The patient as a person

1Why it matters

The patient on the table is a person before they are a procedure. They bring a body that needs care, and they also bring fears, a family, a culture, a faith and plans for their life. Every patient is unique, and a good outcome depends on care built around all of those needs, which is called holistic, patient-centered carepatient-centered carePAY-shunt SEN-terd KAIRCare planned around the client's own needs, values and choices, with the client as a full partner in decisions.Full entry Close.

Most surgical patients feel anxious, and many are afraid. They worry about the outcome, and about everything they cannot control once they enter the hospital. You may spend only a few minutes with a patient, in the holding area or on the stretcher, or much longer in an outpatient center. Either way, you can read a patient's needs from what they say and from what their face and body show you, and every contact, however brief, is a chance to help.

Once anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close begins, the patient cannot see, speak or protect themselves. They depend on the team to respect their body, to uncover only what the procedure needs, and to act as they would ask if they could.

Some patients die. A death in the operating room is rare, but every surgical technologistsurgical technologistSUR-jih-kul tek-NOL-uh-jistA member of the operating room team who prepares the sterile field and instruments and hands them to the surgeon.Full entry Close needs to know how to care for the patient, the family and the team when it happens, and how organ and tissue donation can give life to others.

This chapter teaches the patient's needs, the patients who need extra care, and death and dying. Other chapters hold the pieces around it: communication itself, listening and speaking up in chapter 16; consent, advance directivesadvance directivead-VANS dih-REK-tivA legal document in which a person states their wishes for medical care, for a time when they cannot speak for themselves.Full entry Close, living willsliving willLIV-ing WILA written legal document that says which medical treatments a person does or does not want if they cannot speak for themselves.Full entry Close, the DNRdo-not-resuscitate orderdoo-not-rih-SUS-ih-tayt OR-derA provider's order that CPR will not be started if the client's heart or breathing stops.Full entry Close choices in the OR, the right to refuse blood and the patient rights The Joint CommissionThe Joint Commissionthuh JOYNT kuh-MISH-unAn independent US organization that inspects and accredits hospitals and other health care organizations against safety and quality standards.Full entry Close requires in chapter 15; a child's temperature, fluids, airway and drug doses, parents at inductioninductionin-DUK-shunThe starting of a process on purpose, such as bringing on labor or putting a client under anesthesia.Full entry Close, and the PACU in chapter 13; congenitalcongenitalkun-JEN-ih-tulPresent at birth.con- withgen birth, origin-al relating toFull entry Close defects in chapter 11; diabetes and other gland disease in chapter 9; isolation precautionsisolation precautionseye-suh-LAY-shun prih-KAW-shunzExtra infection-control measures, added to standard precautions, for clients known or thought to have certain contagious infections.Full entry Close and latex allergylatex allergyLAY-teks AL-er-jeeAn allergic reaction to proteins in natural rubber latex, found in some gloves, catheters and other products.Full entry Close in chapter 10; communication barriers, transport, transfer and positioning as steps in chapter 31; radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close safety in chapter 22; the steps of the organ recovery operation on the Organ Procurement card; and the transplant operations in their procedure chapters.

2The whole patient

Holistic care

Holistic careholistic carehoh-LIS-tik kairCare that looks after the whole person: body, mind, emotions, relationships and spiritual needs.Full entry Close treats the whole person: the body, the mind, the person's place among family and friends, and their spirit. A patient facing the loss of a leg may wonder whether they will walk again (a physical question), whether they are still the same person (a psychological one), who will care for their children and how others will see them (social ones), and why this happened to them (a spiritual one). Each of those questions is a need.

Patient-centered carepatient-centered carePAY-shunt SEN-terd KAIRCare planned around the client's own needs, values and choices, with the client as a full partner in decisions.Full entry Close is care, communication and intervention planned around the unique needs of this patient. The team learns those needs from other caregivers, from the chart, from careful observation, and from talking with the patient.

Perioperativeperioperativepair-ee-OP-er-uh-tivRelating to the whole time around a surgery: before, during and after it.peri- aroundoperative relating to surgeryFull entry Close care is also outcome oriented: the team names a desired result for the patient that can be measured, such as "the patient says their anxiety is under control" or "the patient stays free of infection," and then checks whether the care achieved it.

Carl Rogers, a psychologist who worked with Maslow, developed the person-centered approach. Rogers held that every person can grow toward good health in mind and body, and that love, empathy, unconditional acceptance and genuineness from others help a person get there.

Start with yourself

Before you can support patients, look at your own attitudes, because they can get in the way of honest, caring communication. Many people are surprised to find biases they did not know they had. Ask yourself questions such as these:

• How do I feel about faiths other than my own, or about people with no faith?
• How do I act around people with a severe physical disability, a mental illness or a very large body?
• How do I usually treat older adults, children and immigrants?
• What do I believe about people who have been through trauma, and how much of it comes from television and movies?
• How would I cope with a life-threatening illness of my own?

Stepping outside your own beliefs to see through someone else's eyes is hard, and in health care it is required. Attitudes that are stereotyped or prejudiced end up harming care, so this reflection never really ends.

3Maslow's hierarchy of needs

The psychologist Abraham Maslow described human needs as a pyramid of five levels, now called Maslow's hierarchy of needsMaslow hierarchy of needsMAZ-loh HY-er-ar-kee uv needzA theory that ranks human needs in five levels, from basic body needs at the bottom to self-fulfillment at the top.Full entry Close. The most basic needs sit at the bottom. In Maslow's model, the needs of one level must be met before a person can turn to the level above it. Health care uses the model to understand patients and to decide which needs come first.

Level 1: Physiological needs

The most basic needs keep the body alive: air and oxygen, water and food, warmth, rest, elimination, movement and freedom from pain. In surgery, the team meets them by keeping the airway open and giving the right mix of oxygen, giving IV fluids, controlling the patient's temperature with blankets and warming devices, protecting the patient from noise, bright light and cold, giving a chance to void or placing a catheter, moving the patient with care, and watching for and treating pain.

Level 2: Safety and security

Safety means freedom from real or feared harm to the body or the mind, and security includes the ability to care for oneself and one's family. When people cannot feel safe, they become anxious and even afraid. Most surgical patients are anxious, about the operation itself but also about their independence, their income and the people who depend on them.

Level 3: Love and belonging

Family, friends and the groups people belong to give them a sense of being accepted and needed. Social support seems to help the immune system and to lower stress. Family members often come with the patient, wait during the operation and stay through recovery, and the moment of separation at the door can be very emotional. A caring, professional attitude toward the family matters as much as toward the patient.

