Discrepancies between clinical and postmortem diagnoses in critically ill patients: an observational study

Introduction The autopsy has long been regarded as an important tool for confirming the clinical cause of death, education and quality assurance. Concerns surrounding informed consent and the retention of organs have heightened clinicians' anxieties in requesting permission to perform an autopsy. The present study was conducted to determine whether the autopsy still has a role to play in extending knowledge about the cause of death in a group of patients who died while receiving intensive care. Method We retrospectively investigated trends in postmortem examination rates and discrepancies between premortem clinical and postmortem diagnoses in a population of critically ill patients admitted to a 13 bed, general medical/ surgical intensive care unit between January 1998 and June 2001. Agreement between diagnoses before death and postmortem findings were compared using the Goldman system. Results Out of total 636 deaths, 49 (7.7%) underwent postmortem examinations. Of these, 38 (78%) cases were available for review. We found that postmortem findings were in complete agreement with predeath diagnoses in fewer than half of the cases (n= 17, 45%). Major missed diagnoses were present in 15 cases ( 39%). Myocardial infarction, carcinoma and pulmonary embolism represented the most frequently missed diagnoses. Conclusion Postmortem examinations remain a useful tool in confirming diagnostic accuracy and should be considered in all patients who die in the intensive care unit. Recognition of the diagnoses missed before death may improve outcome or avoid unnecessary prolongation of life where terminal disease is present.