15283-B-Blokker

25 Autopsy rates in the Netherlands: 35 years of decline 2 contention, the clinician must have documented all diagnoses and therapy options carefully, and may feel that the need for autopsy is less urgent. Hence, the decline in autopsy rates is multifactorial and cannot be explained only by fewer consents from next-of-kin. This conclusion is supported by Gaensbacher et al., who observed declining autopsy rates in Austria, where no consents are needed for clinical autopsies. 32 Autopsy practices differ per country, for example policies on financing autopsy, the rate of forensic autopsies, sites where autopsies are performed, and the necessity of obtaining consent from next-of-kin. Financing of the clinical autopsy is complicated. 72 Data on the exact costs per autopsy are not available; cost estimates per autopsy vary according to the number of autopsies being performed 73 and the extensiveness of the procedure. 74 At the same time gained benefits per autopsy are difficult to quantify, and, as a consequence, cost-benefits of autopsy cannot easily be determined. Due to competing business activities and scarce healthcare resources, autopsy financing appears not to be a priority of today’s hospitals. 75 It is often not clear from which departmental or institutional budget the autopsy costs are, or should be, derived. The lack of a firm financial basis for autopsy services has very likely contributed to declining autopsy rates. 23 In Dutch hospitals, however, the costs for autopsy are paid off the general hospital budget. There are neither financial nor capacity constraints for clinicians or next-of-kin to have an autopsy performed, therefore, financial and capacity issues cannot explain the decline of the autopsy rate in the Netherlands. There are also different policies for financing the medicolegal/ forensic autopsy. For example, in Denmark forensic autopsies are paid from the police budget and thus compete with other cost, 74 whereas in Finland the forensic autopsies are all payed for by the government. Even in recent years, the overall Finnish autopsy rates have been around 30%, which is explained by increasing medicolegal autopsy rates at the time when clinical autopsy rates started to decrease. In the Netherlands, non-forensic autopsy cases with supposed natural death are carried out in general hospitals, whereas in the investigated period forensic cases were performed at NFI. In some countries, however, forensic autopsy may also be performed on cases that are not of interest to the police, such as deceased whose cause of death is classified as natural, but remains unclear. 74 In many countries consent from next-of-kin is compulsory for a non-forensic autopsy, however in some countries, autopsy may be performed without consent (if there is a clear medical or scientific interest 32 ). In some other countries, next-of-kin may object to autopsy even though consent for autopsy is not required; so-called opt out-system. In few countries autopsy has even been mandatory. 76