Level 4: Esteem

Esteem is respect: how others see a person shapes how that person sees and cares for themselves. People who are disrespected for their culture, income, faith or other traits often develop low self-esteem. Body imagebody imageBOD-ee IM-ijHow a person sees, thinks and feels about their own body and its appearance and function.Full entry Close, the way a person believes others see their body, is closely tied to esteem. A sudden change, or a feared change, such as an amputationamputationam-pyoo-TAY-shunThe removal of all or part of a limb or other body part, by surgery or by injury.Full entry Close or a large scar, can bring embarrassment, a feeling of rejection and isolation, and some patients need counseling or a support group to adjust.

Level 5: Self-actualization

Self-actualization is a person's ability to plan for and reach their own life goals. Illness and surgery can threaten those goals, through a lost function or a changed body, and the grief many patients feel can come from that loss. You help by acknowledging the patient's feeling of loss.

Using the pyramid in the OR

The pyramid tells you what comes first. Under anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, the physiologicalphysiologicfiz-ee-uh-LOJ-ikRelating to the normal working of the body.physi/o nature, body function-logic relating to the study ofFull entry Close level takes priority: airway, breathing, circulation, blood volume and pain. But the higher needs do not disappear while the team works. A patient waiting for a mastectomymastectomyma-STEK-tuh-meeSurgery to remove all or part of a breast.mast/o breast-ectomy surgical removalFull entry Close who asks you twice whether they could "wake up during it" has warm blankets, an IV and oxygen; the need still unmet is safety, and an honest, calm answer, with the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close called to explain further, meets it.

4Fear and anxiety

What patients fear

These fears are common in surgical patients:

• Anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close: not waking up, or feeling pain while paralyzedparalysispuh-RAL-uh-sisLoss of the ability to move a part of the body, and sometimes loss of feeling in it.para- beside, abnormal-lysis looseningFull entry Close. Anesthesia awareness, in which a patient under general anesthesiageneral anesthesiaJEN-er-ul an-es-THEE-zhuhDrug-induced loss of consciousness and feeling over the whole body, so a person feels nothing and is not aware during surgery.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close hears and feels the surgery and remembers it, is real but rare, and films and news stories have made the public far more afraid of it than the risk warrants. The anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close explains the anestheticanesthetican-us-THET-ikA drug that causes loss of feeling, with or without loss of consciousness.an- withoutesthesi/o feeling, sensation-ic relating toFull entry Close before surgery, and a patient at high risk can have their brain activity monitored. Chapter 13 covers depth of anesthesia.
• Death: often greater before a general anesthetic or radical cancer surgery, because being unconscious and in someone else's control feels close to dying.
• Pain: a normal, protective fear, made worse by unanswered questions or a bad experience after an earlier operation.
• Disfigurement: a realistic fear before radical or reconstructive surgery, because the body is part of a person's identity and a changed appearance can bring stigmastigmaSTIG-muhNegative beliefs and labels that society attaches to a condition or group of people, leading to shame and unfair treatment.Full entry Close and rejection.
• Loss of control: patients often feel they have lost their rights and their say once they enter the hospital, and anesthesia makes it worse. Some stay calm; others regress and act helpless or childlike.
• Physical exposure: the fear of being uncovered and losing dignity is strong in many patients, especially adolescents.
• Loss of privacy: fear that their health information will leak out and cost them a job or a relationship.
• The unknown: not knowing what will happen, and expecting the worst.

Why anxiety matters

Fear is more than discomfort. Severe anxiety before surgery changes the way the body works, and with it the way the body responds to anesthesia. A very anxious patient is more prone to deliriumdeliriumdih-LEER-ee-umA sudden state of confusion and poor attention that comes and goes over hours or days.Full entry Close while waking from a general anesthetic, needs more pain medicine afterward, and communicates less well with the team. High anxiety can also raise the blood pressure and the heart's workload, and it is linked to depression, fear and anger after surgery.

Watch for the signs: crying, withdrawing, biting fingernails, talking a lot, or avoiding eye contact. Report a very anxious patient to the circulator and the anesthesia provider. An anxiolyticanxiolyticang-zee-oh-LIT-ikA drug that relieves anxiety.anxi/o anxiety-lytic breaking down, relievingFull entry Close, a drug that relieves anxiety, is often given before surgery to a patient who is highly anxious.

Supportive communication

Supportive communication is a deliberate way of talking with patients that responds to what they need, whether they say it or only show it. Listening comes first. Then you acknowledge the concern and show empathy. Chapter 16 teaches communication skills; here is how they meet a patient's fear:

• Listen. Make eye contact as the patient's culture allows, and give the patient your full attention. Divided attention looks like a lack of concern. People need time to say what worries them.
• Give information, honestly. Most patients want to understand what is happening around them, explained without jargon. Say so when you do not know. If a question is medical, or needs an assessment, refer it to the surgeon or the nurse: a delayed answer is better than a wrong one.
• Reassure by thinking ahead. Tell patients what will happen to the things that worry them, such as where their glasses or hearing aids will be when they wake.
• Clarify. Repeat back what you heard and ask what they meant, so the patient knows you are really listening.
• Never dismiss or joke about a fear. Explain instead. If a patient tenses when the safety strap goes across their thighs, tell them what it is for: the table is narrow, and the strap keeps them safe on it.

Some patients feel calmer with a loved one beside them before surgery; others would rather be alone. Ask, and follow facility policy. Some facilities also offer calming measures such as music, which has been studied for preoperative anxiety.

Calming the frightened or confused patient

Fear can overwhelm a patient who does not understand where they are, cannot cope, or cannot say what they need, such as a person with dementiadementiadih-MEN-shuhA long-term, usually worsening decline in memory and thinking that is serious enough to affect daily life.de- away fromment mind-ia conditionFull entry Close or a severe developmental disabilitydevelopmental disabilitydih-vel-up-MEN-tul dis-uh-BIL-ih-teeA lifelong condition, starting in childhood, that limits a person's physical, learning, language or behavior skills.Full entry Close. The anesthesia team and the circulator usually manage these patients, often with an anxiolytic. You help by keeping the room calm:

• Keep the room quiet; soft music may help, if facility policy allows it.
• Speak in short, direct sentences, in a calm voice, to the patient and to the team. Long explanations and chatter usually make things worse.
• Touch with confidence when you place the safety strap or the ECGelectrocardiogramih-lek-troh-KAR-dee-oh-gramA test that records the heart's electrical activity as waves on paper or a screen.electr/o electricitycardi/o heart-gram recordFull entry Close leads, never hesitantly.
• Watch for growing agitation and tell the anesthesia provider.
• Cover the patient with a warm blanket, which feels secure, unless there is a risk of overheating.

How patients cope

Under stress, patients use coping mechanisms, ways of handling a threat until they can face it. Some common ones:

• Denialdenialdih-NY-ulRefusing to accept or believe a painful fact or situation, often without being aware of doing so.Full entry Close: refusing to accept what is happening.
• Rationalization: explaining it away, such as blaming an illness on "bad genes" rather than facing a needed change.
• Regression: going back to the behavior of an earlier age, such as curling up, crying hard or pouting, and leaning on others.
• Repression: pushing the thoughts away and refusing to talk about the illness at all.

