Is it getting harder to die in hospital ?
Date Posted: 25.09.2012
MEDICAL MATTERS: IS IT just me or has it got more difficult to die in hospital? It’s a loaded question, I know; what I am particularly thinking of is, because of the huge growth in high-tech medicine, has it become more difficult to die simply and humanely in an acute care situation?
The patient who got me thinking about this is someone who recently achieved a lovely death in one of the Republic’s smaller general hospitals.
The 85-year-old woman had a long history of diverticulitis which had caused symptoms on and off for most of her adult life. She had never been hospitalised with an acute episode before the three-day admission that ended in her passing away peacefully.
Diverticular disease is a problem of the colon (the large bowel) in which sac-like protrusions form in the wall of the colon. It affects one in three people over the age of 60 and seems to be related to lifestyle issues in developed countries, especially the amount of fibre in our diet.
In people with the disease, about 25 per cent will develop symptoms, typically abdominal pain, bloating and nausea.
The large bowel usually moves faecal material along its length by means of gentle rhythmic contractions of its muscular wall. When fibre is lacking in the diet, the stool becomes dry and difficult to move.
The wall of the colon then contracts overstrenuously, causing the inner lining of the bowel to push out through the wall to form small pouches or pockets. These are called diverticulae; if they become infected, it is referred to as diverticulitis. And in the absence of the colon perforating, the development of an abscess or of other complications, the diagnosis is one of uncomplicated diverticulitis.
In a review of the condition published in the Canadian Medical Association Journal last month, Dr Andrio Tursi, an Italian gastroenterologist, said: “The pathophysiology of diverticular disease is extremely complicated because of the many different contributing factors, including diet, colonic wall structure, intestinal motility and possible genetic predisposition.”
He explained how the diagnosis was being made more frequently because of the increased numbers of colonoscopies being performed.
But just one in 20 people will go on to develop acute inflammation of a colonic diverticula and it is even rarer for someone to perforate their bowel as a result. Perforation of the bowel is an emergency requiring an urgent operation to repair the hole in the wall of the colon.
However, Evelyn, the 85-year-old woman who perforated her bowel due to acute diverticulitis, was not operated on. This is not as cruel as it first sounds; she had multiple medical problems including a progressive neurological disease with a poor prognosis. She had moved to a nursing home some months previously after losing her independence.
She could have been treated surgically, albeit with a high risk of dying as a result, but her family was united in not wishing to put her through that trauma. Instead they asked the doctors who were looking after her in the acute hospital to initiate a palliative approach to her care. So she was treated with intravenous fluids, painkillers and other medications to keep her comfortable. There was a slim chance the perforation could wall itself off and that she could have recovered. But she did not and instead Evelyn passed away peacefully some days later.
This was very much a “natural” death. Anecdotally, however, this kind of sensitive, medical care seems no longer to be a given. I am aware of a small number of cases where in a similar type of situation what can only be described as a “gung-ho” approach has been taken. Typically this involves a questionable acute intervention, which in turn leads to admission of the person to intensive care, at which point a number of iatrogenic issues such as kidney failure arise.
Even then, with a family practically shouting “stop”, the juggernaut of intervention may continue.
Muiris Houston, Irish Times, Health Plus, Tuesday September 25th