NHS Quality Improvement Scotland has written standards for post-mortem examinations that must be followed by NHS personnel in Scotland. These are available on their website ( www.clinicalstandards.org/nhsqis/) and you can ask for a copy to read. One of the standards is that there is a check on what has been authorised and what is then carried out by the pathology department. The Royal College of Pathologists has also published guidelines about post-mortem practices, and has published patient leaflets and guidance about the retention of tissues and organs at post-mortem examinations.
8 What if the relatives disagree about a post-mortem examination?
It is always best where all those close to the deceased agree on whether or not a post-mortem examination can be done. Where the deceased left instructions authorising or objecting to post-mortem examination, use of his or her medical record and use of organs, doctors will usually act on these instructions. If the deceased nominated a person to make decisions for them and the hospital is made aware of this, then doctors will act in accordance with the views of the nominated representative.
If the deceased did not leave instructions or nominate a representative, then the person's nearest relative would be the person asked to consider authorising a post-mortem examination.
The person's nearest relative would be determined in descending order of priority according to this list:
husband, wife or partner (see below)
son or daughter
father or mother
brother or sister
grandfather or grandmother
grandson or granddaughter
uncle or aunt
nephew or niece.
Where there is more than one possible nearest relative, for example where there is no surviving husband or wife but there are a son and a daughter, the eldest child would be treated as the nearest relative. Illegitimate children have the same rights as legitimate ones.
Unmarried partners should have the same rights to give authorisation as husbands or wives, regardless of whether they are of the same sex as the deceased. However, in line with current law, unmarried partners must have been living with the person as if they were husband or wife for a reasonable time, not less than 6 months. Where the deceased was divorced or permanently separated from a husband or wife, the husband or wife loses the right to give or withhold authorisation of a post-mortem examination.
Where only one of the close relatives is available at the hospital, he or she will be asked if they think the other close relatives would object. The post-mortem examination can go ahead if the nominated representative or the nearest relative authorises it. However, if the other close relatives object or would be likely to object, then usually the post-mortem examination would not be done. There may be unusual circumstances in which relatives disagree strongly over whether a post-mortem examination should be done. Where disagreement cannot be resolved through discussion, the post-mortem examination would not usually go ahead.
9 Further information
What else can I read about post-mortem examination?
Standards for the management of post-mortem examinations: NHS Quality Improvement Scotland April 2003
Royal College of Pathologists: Guidelines on Autopsy Practice, September 2002
Medical Research Council (MRC). Human Tissue and Biological Samples for Use in Research: Operational and Ethical Guidelines MRC 2001.
The hospital will have a list of local and national organisations who can offer support and further information.