[A]t 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.
She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.
When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.
Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.
That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.
Surgery like this has become all too common among those near the end of life, experts say. Nearly 1 in 3 Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.
The practice is driven by financial incentives that reward doctors for doing procedures as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital.
“We have a culture that believes in very aggressive care,” said Redberg, who at the University of California-San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm and how that changes when you get older. We also fail to have conversations about what patients value most.”
While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.
The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people older than 65 — involve more than money, said Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50% more time in the hospital than others and nearly twice as many days in intensive care.
And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.
Eighteen percent of Medicare patients have surgery in their final month of life and 8% in their final week, according to a 2011 study in The Lancet.
Death is an ultimate cosmic constant. The stages of death herald the conclusion of all vitality in all mortals. Let us delve deeper into understanding the dying process.
by Ishani Chatterjee Shukla
“The pale, the cold, and the moony smile
Which the meteor beam of a starless night
Sheds on a lonely and sea-girt isle,
Ere the dawning of morn’s undoubted light,
Is the flame of life so fickle and wan
That flits round our steps till their strength is gone.”
[T]hat was Percy Bysshe Shelley on the approach of death. Death has been an object of fantasy and obsession for many a poet and philosopher, whether classic or contemporary. However, the physiological stages that precede and succeed this dire reality are far from the musings of the poetically inclined. The final phases leading up to death can be categorized as emotional and physical.
Emotional Stages During the Time Leading Up to Death
The emotional stages of dying are experienced by a person when he knows he is dying and is also shared by the people who are very close to the dying person. These emotional stages are also known as stages of grief and include:-
Denial: The dying individual has difficulty in believing that he is so close to death; he refuses to accept that anything could be wrong with him.
Resentment: Once he is convinced of his fate, he feels it is unfair and his frustration finds vent in anger and resentment.
Negotiation: The third stage is where desperation sets in. He tries to bargain with fate, people close to him, his physician, family, friends, etc. to find a cure, whether medical or spiritual, to prolong his life.
Depression: When he realizes that he cannot cheat death, despondency sets in and he begins feeling hopeless. The person suffers from loss of appetite and insomnia.
Resignation or Acceptance: This is the final stage. The person in question gives up all his struggle and accepts his fate and the finality of death.
The signs of approaching death set in about two to four months before death. The person becomes withdrawn and may feel detached from their surroundings. This is a time for introspection for most people and they recall their past to re-evaluate their lives. However, sometimes people suffering terminal illnesses tend to become hyperactive and indulge in their passions and desires. They put the remaining days of their lives in a fast forward mode so as to partake in those activities which they have always wanted to pursue in their lives but never got an opportunity, just like Jack Nicholson and Morgan Freeman did in The Bucket List.
Signs of death can be classified as close and distant. Close signs are the physical stages that start setting in from a couple of weeks prior to the exact time of death.
Physical Stages of Death
The physical stages are experienced solely by the person who is dying. These can be categorized into the stages at the exact moment of death and the stages that occur some moments after death.
Stages at the Exact Moment:-
The heart stops beating
The muscles loosen
The skin tightens and a grayish pallor sets in
The body loses heat and its temperature lowers to about 1.5°F (every hour; the liver retains heat for the longest time after death, based on which the time of death may be established (provided the body is found during that period)
The bowels and bladder become devoid of all contents
Stages After About Half-an-Hour:-
Terminal appendages such as finger and toe nails, lips, etc., become pale as blood circulation stops
The skin, hands and feet turn bluish due to lack of oxygen and blood circulation
All the blood of the body gathers at the lowest parts, making them appear darkish purple
The eyes begin sinking into the skull
The body starts stiffening, due to a phenomenon known as rigor mortis, after around 3-5 hours of death
Other than deaths by accident, most of the time, the stages start well in advance for people who are about to die, be it from illness or old age.
Distant Signs of Death
Distant signs start occurring between three to six months prior to death. These signs may be experienced even when the subject is not suffering any health issues. These signs may include:-
Having hiccups while urinating or excreting;
Inability to hear the buzzing sound of inner ears when ears are blocked;
Drop in normal body temperature;
Inability to taste or smell for no apparent reason;
Changed likes and dislikes;
Repeated dreams symbolizing increasing distance and misdirection.