Positive or negative, these are the patient's ways of working toward accepting what is happening and, in time, making decisions about their care. Recognize them for what they are.

5Dignity and privacy

Keep the body covered

Cover the patient's body at all times, uncovering only what the procedure needs, and only when it needs it. Protect the patient's modesty and dignity even after anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, when they cannot protect it themselves, such as when the legs are raised into stirrups. Sheets and blankets, and closed blinds on any window, protect privacy.

A patient who is sedatedsedationsih-DAY-shunA calm, relaxed or sleepy state brought on by drugs, or the use of drugs to cause it.sed calm, settle-ation processFull entry Close or asleep is trusting every member of the team to protect their dignity, show them respect and behave professionally for the whole case.

Watch what you say

The team was once reminded that hearing is the last sense to go under anesthesia and the first to come back, and many took that to mean what was said during surgery did not matter. Today we know that some patients remember what they heard. Never assume a patient is unaffected by the conversation and comments in the room.

A patient under local or regional anesthesia, even when sedated, may be awake enough to hear. Keep talk of the diagnosis and idle conversation to a minimum: a personal conversation the patient overhears can be misunderstood and cause needless worry. Hearing also seems to last late into the dying process, so speak to and around a dying patient as though they can hear you.

Names and respect

Call patients by their proper names. Words such as "sweetie" or "honey" offend many patients and sound disrespectful. In some regions staff use first names freely; use discretion, and ask what the patient prefers.

Patients also fear for the privacy of their information. Holding everything you learn about a patient in strict confidence is an ethicalethicalETH-ih-kulHaving to do with what is morally right, or acting in line with accepted moral principles.Full entry Close duty; chapter 15 covers HIPAA and confidentiality. The Joint CommissionThe Joint Commissionthuh JOYNT kuh-MISH-unAn independent US organization that inspects and accredits hospitals and other health care organizations against safety and quality standards.Full entry Close requires hospitals to treat every patient with dignity and respect.

6Culture, faith and spirituality

Culture shapes care

Culture is the beliefs, values, practices and preferences a person learns from the people they grow up with. Knowing a patient's background improves communication, builds trust and leads to better outcomes. Cultural competencecultural competenceKUL-cher-ul KOM-puh-tensThe ability to give care that respects and fits a client's culture, values, beliefs and language.Full entry Close is the ability to support and care for people whose culture and beliefs differ from your own. It begins with acceptance and respect, and it is learned through experience and active study. Cultural humilitycultural humilityKUL-chur-ul hyoo-MIL-ih-teeA lifelong habit of self-reflection and learning in which the nurse treats each client as the expert on their own culture.Full entry Close goes with it: admitting that you cannot know everything about another culture, and making learning about other cultures a lifelong goal.

Culture is never a rule that tells you what one person wants. Two people from the same country, or the same faith, may want very different things. Never look at another culture through the lens of your own, and never guess: ask the patient, and the family if the patient wishes, what they prefer.

What a patient may ask for

These are some of the requests patients make for reasons of culture, faith or identity. Treat each as a question to raise with the patient, never as a rule for a group:

• Language: a medically trained interpreter for consent and teaching, and written material in the language the patient reads (see Communication barriers, below).
• Modesty: a gown or drape that covers more, and positioning and draping that respect the patient's norms.
• Gender: caregivers of the same gender, when that can be arranged.
• Name and pronouns: a patient, such as an LGBTQLGBTQIA+el-jee-bee-tee-kyoo-eye-ay-PLUS (said as letters)A short form for sexual and gender minority groups: L lesbian, G gay, B bisexual, T transgender, Q queer or questioning, I intersex, A asexual, + others.Full entry Close+ patient, may have a preferred name and pronouns. Ask what the patient prefers, use them every time, record them, and pass them on to everyone who cares for them.
• Touch: for some people a hand on the arm is a comfort; for others, touch from a stranger is offensive. Some patients consider the top of the head sacred and would rather put on their own surgical cap.
• Eye contact: avoiding eye contact may be a sign of respect, never proof of fear or dishonesty. Silence does not always mean agreement or understanding, either.
• Who speaks: in some families another member answers questions for the patient or helps make decisions. Ask the patient how they want decisions made.
• Food and fasting: religious fasting periods and diet rules can affectaffectAF-ekt (stress on the first syllable)In mental health, the outward expression of a person's emotions, as seen in the face, voice and body language.Full entry Close the instructions before and after surgery.
• Traditional remedies: ask about herbs, supplements and traditional healing practices, because some interact with anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close or raise the risk of bleeding.

When a belief cannot be honored because it would harm the patient, explain why and offer an alternative if there is one.

Spirituality and religion

Spirituality is a sense of something greater than humankind, beyond the physical senses. It is not the same as religion, though the two are often joined. A patient may call that power the creator, spirit or God, or have no name for it. Religions express spiritual life through rituals, practices with special meaning, such as prayer. For many patients faith is a major source of healing, as important to their well-being as the operation itself.

Faiths often have rules that touch health care. Topics they commonly cover include:

• blood and blood productsblood productBLUD PROD-uktAny part of donated blood prepared for transfusion, such as red cells, plasma or platelets.Full entry Close, and medicines made from blood
• organ donation, autopsyautopsyAW-top-seeAn exam of a body after death to find the cause of death or to study a disease.Full entry Close, and donating the body after death
• amputationamputationam-pyoo-TAY-shunThe removal of all or part of a limb or other body part, by surgery or by injury.Full entry Close, and burial of an amputated limb or the placentaplacentapluh-SEN-tuhThe organ that grows in the uterus during pregnancy and passes oxygen and food from the parent's blood to the fetus.Full entry Close
• cutting body hair, and spiritual objects worn on the body
• diet, opioidsopioid analgesicOH-pee-oyd an-ul-JEE-zikA strong drug that relieves moderate to severe pain by acting on the brain and spinal cord.Full entry Close and other drugs, and alternative remedies
• embalming, cremation, and anointing with oil during sickness and death

A practice may be followed strictly even when religious law does not require it, so the patient's own wishes are what count. Refusal of blood is covered in chapter 15.

Patients may bring religious items, such as prayer beads, icons, religious jewelry or a prayer book, that give them strength. Safeguard them so they are never lost. Jewelry cannot be worn in surgery, so if a patient does not want to take an item off, explain the risk carefully; when possible, a family member keeps it until the patient returns.

Every facility has rules for what happens to body parts removed in surgery, including the placenta. When a patient asks to take one home, for burial or another rite, follow your facility's policy.

Learn where your facility's chapel or prayer room is and how to reach the chaplain. Chaplains are trained to support patients and families, and they can find a leader of a faith that has none on staff. A patient may ask for a visit from clergy before surgery.

