Tag Archives: healthcare

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Defining Death

The first dead person I saw was my grandfather.  At first, I didn’t know he was dead. Lying on the hospital bed that filled the living room of his single wide, he looked the same. Cancer had turned him into an insubstantial man, gaunt and translucent. His eyes had sunk into his face and closed themselves off from the world. His mouth was open, like a baby bird begging for food, and his breathing ragged. Suddenly my sister gestured me to her side and said I think grandpa’s dead.  
I waited to hear him breathe, for his chest to rise, but nothing happened. I finally did the only thing I could think of, I went to the bathroom and found a small mirror. I carried it to his bedside, half hidden behind me, then held the mirror up to his mouth. No moisture appeared to indicate he was breathing.
We called the doctor. He came over to the house, briefly placed his stethoscope on my grandfather’s chest, and made the news official. He was dead. I remember the puzzled look on the doctor’s face when I asked, are you sure? You hardly listened. But he was sure. And I wondered what knowledge he had that I didn’t. How did my grandfather, who looked the same as he did when I first entered his house, go from live to dead with no fanfare and no striking change that signaled, dead guy here. Humans have no equivalent of a chicken’s pop up timer to show when their time is up.
The second dead person I saw was as a new nurse. At report I was told he didn’t have long to live. The wife was in the room with him and my job was to check in every once in a while, make sure they were comfortable, and give them privacy. Around two a.m. I went in and saw the man’s chest wasn’t rising. Walking quietly across the polished floor, I placed a stethoscope over his heart. I listened, and listened, and listened, but I couldn’t hear the reassuring thump of a heartbeat. Creeping silently back out of the room, I prayed the wife wouldn’t wake up and question me. I thought her spouse was dead, but I wasn’t 100% sure. Certainly not enough to break the news to anyone, let alone the wife. I found my preceptor and the two of us snuck back into the room. She placed her stethoscope on his chest and shook her head at me. He was dead. Back out into the hall we went and she coached me on how to wake the wife and break the news.
I remember shaking the wife softly, then harder, almost panicking wondering if she was dead, too, until she opened her eyes and peered at me in the dimly lit room. He’s dead, I told her.
I was ready for tears, for sounds of anguish, for cries to God. Instead she sat up, pulled her husband’s arm away from his body, and stuck her hand into his armpit. He’s still warm, she said, he hasn’t been dead very long. I didn’t know what to do with her reaction. Did it make a difference? Was it better to know right away rather than spending the night lying against a cold, dead corpse? Perhaps instead of a pop up timer, it would be preferable to have an actual timer that announced and marked the exact moment of death.
My third death was a lovely woman with heart failure and a host of other medical problems I have long forgotten. On the second day of her hospitalization, she decided she didn’t want any more heroic measures. She was ready to die.
Too bad death wasn’t ready for her. 
On the fourth day, struggling to breathe through the fluid that backed up into her lungs and slowly suffocated her, she looked in my eyes and said I never knew it would be so hard to die.
I wish I could say that at her death the pain and fear in her eyes was replaced with an expression of bliss, but the tortured look on her face never went away. The only change was the silence when the moist sound of her panicked breathing finally ended and her heart stopped.
All three deaths had something in common. Death was defined as the absence of a heartbeat. I don’t know if they continued to have thoughts or sensations. I don’t know if their soul leapt out of their bodies and went to wherever souls go when someone dies. All I knew was they no longer had a heartbeat. Therefore, they were dead.
Since then I’ve pondered the subject of declaring someone dead. For me, the bottom line is that I’m still the girl at my grandfather’s bedside asking the doctor, are you sure? As medical science develops different definitions of death in an effort to use the latest technology and interventions, I ask that question and find myself dissatisfied with the answer.
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It isn’t brain surgery

Daily life requires some attention to detail. When I drive my car, I’m expected to stay on the right side of the road. Doesn’t make a difference if I spent a month in Ireland driving on the wrong side or if the road isn’t clearly marked as to what side is the correct one. Once I get behind the wheel of a car I’m expected to follow this minimum expectation.  If not, well, best case scenario I’ll get a ticket, worst case a head on crash. Details do matter.
That’s why it’s puzzling that healthcare professionals have such a difficult time making sure they operate on the right side of someone. Cutting off the wrong leg, “fixing” the wrong hand, or operating on the wrong side of the brain is considered a “never” event by the Centers for Medicare and Medicaid Services (CMS) as in “this should never happen.”  Amazingly, a study published in the April 2006 issue of the journal Archives of Surgery estimates that wrong-side surgeries occur between 1,300 and 2,700 times a year in the United States (3-7 a day).
Horrified? You should be. The problem is not a new one.
A quick Google search shows in 1995 a Florida hospital had two cases of wrong side surgery. In one case the surgeon amputated the wrong leg, another surgeon operated on the wrong knee. In 1996 a surgeon removed the wrong kidney from a patient. In 2007 a California hospital performed three wrong side surgeries in the space of 14 months. In December 2010, a Boston hospital reported three wrong-site spinal surgeries in a two-month period.
Scary stuff.
You’d think a hospital would learn after the first never event and develop methods to ensure there isn’t a repeat. Wrong. In 2007 a Rhode Island Hospital reported three cases of wrong side brain surgery. If you expect the surgeons involved developed practices to prevent a repeat, you’d be wrong too. Rhode Island neurosurgeon J. Frederick Harrington had already performed a wrong-sided brain surgery in 2006 at another hospital. He repeated his mistake in 2007, even when someone in the operating room questioned whether he was on the right side.

Now, I’m not discounting the universally held, incorrect belief that “it won’t happen to me.” I am sure most surgeons and operating room personnel believe their superior skill, knowledge, and intelligence prevents them from making stupid mistakes. But after the first mistake, do they think lightning can’t strike twice?  No use changing the way things are done because it will never happen again? The statistics don’t support that notion.
Because this is an international problem, the World Health Organization (WHO) developed a surgical checklist, also known as a time out. A time for everyone in the operating room, including the patient, to agree on several key things, including the operative side. If properly followed, the checklist would catch errors before they happened and stop wrong site/side surgery for once and all. Unfortunately putting a policy in place, affixing some posters to the locker room, and filling out a checklist gives the illusion of patient safety, but the reality is, even in hospitals with the checklist and time out, wrong side surgery occurs.
Why? Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. Unfortunately, instead of expecting accountability from physicians, hospital strategies to prevent wrong side surgeries include assigning operating room monitors, installing video cameras, and telling the operating room nurse not to hand a knife to the surgeon until the time out is completed.  
Wouldn’t it be better if physicians complied because it is a minimum expectation that they operate on the right side of a patient? We can do it on the highway, it’s worth the extra effort in the operating room.