About a six to eight weeks before death, the person may spend more time sleeping and lazing around. Diminished movement is witnessed, along with signs of disorientation. The person may either have hallucinations, feel paranoid, or he may be washed with a sense of peace and security. As the final stages close in, the person may feel a sudden, short-lived wave of euphoria and energy, the same way as a lamp flickers the brightest before going out. Breathing becomes irregular and then stops altogether.
The family and friends of the deceased person suffer a trauma of loss for a long time, sometimes for throughout their entire lives. Dealing with the death of a loved one, especially, coping with the death of a parent, spouse or sibling can be emotionally taxing and should be dealt with patience and sensitivity. In severe cases, grief counseling and sessions on death management can help ease the pain of dealing with the loss of a dear one.
Death is the greatest truth, even greater than life itself! There is no assurance of the fetus getting born even after being conceived in the womb, but there is the stoic assurance of encountering death even as the faintest pulse of life starts throbbing. It is not the end but a transition to the afterlife, the beginning of a new journey towards further education and enlightenment of the soul; and we all know that the soul is immortal. Death only marks the end of one aspect of our journey as the soul transcends to a higher realm of consciousness.
[T]hough it may seem bizarre today, having your heart buried apart from the rest of your body wasn’t uncommon for European aristocracy of the Middle Ages and beyond. The practice arose in part during the Crusades, when high-ranking warriors had a tendency to die in “heathen” places that weren’t seen as desirable burial locations. But transporting a whole body back to Europe made things pretty stinky, so corpses were stripped of flesh and ferried back to Europe as skeletons, with the inner organs (including the heart) removed and buried where the Crusaders had died. By the 12th century, members of the English and French aristocracy also frequently had their hearts buried separately from the rest of them.
Heart burial became less practical and more symbolic by the 17th century, partly as a religious practice associated with the Jesuits and other Counter Reformation groups. (Some scholars think the heart’s powerful symbolism became particularly important while the Catholic Church was undergoing a moment of crisis.) In Western Europe, it became common for powerful individuals, such as kings and queens, to ask that their hearts be buried in a spot they’d favored during life. In more recent years, Romantic poets and other artists also picked up the practice, which has yet to be entirely abandoned.
1. RICHARD I
Richard I, a.k.a. “Richard the Lion-Heart,” ruled as King of England 1189-99 but spent most of his reign fighting abroad, which is how he earned his reputation for military prowess. (He also may or may not have eaten the heart of a lion.) He died after being struck by a crossbow while campaigning in Chalus, France, and while most of his body was buried at Fontevraud Abbey, his heart was interred in a lead box at the Cathedral of Notre Dame in Rouen, France. The organ was rediscovered during excavations in the 1830s, and in 2012, forensic scientists examined it—now mostly reduced to a grayish-brown powder—to learn more about Richard’s precise cause of death (some think a poisoned arrow dealt the fatal blow). The crumbling heart was too decayed to tell them much about how Richard had died, but the scientists did learn about medieval burial rituals, noting the use of vegetables and spices “directly inspired by the ones used for the embalming of Christ.”
2. ROBERT THE BRUCE
Robert the Bruce, King of Scots 1306-29, asked for his heart to be buried in Jerusalem. But it didn’t get all the way there—the knight he entrusted it to, Sir James Douglas, was killed in battle with the Moors while wearing the heart in a silver case around his neck. Other knights recovered the heart from the battlefield, and brought it back to Melrose Abbey in Scotland for burial. Archeologists rediscovered what they believed to be the heart in 1920 and reburied it in a modern container; it was exhumed again in 1996, and reburied beneath the abbey’s lawn in 1998.