The Joint CommissionThe Joint Commissionthuh JOYNT kuh-MISH-unAn independent US organization that inspects and accredits hospitals and other health care organizations against safety and quality standards.Full entry Close requires hospitals to respect each patient's cultural and personal values, beliefs and preferences, and to make room for religious and spiritual services.

7Patients who need more

Every patient needs support through surgery, but some need more: patients who cannot easily understand or cope with the surgical setting, and patients whose bodies face extra risk. The Core Curriculum calls them susceptible populations. Their physical care is taught with anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close, transport and positioning; this section is about what each one needs from you as a person.

Every patient also needs their allergies known. Allergies to drugs, latexlatexLAY-teksNatural rubber made from the sap of the rubber tree, used in some gloves, catheters and other medical supplies.Full entry Close, foods, blood productsblood productBLUD PROD-uktAny part of donated blood prepared for transfusion, such as red cells, plasma or platelets.Full entry Close and contrast dyecontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close are found before surgery, recorded in the chart, and shown on an allergy band placed on a limb that is out of the way of the operation. Chapter 10 covers latex allergylatex allergyLAY-teks AL-er-jeeAn allergic reaction to proteins in natural rubber latex, found in some gloves, catheters and other products.Full entry Close and chapter 12 drug reactions.

Communication barriers

Some patients cannot easily understand you, or tell you what they need. The barrier may be physical, such as hearing, sight or speech loss, or nonphysical, such as a different language or a cognitive impairmentcognitive impairmentKOG-nih-tiv im-PAIR-muntTrouble with thinking, memory, learning, attention or making decisions that is more than expected for the person's age.cognit- knowing-ive relating toFull entry Close. A patient with a severe hearing loss or a language barrier needs an interpreter to understand the operation and what it means for them.

Hearing loss. Nearly a quarter of adults aged 65 to 74, and half of those 75 and older, have disabling hearing loss. Hearing loss says nothing about intelligence, and not every patient with hearing loss can lip-read or sign. Only about 20 to 30 percent of words can be read on the lips, and a mask hides the mouth entirely.

• Ask how the patient prefers to communicate: hearing aids, lip-reading, sign language, writing, or a picture or word board.
• Keep hearing aids in as long as possible. A visit before surgery, while the hearing aids are still in, lets you explain what will happen.
• Get the patient's attention before you speak. Face them, in good light, in a quiet spot, and speak slowly and clearly in few words.
• A patient who is deaf needs an interpreter, such as one fluent in American Sign Language.

Sight loss. Introduce yourself, explain each event before it happens, such as the move to the OR bed, describe the room and who is in it, and stay in contact. Return glasses as soon as possible after surgery.

Speech loss. Patients who cannot speak may use alphabet or picture boards, speech-generating devices or speaking valves. These aids, and the help the patient needs, are noted in the record and passed on to everyone caring for them.

A different language. Use a trained medical interpreter, in person, by video or by phone. Using a trained interpreter is linked to fewer errors, shorter stays and more satisfied patients. Do not use family members, or staff who are not trained interpreters, to interpret: family may not know medical words, and a patient may hold back private information in front of them. The Joint CommissionThe Joint Commissionthuh JOYNT kuh-MISH-unAn independent US organization that inspects and accredits hospitals and other health care organizations against safety and quality standards.Full entry Close accepts trained bilingual staff, contracted services or employed interpreters. When the topic is sensitive, an interpreter of the same gender may spare the patient embarrassment.

Cognitive impairment. Meet the patient at their level of understanding, with simple words and pictures or short videos. A caregiver or advocateadvocateAD-vuh-kayt (verb), AD-vuh-kit (noun)To speak up and act for a client's rights, safety and wishes; also, a person who does this.Full entry Close can help, but never talk over the patient as if they were not there.

The Joint Commission requires hospitals to give patients information in a way they understand, with interpreters as needed. Chapter 31 covers how to work with these patients during preparation and transport.

Children

In children's surgery, the patient and the family cannot be separated: both need the same care in communication and support. A child's understanding depends on their developmental age, which does not always match their age in years.

The greatest fears of young children in surgery are fear of the unknown, fear of being separated from their parents or caregivers, and fear of being hurt or cut apart (mutilation). Trust begins with honest, careful descriptions of what will happen.

A child life specialist is trained to support children and families and to explain surgery to a child at their own level. Many hospitals offer a visit before surgery, a tour, or child-friendly videos and other age-appropriate tools, so the child can see the place and ask questions before the day comes.

The age lines differ a little between references, so use them as a guide and watch the child in front of you.

Magical thinking is the belief that objects have intentions of their own, or that something happens because one wished it. It is a normal stage in young children. A toddler may believe the blood pressure cuff squeezing their arm is angry with them, or that their skin holds their body together, so any break in the skin is frightening and a bandage over it matters.

Words matter. Use simple words without double meanings, and avoid words that sound like harm. Say "a pinch" rather than "a stick" or "a poke," and avoid "put to sleep." Be honest about pain: a child who is lied to stops trusting. Get down to the child's eye level, speak softly, and do not assume you were understood.

In the room. Keep frightening instruments out of sight and the room quiet, and bring a toddler in only when the room and the team are completely ready, so inductioninductionin-DUK-shunThe starting of a process on purpose, such as bringing on labor or putting a client under anesthesia.Full entry Close is quick. Someone stays with the child until they are asleep, and a security object stays until induction is over. Accept crying: it is how a child shows fear. A child who goes to sleep calm usually wakes up calm.

Adolescents need as much privacy and choice as possible. A teen who is not sedatedsedationsih-DAY-shunA calm, relaxed or sleepy state brought on by drugs, or the use of drugs to cause it.sed calm, settle-ation processFull entry Close may walk into the OR. They may not answer some questions in front of a parent. Procedures that expose them, such as hair removal, the skin prep or placing a urinary catheter, are done after they are asleep, and they stay covered as much as the procedure allows.

Chapter 13 covers a child's temperature, fluids, airway and drug doses, and parents at induction; chapter 28 covers planning the case and the setup for a child; chapter 31 covers transport and positioning; chapter 11 covers the congenitalcongenitalkun-JEN-ih-tulPresent at birth.con- withgen birth, origin-al relating toFull entry Close defects that much of children's surgery corrects, and the operations are in their specialty chapters.

Older adults

Older adults are usually defined as people 65 and older, but age alone says little about risk: many older people are healthier than some young adults. Most, though, bring at least one chronic condition, and their organs have less reserve, so they recover more slowly and are more sensitive to anestheticanesthetican-us-THET-ikA drug that causes loss of feeling, with or without loss of consciousness.an- withoutesthesi/o feeling, sensation-ic relating toFull entry Close and pain drugs.

