Death and Dying
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.
Preparing for death or incapacitation legally
An advance directive is a way to allow caregivers to know a patient's wishes, should the patient become unable to make a medical decision. The hospital must be told about a patient's advance directive at the time of admission. Description of the type of care for different levels of illness should be in an advance directive. For instance, a patient may wish to have or not to have a certain type of care in the case of terminal or critical illness or unconsciousness. An advance directive will protect the patient's wishes in these matters.
A living will is one type of advance directive and may take effect when a patient has been deemed terminally ill. Terminal illness in general assumes a life span of six months or less. A living will allows a patient to outline treatment options without interference from an outside party.
A durable power of attorney for health care (DPA) is similar to a living will; however, it takes effect any time unconsciousness or inability to make informed medical decisions is present. A family member or friend is stipulated in the DPA to make medical decisions on behalf of the patient.
While both living wills and DPAs are legal in most states, there are some states that do not officially recognize these documents. However, they may still be used to guide families and doctors in treatment wishes.
Do-not-resuscitate (DNR) orders can be incorporated into an advance directive or by informing hospital staff. Unless instructions for a DNR are in effect, hospital staff will make every effort to help patients whose hearts have stopped or who have stopped breathing. DNR orders are recognized in all states and will be incorporated into a patient's medical chart if requested. Patients who benefit from a DNR order are those who have terminal or other debilitating illnesses. It is recommended that a patient who has not already been considered unable to make sound medical decisions discuss this option with his or her physician.
None of the above documents are complicated. They may be simple statements of desires for medical care options. If they are not completed by an attorney, they should be notarized and a copy should be given to the doctor, as well as to a trusted family member.
Mourning and grieving among cultures
The death of a loved one is a severe trauma, and the grief that follows is a natural and important part of life. No two people grieve exactly the same way, and cultural differences play a significant part in the grieving process. For many, however, the most immediate response is shock, numbness, and disbelief. Physical reactions may include shortness of breath, heart palpitations, sweating, and dizziness. At other times, there may be reactions
Emotional reactions are as individual as physical reactions. A preoccupation with the image of the deceased, feelings of fear, hostility, apathy, emptiness, and even fear of one's own death, may occur. Depression, diminished sex drive, sadness, and anger at the deceased may occur. Bereavement may cause short- or long-term changes in the family unit and other relationships of the bereaved.
It is important for the bereaved to work through their feelings and not avoid their emotions. If emotions and feelings are not discussed with family members, friends, or primary support groups, then a therapist should be consulted to assist with the process.
Various cultures and religions view death in different manners and conduct mourning rituals according to their own traditions. In most cultures, visitors often come to express their condolences to the family and to bid farewell to the deceased. At times, funeral services are private. Various ethnic groups host a gathering after the funeral for those who attended. It is common for these events to become a celebration of the life of the deceased, which also helps the bereaved to begin the mourning process positively. Memories are often exchanged and toasts made in memory of the deceased. Knowing how much a loved one is cherished and remembered by friends and family is a comfort to those who experience the loss. Other methods of condolences include sending flowers to the home or the funeral parlor; sending a mass card, sending a donation to a charity that the family has chosen; or bringing a meal to the family during the weeks after the death.
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American College of Physicians—American Society of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106-1572. Washington Office: 2011 Pennsylvania Avenue NW, Suite 800, Washington, DC 20006-1837. (202) 261-4500 or (800) 338-2746. <http://www.acponline.org>.
Hospice Foundation of America, 2001 S Street, NW, Suite 300, Washington, DC 20009. (800) 854-3402 or (202) 638-5419. Fax: (202) 638-5312. E-mail: firstname.lastname@example.org. <www.hospicefoundation.org>.
Inter-Institutional Collaborating Network On End-of-life Care (IICN). (415) 863-3045. <http://www.growthhouse.org>.
National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-4000. E-mail: NIHInfo@od. nih.gov. <http://www.nih.gov/>.
Promoting Excellence in End of Life Care, RWJ Foundation National Program Office, c/o The Practical Ethics Center, The University of Montana, 1000 East Beckwith Avenue, Missoula, MT 59812. (406) 243-6601. Fax: (406) 243-6633. E-mail: email@example.com. <http://www.promotingexcellence.org>.
Washington Home Center for Palliative Care Studies (CPCS), 4200 Wisconsin Avenue, NW, 4th Floor, Washington, DC 20016. (202) 895-2625. Fax: (202) 966-5410. E-mail: firstname.lastname@example.org. <http://www.medicaring.org>.
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Jacqueline N. Martin, M.S. Crystal H. Kaczkowski, M.Sc.