Hospital Hazards: Unseen Dangers, Unfortunate Deaths

Hospitals are a common place for people to die, with around 43% of deaths occurring in hospitals in England and Wales in 2023. While the percentage of people dying in hospitals has dropped over time, many still die in hospitals due to a variety of reasons, including the unpredictable nature of death, the overestimation of medical care, and a lack of alternatives. When people die in hospitals, there are certain procedures that are followed, including pronouncing the death, moving the body to the morgue, and, if necessary, conducting an autopsy to determine the cause of death. Inpatient deaths may also be influenced by the culture of care in large hospitals, where the focus is on healing and survival rather than palliative care. Additionally, aggressive and invasive treatments may continue even when doctors are aware of the patient's imminent death. Understanding how hospital services are utilized at the end of life can help improve patient care and ensure that their wishes are respected.

Inadequate care for dying inpatients

Hospitals are designed to heal patients and make them survive. However, sometimes patients' needs do not align with the culture of care in large hospitals, leading to inadequate care for dying inpatients. This issue is particularly prominent in large hospitals, where more aggressive inpatient medical care is often offered due to the higher number of specialists available.

One reason for inadequate care is the difficulty of shifting from a curative to a palliative approach. Even when doctors are aware that a patient's death is imminent, aggressive and invasive treatments may continue. This can be attributed to an overly optimistic view of the prognosis or a lack of systematic information on how patients die in hospitals. Additionally, in some countries, such as Italy, inpatients are not asked about their treatment preferences in the event of life-threatening events.

Furthermore, there is often a lack of awareness about palliative care among policymakers, health professionals, and the public. Palliative care aims to provide a support system to help patients live as actively as possible until death, with special attention to their specific needs and preferences. However, funding for palliative care is inadequate in many countries, and access to essential medicines, such as opioid pain relief, may not meet international conventions. As a result, dying inpatients often suffer from inadequate pain management, with persistent symptoms and a scarce use of analgesics.

The culture of medicine and the availability of medical care also play a role in inadequate care for dying inpatients. Many inpatient deaths occur after long admissions that begin with treatable problems, leading to an overestimation of the ability of medical care to cure incurable illnesses. Additionally, the healthcare system's focus on short-term outcomes may influence doctors' encouragement of inpatient treatment, even when it has little chance of changing the long-term outcome.

Lastly, the emotional aspect of end-of-life care cannot be overlooked. Family and friends may withdraw due to their grief, and doctors may avoid dying patients because they feel helpless. This can lead to dying inpatients feeling isolated and unsupported during their final days.

Invasive treatments

One key issue with invasive treatments is the potential for medical error or "misadventure." Critically ill patients are highly vulnerable to the adverse effects of such interventions, which can sometimes hasten or contribute to their demise. Additionally, the culture of medicine and the availability of medical care can lead to overestimation of the ability to cure incurable illnesses or reverse setbacks, resulting in futile treatments that may cause more harm than good.

A study by the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) investigators highlighted the challenges of transitioning from a curative to a palliative approach. They found that even when doctors were informed of a patient's imminent death, aggressive treatments often continued. This may be due to a combination of factors, including a bias toward curative care in the medical profession, a lack of systematic information on patient preferences for end-of-life care, and the emotional difficulty of accepting mortality for both patients and their loved ones.

For example, in cases of Code Blue resuscitation attempts in older patients with chronic illnesses, the survival rate beyond the hospital is extremely low, and those who do survive may experience a significant decline in their physical and mental health. Despite this, patients and their families often request that everything be done, without a clear understanding of what that entails and the potential for a traumatic and futile end-of-life experience.

To address these issues, there is a growing movement to initiate conversations about end-of-life preferences and advance care planning. By exploring patients' wishes and values regarding invasive treatments, palliative care, and quality of life, healthcare providers can ensure that interventions align with patients' goals and priorities, ultimately reducing the potential for invasive treatments to contribute to hospital deaths.

Medical error

Despite this, it is clear that medical errors do occur and can have devastating consequences. Some common types of medical errors include surgical errors, diagnostic errors, medication errors, equipment failures, patient falls, hospital-acquired infections, and communication failures. For example, a patient may be sent for prolonged imaging studies instead of immediate surgery, resulting in traumatic arrest and death. Medication errors can also have serious implications, with one study finding that almost 2% of admissions experienced a preventable adverse drug event, leading to increased hospital costs and negative outcomes for patients.