Older patients are often stereotyped. Speaking to them like small children, in short, simple sentences, a high-pitched voice and "we" in place of "you," is called infantilizing, and it is linked to poorer outcomes. Speak to an older patient as you would to any adult. Listen and acknowledge a worry rather than brushing it off with a cliché, and use the patient's proper name, never "sweetie."

Never assume an older patient is confused. Dementiadementiadih-MEN-shuhA long-term, usually worsening decline in memory and thinking that is serious enough to affect daily life.de- away fromment mind-ia conditionFull entry Close is not part of normal aging. A patient who seems disoriented may simply not see or hear well, and moving from a dim holding area into the bright lights of the OR can leave them blinded for a moment. Orient them: tell them where they are, who is there and what is happening.

Older adults want a voice in their own care, and being independent matters to them a great deal. A patient with declining cognitioncognitionkog-NISH-unThe mental processes of thinking, knowing, remembering, judging and solving problems.Full entry Close may struggle with consent, with the site check and with describing pain, and deliriumdeliriumdih-LEER-ee-umA sudden state of confusion and poor attention that comes and goes over hours or days.Full entry Close is one of the most common complications after surgery in patients over 65. Returning glasses, hearing aids and dentures early, frequent reorienting, and familiar people and objects help prevent it.

Their skin is thin and fragile, joints are often stiff, and they lose heat easily, so they need gentle handling, careful padding and warmth (chapters 13 and 31). While helping to position an older patient, the team may see signs of abuse or neglectneglectnih-GLEKTFailure to give a child or dependent adult the food, shelter, care, safety or medical help they need.Full entry Close, which are reported according to facility policy and the law.

Pregnant patients

A pregnant patient may need surgery related to the pregnancy or unrelated to it. Either way, the team cares for two patients, and the patient's obstetric care provider helps plan the operation. Many pregnant patients worry that anesthesia or the operation will harm the baby, and those worries deserve full, honest answers.

Elective surgery is put off until after delivery when it can be. When surgery cannot wait, the team watches the fetus as well as the patient, often with a fetal heart monitor, and works to prevent preterm laborpreterm laborPREE-turm LAY-berLabor that begins after 20 weeks and before 37 weeks of pregnancy.Full entry Close and blood clots. Pregnancy changes the vital signs, so a pregnant patient may lose a large amount of blood before the usual signs of shockshockshokA life-threatening state in which blood flow is too low to bring enough oxygen to the body's tissues.Full entry Close appear.

Lying flat, the pregnant uterus can squeeze the vena cavavena cavaVEE-nuh KAY-vuhOne of the two large veins that return oxygen-poor blood from the body to the right atrium of the heart.Full entry Close and aorta, which drops the blood pressure and the blood flow to the baby. A wedge under the right hip, or tilting the table about 15 degrees to the left, relieves it. Anesthetic drugs cross the placentaplacentapluh-SEN-tuhThe organ that grows in the uterus during pregnancy and passes oxygen and food from the parent's blood to the fetus.Full entry Close to the baby. Chapter 31 covers positioning, chapter 12 drugs in pregnancy, and chapter 22 radiationradiationray-dee-AY-shunEnergy that travels as waves or particles, such as X-rays, used to make images or treat cancer; also pain that spreads from its starting point.radi/o rays, radiation-ation processFull entry Close safety.

Immunocompromised patients

An immunocompromisedimmunocompromisedim-yoo-noh-KOM-pruh-myzdHaving an immune system that is weaker than normal at fighting infection.immun/o immune, protectioncompromised weakenedFull entry Close patient's immune system is weakened, so they fight infection poorly. The very young and the very old are often affected. So are patients with diseases that weaken the immune system, such as AIDSAIDSAYDZAcquired immunodeficiency syndrome: the most advanced stage of HIV infection, when the immune system is badly damaged.Full entry Close, diabetes or overwhelming sepsissepsisSEP-sisA severe whole-body response to an infection that damages the body's own organs.Full entry Close, and patients whose immune systems are suppressed by treatment: corticosteroidscorticosteroidkor-tih-koh-STER-oydA drug that acts like the hormones of the adrenal glands, used mainly to calm inflammation and the immune system.cortic/o cortex (the outer layer of the adrenal gland)-oid likeFull entry Close, cancer chemotherapyantineoplastican-tee-nee-oh-PLAS-tikA drug used to treat cancer by killing cancer cells or stopping them from growing and dividing.anti- againstneo- newplas growth, formation-tic relating toFull entry Close, radiation, and the drugs that stop the body from rejecting a transplanted organ. A sign of infection before surgery is reported, because an infection may mean the operation should wait.

For these patients, strict sterile techniquesurgical asepsisSUR-jih-kul ay-SEP-sisPractices that keep an area or object completely free of microorganisms; also called sterile technique.a- withoutsepsis decay, infectionFull entry Close is even more vital (chapter 26). They may also have skin lesionslesionLEE-zhunAn area of tissue that has been damaged or has changed from normal, such as a sore, wound, lump or spot.Full entry Close, poor nutrition, painful joints and weakness, so extra people may be needed to move them, padding goes over wasted tissue and bony areas, and blankets and drapes are placed gently over painful sores.

AST's position is that every patient, including a patient with AIDS, receives safe, high-quality, individual care, with the CDC's precautionsprecautionprih-KAW-shunA step taken ahead of time to prevent harm, such as the infection-control practices used with every client.Full entry Close protecting both the patient and the team. Show compassion and professionalism, and never let a disease's stigmastigmaSTIG-muhNegative beliefs and labels that society attaches to a condition or group of people, leading to shame and unfair treatment.Full entry Close change your care. Keep the patient's diagnosis confidential, as for every patient.

Patients in isolation

A patient on transmission-based precautionsisolation precautionseye-suh-LAY-shun prih-KAW-shunzExtra infection-control measures, added to standard precautions, for clients known or thought to have certain contagious infections.Full entry Close (chapter 10) is often lonely. Isolation cuts the patient off from visitors and from ordinary contact with caregivers. Some patients feel unclean, rejected or guilty, and studies link isolation to more depression and anxiety, and it is especially hard on children. Gowns, gloves and respiratorsrespiratorRES-pih-ray-terA close-fitting mask or hood that filters the air a person breathes to protect them from germs or harmful particles.Full entry Close can make care feel cold and impersonal.

So make the extra effort. Explain why the precautions are needed, take time to listen, and never rush care in a way that tells the patient they are unwanted. In surgery, communicate and reassure, so the patient knows they are still cared for.

Patients with diabetes

A high blood sugarhyperglycemiahy-per-gly-SEE-mee-uhA blood glucose level above normal, over 100 mg/dL when fasting.hyper- aboveglyc/o sugar-emia in the bloodFull entry Close slows healing and raises the risk of a surgical site infection, so the blood sugar is checked before, during and after surgery. Surgery upsets the patient's meals and insulininsulinIN-suh-linA hormone made by the pancreas that lets the body's cells take in glucose, also made as a medicine.Full entry Close, so a patient with diabetes is best scheduled as the first case of the day. Poor circulation and lost feeling put the skin at risk, so padding over bony areas matters, especially in a long case. Chapter 9 teaches diabetes and its care around surgery.

