Death and Dying Health Article

Definition

Death is the end of life, a permanent cessation of all vital functions. Dying refers to the body's preparation for death, which may be very short in the case of accidental death, or can last weeks or months in some patients such as those with cancer.

Risks of surgery

Specific risks vary from surgery to surgery and should be discussed with a physician. All surgeries and every administration of anesthesia have some risks; they are dependent upon many factors including the type of surgery and the medical condition of the patient. The patient should ask the anesthesiologist about any risks that may be associated with the anesthesia. Specific standards are set by the American Society of Anesthesiologists to enhance the safety and quality of anesthesia before surgery, basic methods of monitoring patients during surgery, and the best patient care during recovery.

Overwhelming data compiled in 2001 has confirmed that albumin is an effective marker of general nutrition; low albumin levels can increase the likelihood of post-surgery complications such as pneumonia, infection, and the inability to wean from a ventilator, by as much as 50%. In a national study of 54,000 surgery patients (average age of 61 years old), it was found that only one in five surgical patients were tested for low albumin before their operations.

In a study of 2,989 hospitalized patients admitted for more than one day, risk factors such as cholesterol levels (primarily low levels of high-density lipoprotein, HDL) and low serum albumin were associated with inhospital death, infection, and length of stay. During the study follow-up, 62 (2%) of the patients died, 382 (13%) developed a nosocomial infection, and 257 (9%) developed a surgical site infection.

The National Veterans Affairs Surgical Risk Study was conducted in 44 Veterans Affairs Medical Centers and included 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia. Patient risk factors predictive of postoperative death included serum albumin level, American Society of Anesthesia class, emergency operation, and 31 additional preoperative variables.

Other factors related to death during surgery are: increasing age, emergency surgery, and general postoperative complications including cardiac, renal, and pulmonary complications. Age-related changes in the immune system play a significant role in the increased risk of infection, decreased ability to fight diseases, and slower wound healing after surgery. An aging body is more susceptible to subsequent infections because of previous illness or surgery and the subsequent weakening of the immune system. The anti-inflammatory medications (e.g., to control conditions such as arthritis) that many older people take are also known to slow wound healing.

One study found that risk of death during coronary artery bypass graft surgery is associated with hospital volume, i.e., the number of surgeries performed. High volume hospitals had a lower mortality rate during surgery. Mortality decreased with increasing volume of surgeries performed (3.6% in low [less than 500 cases], 3% in moderate [500-1,000 cases], and 2% in high [over 1,000 cases] volume hospitals). Thus, the volume of surgeries performed may be an important consideration when selecting a hospital.

Complications of surgery

The most common complications to surgery that can prove fatal are infection, bleeding, and complications of anesthesia.

The Joint Commission's Board of Commissioners reviewed 64 cases related to operative and post-operative complications since the late 1990s. Of the events reviewed, 84% of the complications resulted in patient deaths, while 16% resulted in a serious injury. All of the cases occurred in acute care hospitals; cases directly related to medication errors or to the administration of anesthesia were excluded. Of these complications, 58% occurred during the postoperative procedure period, 23% during intraoperative procedures, 13% during post-anesthesia recovery, and 6% during anesthesia induction.

The following types of procedures were most frequently associated with these reported complications:

• endoscopy and/or interventional imaging
• catheter or tube insertion
• open abdominal surgery
• head and neck surgery
• thoracic surgery
• orthopedic surgery

Of the 64 cases reviewed, 90% occurred in relation to non-emergent (elective or scheduled) procedures. The most frequent complications by type of procedure included the following:

• Naso-gastric/feeding tube insertion into the trachea or a bronchus.
• Massive fluid overload from absorption of irrigation fluids during genito-urinary/gynecological procedures.
• Endoscopic procedures (including non-gastrointestinal procedures) with perforation of adjacent organs. Of all abdominal and thoracic endoscopic surgery, liver lacerations were among the most common complications.
• Central venous catheter insertion into an artery.
• Burns from electrocautery used with a flammable prep solution.
• Open orthopedic procedures associated with acute respiratory failure, including cardiac arrest in the operating room.
• Imaging-directed percutaneous biopsy or tube placement resulting in liver laceration, peritonitis, or respiratory arrest while temporarily off prescribed oxygen.

Complications associated with misplacement of tubes or catheters usually involved a failure to confirm the position of the tube or catheter, a failure to communicate the results of the confirmation procedure, or misinterpretation of the radiographic image by a non-radiologist.