In addition to the direct impact on patients, medical errors can also affect healthcare professionals, who may experience anger, guilt, inadequacy, depression, and even suicidal ideation. Furthermore, the healthcare system bears the financial burden of medical errors, with some experts estimating costs of $20 billion to $45 billion annually due to adverse events.

While the exact number of deaths caused by medical errors may be difficult to determine, it is clear that patient safety should be a priority. By identifying the deficiencies and failures that lead to adverse events, corrective measures can be implemented to reduce medical errors and improve patient outcomes.

To conclude, medical errors are a significant issue within hospitals, and efforts to minimise their occurrence are essential to ensure patient safety and improve the quality of healthcare.

Autopsy and coroner

An autopsy, also known as a post-mortem examination, is a medical examination of a body after death. Autopsies are usually carried out by specialised medical doctors called pathologists, who have extensive knowledge and specific training on the human body. The process of an autopsy can vary depending on the reason for it, but it typically involves a thorough examination of a corpse by dissection to determine the cause, mode, and manner of death.

There are two types of autopsies: forensic and clinical. Forensic autopsies are often very thorough, examining every part of the body, and typically include crime scene investigation and toxicology—the study of poisons and their effects on the body. Clinical autopsies, on the other hand, may only investigate certain parts of the body and typically do not include toxicology. Clinical autopsies are often performed in cases of natural death to better understand the cause, which may be due to internal factors such as cancer, a heart attack, or an infectious disease.

In some cases, virtual autopsies may be performed using radiographic techniques such as MRI and CT scans. This method can help determine the cause and manner of death without the need for dissecting the deceased, which can be helpful when dealing with biohazardous materials.

The decision to perform an autopsy and the type of autopsy conducted may fall under the jurisdiction of a coroner or medical examiner. A coroner is a government official who investigates deaths, particularly those that are sudden, violent, or suspicious. They have the authority to order a medico-legal autopsy, also known as a coroner's autopsy, to determine the cause and manner of death and identify the decedent. In contrast, clinical autopsies typically require the consent of the deceased's family and are performed to gain insight into pathological processes and contribute to medical research.

Resuscitation attempts

Resuscitation is a critical procedure performed in hospitals to revive patients who have experienced cardiac arrest or stopped breathing. The success of resuscitation attempts can vary, and there are ethical considerations surrounding the initiation and termination of resuscitation.

Initiating Resuscitation

The decision to initiate resuscitation attempts is crucial and can be influenced by various factors. Emergency medical services (EMS) personnel are often the first to encounter patients in critical peri- and cardiac arrest states and must decide whether to initiate cardiopulmonary resuscitation (CPR). EMS providers are guided by specific guidelines, such as the 2015 AHA guidelines, which recommend against initiating resuscitation if it would place the rescuer at risk of serious injury or mortal peril.

Duration of Resuscitation Attempts

The duration of resuscitation attempts can vary significantly across hospitals. Studies have shown that hospitals with longer resuscitation durations have higher overall survival rates. The decision on how long to continue resuscitation efforts depends on various factors and is typically made by the physician attending the patient. While most patients who are successfully resuscitated respond soon after arrest, a small percentage may require more time.

Factors Affecting Resuscitation Success

The success of resuscitation attempts can be influenced by several factors. The patient's underlying health status, the presence of any co-morbidities, and the initial rhythm of cardiac arrest (PEA, asystole, VT, or VF) can impact the likelihood of achieving a return of spontaneous circulation (ROSC). Additionally, the quality of CPR and the timing of other interventions can also play a role in the outcome.

Ethical Considerations

There are ethical dilemmas associated with resuscitation attempts, particularly around do-not-resuscitate (DNR) orders. A DNR order, also known as Do Not Attempt Resuscitation (DNAR) or Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), is a legally recognized instruction indicating that a person should not receive CPR if their heart stops beating. Patients may choose a DNR status based on personal, relational, and philosophical factors, especially in cases of terminal illness where CPR may be considered futile.

The Lazarus Effect

The Lazarus effect is a rare phenomenon where a person who has been declared dead after cardiac arrest and CPR suddenly shows signs of life. While rare, it highlights the complexities and uncertainties surrounding resuscitation attempts and end-of-life care.

Frequently asked questions