An unhealthy body weight

The body mass index (BMI) compares weight with height. For adults, the CDC's categories are: a BMI under 18.5 is underweight, 18.5 to 24.9 healthy weight, and 25 to 29.9 overweight; 30 or more is obesity, and 40 or more severe obesity (class III, also called morbid obesity).

Patients with obesity face higher risks of airway trouble, breathing problems, blood clots, pressure injuriespressure injuryPRESH-er IN-juh-reeDamage to the skin and the tissue beneath it from pressure, or pressure with shear, usually over a bony area or under a device.Full entry Close, wound infection and a wound that opens, and many also have diabetes or heart disease. The bariatric table, positioning aids, long safety straps and transfer devices are ready before the patient arrives (chapter 31).

Moving and handling a patient with obesity takes planning to prevent injury to the patient and the staff, and it must also protect the patient's dignity and give emotional support. Check your own attitude: a remark or a look about a patient's size wounds their esteem.

An underweight or malnourished patient heals poorly, and with little padding over the bones is at higher risk of a positioning injury.

Intellectual and developmental disability

Developmental disabilitiesdevelopmental disabilitydih-vel-up-MEN-tul dis-uh-BIL-ih-teeA lifelong condition, starting in childhood, that limits a person's physical, learning, language or behavior skills.Full entry Close are a large group of conditions that affectaffectAF-ekt (stress on the first syllable)In mental health, the outward expression of a person's emotions, as seen in the face, voice and body language.Full entry Close movement, posture, thinking and behavior, such as cognitive and learning disabilities and autism spectrum disorderautism spectrum disorderAW-tiz-um SPEK-trum dis-OR-derA lifelong difference in brain development that shapes how a person communicates, relates to others and experiences the world.Full entry Close. An intellectual disabilityintellectual disabilityin-tuh-LEK-choo-ul dis-uh-BIL-ih-teeA condition that starts in childhood with limits in thinking and learning and in everyday living skills.Full entry Close limits thinking and everyday adaptive skills, and it shows itself during childhood. Each person expresses their condition in their own way, shaped by their personality, their surroundings and their past experience of health care.

The person comes first. Use words that respect the person: "a person with a disability," "a child with autism," "a patient who had a stroke," never "a stroke victim" or someone "afflicted with" a condition. Such phrases make the person into the disease.

Many of these patients need nothing more than empathetic, safety-minded care. A patient with a cognitive impairment may find every part of surgery frightening, and their cooperation may be hard to get, so speak to the patient at their level of understanding, and involve the parent, legal guardian or caregiver, especially about the consent. Never talk over the patient as if they were not there. When a patient is agitated, the anesthesia team guides the team to keep them from injury.

Down syndromeDown syndromeDOWN SIN-drohmA genetic condition in which a person has a third copy of chromosome 21.Full entry Close is one example. A patient with Down syndrome may understand more than they can say, and early surgery can be very frightening. Patience builds trust: slow, deliberate movements, a parent or guardian nearby, a quiet room (the scrub may pause the setup until the patient is asleep), a calm voice and a held hand. Low muscle tone, loose joints, a large tongue and a short neck matter for the airway and for positioning.

Autism spectrum disorder. Bright lights, loud noises and strong smells can overwhelm a patient with autism, and changes in routine are very hard for them. An individual plan, built with the family before the day of surgery, helps. It may include:

• the patient's own way of communicating, simple slow requests, and time to respond
• a first case of the day, short waits and as few moves between rooms as possible
• comfort and sensory items, such as a weighted blanket or headphones, and a visit to the OR beforehand
• few staff, the same people before and after surgery, low noise and dim light
• letting the patient keep their own clothes, and placing the IDIDeye-DEE (said as letters)An abbreviation that can mean intradermal, identification, infectious disease or intellectual disability.Full entry Close band after they are asleep

Physical disability

A physical impairmentimpairmentim-PAIR-mentA loss or weakening of a body function or ability, such as sight, hearing, movement or thinking.Full entry Close may be structural, a problem with a part of the body, such as a missing limb, or functional, a limit on what the body can do. Ask the patient which tasks they need help with and which they can manage, and respect their independence.

An absent limb, severe arthritis, contracturescontracturekun-TRAK-cherA lasting shortening and tightening of muscle, tendon, skin or joint tissue that keeps a joint from moving through its full range.Full entry Close, deformity, paralysisparalysispuh-RAL-uh-sisLoss of the ability to move a part of the body, and sometimes loss of feeling in it.para- beside, abnormal-lysis looseningFull entry Close or tremorstremorTREM-erShaking of a part of the body, such as the hands, in small rhythmic movements that the person cannot control.Full entry Close call for extra people and padding when the patient is moved to the table and positioned. A paralyzed patient's wasted muscles leave the skin, nerves and vessels open to pressure injury. Record the patient's assistive devices, such as a wheelchair, walker or prosthesisprosthesispros-THEE-sisAn artificial body part that replaces one that is missing or does not work, such as an artificial leg, joint, eye or heart valve.Full entry Close, and where they were put, so they come back to the patient after surgery, and pass on what help the patient needs when you hand off their care.

Physical or mental trauma

Physical trauma. An injured patient often arrives with little information and little time to prepare, may need several operations at once, and is usually afraid and in pain. Chapter 11 covers trauma itself and chapter 28 the trauma setup.

When a patient may be the victim of a crime, evidence is preserved for the police, by facility policy:

• Cut clothing along the seams, around bullet or knife holes, and put it in a paper bag or a clean sheet.
• Bag the hands, if they need no surgery, to keep any residue on them.
• Never handle a bullet with metal instruments, which scratch the markings. Place it on a gauze sponge and pass it to the circulator for a dry container.
• Document the chain of custody: who handled each item, in what order, where on the body it came from, and when.

Abuse. Some injuries come from abuse. Child abuse often shows as several injuries of different ages, such as old and new fractures. Older adults may be abused or neglected too. The Joint Commission requires hospitals to identify possible victims of abuse, neglect and exploitation and to teach staff the signs; report what you see, by facility policy and the law.