3. ST. LAURENCE O’TOOLE
St. Laurence O’Toole, the second archbishop of Dublin and one of that city’s patron saints, died in 1180 in France. His heart was sent back to Dublin’s Christ Church Cathedral, where it rested inside a heart-shaped wooden box within an iron cage—at least until 2012, when it was stolen. The dean of Christ Church Cathedral has speculated that the heart might have been taken by some kind of religious fanatic, since it has little economic value, and much more valuable gold and silver objects were ignored. (Weirdly, the thief, or thieves, also lit candles on one of the altars before fleeing.) The item has yet to be recovered.
4. THE PRINCE-BISHOPS OF WÜRZBURG
The prince-bishops of Würzburg (part of modern Germany) practiced a three-part burial: their corpses were usually sent to Würzburg cathedral, their intestines to the castle church at Marienberg, and their hearts, embalmed in glass jars, to what is now Ebrach Abbey. The practice was common by the 15th century, though it may go back as far as the 12th. Their funerals at the Marienberg castle also featured what may be one of history’s worst jobs: a servant was required to hold the heads of the corpses upright during the funeral, which featured the body seated upright and impaled on a pole. The funerals lasted for several days. There were more than 80 prince-bishops; a German cardiologist who made a special study of heart burial says “about 30” of their hearts found their resting places in the abbey.
5. ANNE BOLEYN
According to legend, after Anne Boleyn’s beheading in 1536, her heart was removed from her body and taken to a rural church in Erwarton, Suffolk, where the queen is said to have spent some happy days during her youth. In 1837, excavations at the church uncovered a small, heart-shaped lead casket inside a wall. The only thing inside was a handful of dust (it’s not clear whether it was actually the heart), but the casket was reburied in a vault beneath the organ, where a plaque today marks the spot.
6. LOTS OF POPES
Twenty-two hearts from various popes—from Sixtus V in 1583 to Leo XIII in 1903—are kept in marble urns at Santi Vincenzo e Anastasio a Trevi in Rome. Traditionally, the hearts were removed with the rest of the organs as part of the postmortem preservation process, and kept as relics just in case the pope became a saint.
7. FRÉDÉRIC CHOPIN
Romantic composer Frédéric Chopin died in Paris in 1849, and most of him is buried in that city’s Pere Lachaise, but he asked for his heart to be buried in his native Poland. His sister carried it back to their home country, where it is preserved in alcohol (some say cognac) within a crystal urn inside a pillar at the Church of the Holy Cross in Warsaw. In 2014, scientists conducted a late-night examination of the heart to make sure the alcohol hadn’t evaporated, although their secrecy frustrated scientists who hope to one day examine the organ for clues about what killed the composer.
8. THOMAS HARDY
The English poet and novelist Thomas Hardy wanted to be buried in his hometown of Stinsford, Dorset, but friends insisted that a burial in Westminster Abbey was the only appropriate choice for someone of Hardy’s literary prominence. But when town officials found out that Hardy’s body was destined for the abbey, they threw a fit, and so a compromise was reached—most of Hardy went to Westminster, but his heart was buried in Stinsford churchyard (where it has its own grave marker). A persistent, but unproven, story has it that a cat ate part of the heart when the doctor who was removing it got distracted; a gruesome addendum says the animal was killed and buried alongside the organ.
9. PERCY SHELLEY
When the poet Percy Shelley died sailing the Mediterranean in 1822, local quarantine regulations dictated that his body had to be cremated on the beach. But his heart allegedly refused to burn, and a friend, the adventurer Edward Trelawny, supposedly plucked it out of the flames. After a custody battle among Shelley’s friends, the heart was given to Percy’s wife Mary, who kept it until she died. Her children found it in a silk bag inside her desk, and it is now said to be buried with her at the family vault in Bournemouth, England.
10. OTTO VON HABSBURG
The powerful House of Habsburg practiced heart burial for centuries, with many of the organs buried in copper urns in Vienna’s Augustiner Church. In 2011, Otto von Habsburg, the last heir to the Austro-Hungarian Empire (which was dissolved in 1918), had his heart buried in the Benedictine Abbey in Pannonhalma, Hungary. The rest of him was buried in Vienna. The erstwhile crown prince said he wanted his heart buried in Hungary as a gesture of affection for the country—one half of his former empire.