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Wed Mar 28 14:14:18 BST 2007

Pret,

I certainly don't want to bust trauma centers but blaming the system isn't
what I would aim for either. As a regulator, I took the position that the
trauma director (as the proxy for the providers) wanted to do what was right
for the patients. The systems requirement could often be used as a stick to
help them with administrative or other barriers.

The system should require/encourage autopsies because it is desirable from a
public health perspective to know accurate causes of death. This can inform
preventive measures. The family, at the time of the death of a loved one, is
probably not in the best frame of mind to "vote" on many individual aspects
of care. And certainly they are probably not taking a public health
perspective on a very individual time of crisis. A regulation would just
take the need for choice out of the process. Of course a family could
functionally veto this action as with many possible interventions.

As a regulator, if you are not achieving the results you desire, I don't
think the first move should be to punish the trauma centers. Try to
determine what the barriers to success are and work with the centers to
craft solutions.

Rob

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Bjorn, Pret
Sent: Wednesday, March 28, 2007 8:10 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Autopsy Requests: Scripting & Best Practices

A logical approach; but ours is a voluntary system, more carrot than
stick.  I think that there would be a reluctance for hospitals to ratify
any global policy; and enforcement, should it become necessary, would be
difficult.  We have three regional trauma centers doing good work (one
ACS Level I and two Level II's).  Busting any of the three over
something like this might do more harm than good.

All that on the table, I nonetheless see what you're after (I think): if
we can "blame the system" for families' lack of a vote, then we'd have
more consistent and thorough PI on a handful of cases.  But even if that
were acceptable, a little scripting might avoid the predictable
withdrawal into a "it's the state's fault, not ours" culture.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert F. Smith
Sent: Monday, March 26, 2007 11:10 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Autopsy Requests: Scripting & Best Practices

Is your hospital part of any trauma system? Could they "require" it?

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Bjorn, Pret
Sent: Monday, March 26, 2007 8:01 AM
To: Trauma &amp; Critical Care mailing list
Subject: Autopsy Requests: Scripting & Best Practices

Maine is a state like many in the U.S. WITHOUT mandatory autopsy for
trauma deaths -- there simply isn't the money for it.  As such, deaths
are referred to local Medical Examiners (mostly general medicine folk),
who have a look at the record and the corpse and determine whether a
necropsy would help -- for lack of another motivation -- to determine
foul play.  In short, if you can make it look like accidental
blunt-force injury, you can probably get away with murder around here.

My hospital provides autopsy (gross post mortem only) for trauma deaths
where the cause is unknown, or when performance issues are in play.
Problem is, these are voluntary and subject to consent of the family.
Getting consent is a neat trick, though.  I wonder if anyone out there
is in the same boat, and suffers varying responses from loved ones to
the option of autopsy.  

Specifically, I'd be very grateful for any advice on how to present the
issue to families in the most productive manner possible.  Is there any
winning script, or are there key phrases that maybe we haven't thought
of?  

I think our surgeons are very sensitive and encouraging, and quick to
point out that the service is underwritten by the hospital (should be
obvious to families, but isn't); but there's a predictable visceral
reaction to the request that we haven't been able to overcome.

Thanks for your thoughts and advice.

Pret Bjorn, RN
Bangor, ME USA

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Autopsy Requests: Scripting & Best Practices