Mental trauma. Post-traumatic stress disorderpost-traumatic stress disorderpohst-truh-MAT-ik STRES dis-OR-derA mental health condition that develops after a person lives through or sees a terrifying event.Full entry Close (PTSD) follows exposure to trauma and brings lasting emotional, psychological and social problems, such as flashbacks, avoiding people and poor sleep. It is often linked with military service, but survivors of rape and young people exposed to violence suffer it too. Surgery, with its cutting, can recall the violence a patient lived through. Patients with PTSD may startle easily, so:

• keep the holding area quiet, and pause the work on your back table and Mayo standMayo standMAY-oh standA small tray on an adjustable stand placed over or beside the patient during surgery to hold the instruments used most often.Full entry Close while the patient is awake in the room
• keep sharps out of sight and out of reach, and approach the patient slowly
• expect that a mask over the face may feel confining
• tell the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close the medicines the patient takes, and include the patient's counselor when possible
• know that many patients with PTSD feel hopeless and some have thoughts of suicide: take seriously a patient who says they will die today, and tell the nurse and the anesthesia provider at once (see Suicide, below)

Trauma-informed care is an approach that recognizes how past trauma shapes a person's reactions to health care, and aims above all to avoid traumatizing them again.

A mental health history

A mental health disorder becomes a disability when a person cannot manage its symptoms well enough to keep up daily life. Stigma, the negative attitudes and discrimination around mental illness, is still found among health workers. Treat a patient with a mental health history with the same respect as any other, and listen to what they need: a trusting relationship protects their dignity.

A patient with an anxiety disorderanxiety disorderang-ZY-uh-tee dis-OR-derA mental health condition in which anxiety is excessive, lasting and hard to control, and gets in the way of daily life.Full entry Close may need extra calming (see Fear and anxiety). The anesthesia provider needs to know every medicine the patient takes for their mental health. Older adults are often screened for depression before surgery, because depression and a lack of social support are linked to poorer outcomes.

A substance use history

Alcohol and drugs change how a patient responds to anesthesia. Heavy drinkers may need more anesthetic, and some drugs deepen the sedation and can cause respiratory failurerespiratory failureRES-pur-uh-tor-ee FAYL-yerA state in which the lungs cannot put enough oxygen into the blood, or cannot remove enough carbon dioxide from it.Full entry Close or heart problems. Patients may not answer honestly, so questions are asked directly, in a caring, nonjudgmental way, and daily drinking is reported to the anesthesia provider. Substance usesubstance useSUB-stuns YOOSThe use of alcohol, tobacco, drugs or medicines not as prescribed; when it causes harm, it is called substance use disorder.Full entry Close also raises the risk of a poor outcome, readmission and another operation.

A patient who arrives under the influence for planned surgery usually has it cancelled; in an emergency the team takes special precautions. After surgery, a patient may go into withdrawalwithdrawalwith-DRAW-ulThe physical and mental symptoms that occur when a person stops or cuts down a substance the body has come to depend on.Full entry Close; suddenly stopping alcohol can bring seizuresseizureSEE-zherA sudden burst of abnormal electrical activity in the brain that changes movement, feeling, behavior or awareness.Full entry Close, delirium or even death, so they are watched closely.

A patient's behavior can range from violent to calm, depending on what they took and how much, and many also have a mental health disorder. A counselor or social worker can help the team and the patient, and a family member or counselor can tell the team ahead of time what mood to expect. AST supports surgical technologistssurgical technologistSUR-jih-kul tek-NOL-uh-jistA member of the operating room team who prepares the sterile field and instruments and hands them to the surgeon.Full entry Close in helping to prevent opioidopioid analgesicOH-pee-oyd an-ul-JEE-zikA strong drug that relieves moderate to severe pain by acting on the brain and spinal cord.Full entry Close misuse and in helping people with addictionaddictionuh-DIK-shunA long-term condition in which a person keeps using a substance or doing a behavior despite the harm it causes.Full entry Close find treatment. Chapter 15 covers substance abusesubstance abuseSUB-stuns uh-BYOOSAn older term for using alcohol or drugs in a harmful way; today it is usually called substance use disorder.Full entry Close in a coworker and in yourself.

8How people see death

Death is the end of the body's life functions, but what death means differs with each person's culture and spiritual beliefs. A person's feelings about dying can move between fear and peace and change over time.

Caregivers

How health workers react to a death depends on their past experience with death, the support around them, their beliefs and values, what they know about dying, and their own emotional health. Many find caring for the dying deeply rewarding. Others are troubled by it, especially when a death stirs up an old loss.

Health workers sometimes judge a patient's faith against their own. By definition, a spiritual belief is valid for the person who holds it, and it needs no one else's approval.

Families

Families react to dying and death in many ways. Grief may come with anger and frustration aimed at the health care system, at each other, even at the person who is dying. At the same time, families must make hard decisions, about palliative carepalliative carePAL-ee-uh-tiv KAIRCare that relieves pain, other symptoms and stress for people with serious illness, at any stage and alongside other treatment.Full entry Close or DNRdo-not-resuscitate orderdoo-not-rih-SUS-ih-tayt OR-derA provider's order that CPR will not be started if the client's heart or breathing stops.Full entry Close status, and handle forms and funeral plans that can feel cold in the middle of grief. A death can also bring money worries and shift responsibilities to others in the family.

How a family copes depends on how close it is, how its members talk and show feeling, and the support around them. Some people want to be alone at the time of a death; others want their whole community around them. When you are not sure what a family member wants, ask a simple question and offer help.

Culture, ethnicity and religion

Across cultures, death is often defined by spiritual beliefs, and meaning in life and death is often tied to spiritual hope. The rituals families observe help them fulfill their duty to the person who is dying, and they comfort the living; in many cultures they are believed to comfort the dead as well. In many cultures death is seen as a natural end to a serious illness, rather than a battle that was lost. People who follow no religion have their own views of death, and those deserve the same respect.

Groups differ in how they see end-of-life careend-of-life careEND-uv-LYF KAIRThe care given to a person and their family in the last days, weeks or months of life.Full entry Close. Some families believe treatment should go on as long as possible and that only God decides when a person dies; others are uncomfortable talking about death or being near the body. Never assume which a family is: ask.

Questions like these help you learn what a family needs at a death:

• Should a religious leader come to pray or give a blessing, such as anointing?
• Does the family want to stay with the person who is dying, and with the body afterward, until transport?
• Does the family want to wash and dress the body, or have only people of the same gender care for it?
• Should the body lie facing a certain direction, or wear special clothing or a religious item?
• Are there wishes about autopsyautopsyAW-top-seeAn exam of a body after death to find the cause of death or to study a disease.Full entry Close, organ donation, embalming, cremation or shaving?

As long as a practice does not conflict with health and safety standards, it is carried out with dignity and respect. Postmortem carepostmortem carepohst-MOR-tum KAIRThe care given to a person's body after death, preparing it with respect for the family and for transport.Full entry Close that conflicts with the patient's religion is not performed.

9Causes and definitions of death

Causes of death

The Core Curriculum sorts causes of death into five kinds, and the kind of death shapes how the family and the community respond:

• Accidental: an event caused by the person who died or by others, such as a vehicle crash, an accident at work, violence, or a natural disaster. Accidental deaths may lead to lawsuits, and evidence may need to be preserved.
• Prolonged (chronic): death from a long-term condition, one that lasts more than a few weeks, often for life, and is managed over the long term, such as kidney disease.
• Sudden: death without warning, such as cardiac arrestcardiac arrestKAR-dee-ak uh-RESTThe sudden stop of the heart's pumping, so blood no longer reaches the brain and body.Full entry Close or sudden infant death syndromesudden infant death syndromeSUD-un IN-fent DETH SIN-drohmThe sudden, unexplained death of a baby under 1 year old, usually during sleep, where no cause is found after full investigation.Full entry Close (SIDS). In the United States, cardiovascular disease is the most common cause of sudden death. Sudden death is often the hardest for families, because nothing prepared them.
• Suicide: death caused by intentionally harming oneself (see Suicide, below).
• Terminal: death from a disease that cannot be cured and keeps progressing, such as cancer that has spread or end-stageend-stageEND-stayjDescribes the last stage of a long-term disease, when an organ has almost stopped working.Full entry Close liver diseaseliver diseaseLIV-er dih-ZEEZAny condition that damages the liver or keeps it from working normally.hepat/o liverFull entry Close. Families usually expect it.

The death certificate records both the underlying cause and the direct cause: a patient's underlying cause may be kidney disease while the direct cause is cardiac arrest.

When does life end?

The end of lifeend-of-life careEND-uv-LYF KAIRThe care given to a person and their family in the last days, weeks or months of life.Full entry Close is the time in which a patient is expected to die, usually within days, weeks or months. It begins when attempts to prolong life stop or can no longer help. Comfort carecomfort careKUM-fert KAIRCare that aims to relieve pain and distress and give the best quality of life, rather than to cure, usually near the end of life.Full entry Close goes on: the end of life only means that death can no longer be avoided.

The Core Curriculum names three definitions of death:

• Cardiac death, also called circulatory death: the irreversible loss of heart and lung function, so that the heartbeat and breathing stop for good.
• Whole-brain death: the permanent loss of every function of the whole brain, the brain stembrain stemBRAYN STEMThe lowest part of the brain, which connects it to the spinal cord and controls breathing, heart rate and other automatic functions.Full entry Close included. Machines can keep the heart beating and the lungs breathing, but the person has died. In the United States, brain death is death, legally and medically.
• Higher-brain death: the irreversible loss of the higher brain's functions, such as awareness and thought, while the brain stem still runs breathing, blood pressure and the heartbeat without a ventilatormechanical ventilationmeh-KAN-ih-kul ven-tuh-LAY-shunBreathing support from a machine, a ventilator, that pushes air into the lungs through a tube or a mask.Full entry Close.

In the United States, the Uniform Determination of Death Act (1981) says that a person who has suffered either the irreversible loss of circulatory and respiratory function, or the permanent loss of every function of the whole brain, brain stem included, is dead. Higher-brain death alone is not legal death, because the brain stem still works. States word their definitions somewhat differently, and each hospital sets its criteria for declaring death, so learn yours.

A comacomaKOH-muhA deep state of unconsciousness in which a person cannot be woken and does not respond with purpose.Full entry Close is not brain death.

Determining death

Determination of death is the formal medical process of deciding that a person has died. It follows set medical criteria, because the decision has legal consequences. When a patient dies in surgery, the surgeon and the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close determine death.

To determine brain death, physicians look for no response to any stimulus, no cranial nervecranial nerveKRAY-nee-ul NERVOne of the 12 pairs of nerves that come straight from the brain and brainstem rather than the spinal cord.Full entry Close reflexesreflexREE-fleksAn automatic body response to something that stimulates it, which happens without thought, such as the knee jerk.Full entry Close, and no breathing on an apneaapneaAP-nee-uhA pause in breathing, or breathing that has stopped.a- without-pnea breathingFull entry Close test, after ruling out drugs and a low body temperature as the cause. A neurologist usually examines the patient, and two physicians generally do so, with set time between the exams. Further tests, such as an EEGelectroencephalogramih-lek-troh-en-SEF-uh-loh-gramA test that records the electrical activity of the brain through small sensors placed on the scalp.electr/o electricityencephal/o brain-gram recordFull entry Close of the brain's electrical activity or a radionuclide (nuclear medicine) scan of the brain, are used when needed, but they are not required. Brain death is not diagnosed in a premature newborn. Physicians involved with transplants do not take part.

10Grief and loss

Grief is the emotional response to a loss. Mourning is the outward expression of grief, much of it shaped by culture, and bereavementbereavementbih-REEV-mentThe period of grief and mourning after the death of someone close.Full entry Close is the period of sadness after a death. Everyone grieves differently and at their own pace.

The Kübler-Ross stages

In the 1960s the Swiss psychiatrist Elisabeth Kübler-Ross described five stages that people facing death, and people grieving a loss, may pass through. They are not separate steps, and they do not come in a fixed order: a person may move back and forth, repeat a stage or skip one.

1. Denialdenialdih-NY-ulRefusing to accept or believe a painful fact or situation, often without being aware of doing so.Full entry Close: "This cannot be happening." Denial protects the mind from the full shockshockshokA life-threatening state in which blood flow is too low to bring enough oxygen to the body's tissues.Full entry Close until it is ready.
2. Anger: at oneself, the family, the staff or a higher power. A grieving person's anger may land on you. It is not a personal attack: give them a safe place to say it, while keeping professional boundariesprofessional boundariespruh-FESH-uh-nul BOWN-duh-reezThe limits that keep the nurse-client relationship focused on the client's needs and not on the nurse's own.Full entry Close.
3. Bargaining: trying to make a deal to change or delay the outcome, such as "If I pray every day, maybe I will live."
4. Depression: deep sadness that makes everyday tasks hard. True clinical depression may develop, and today it is treated rather than accepted as part of dying.
5. Acceptance: the person understands the loss and can cope with it. Acceptance does not mean the sadness is gone.

Critics say the stages are too rigid for something so personal, and newer work stresses that each person's response to death is their own. The Kübler-Ross model is still often cited as a basic study, and it is the one the Core Curriculum names.

Other kinds of grief

• Normal griefnormal griefNOR-mul GREEFThe usual feelings, thoughts and behaviors that follow a loss, such as a death.Full entry Close includes disbelief, yearning, anger and sadness, and most people recover enough within about a year.
• Anticipatory grief comes before a loss, such as while a family cares for someone with dementiadementiadih-MEN-shuhA long-term, usually worsening decline in memory and thinking that is serious enough to affect daily life.de- away fromment mind-ia conditionFull entry Close or a terminal illnessterminal illnessTUR-mih-nul IL-nisAn illness that cannot be cured and is expected to lead to death.Full entry Close.
• Complicated grief is grief that is prolonged, delayed or exaggerated, so the person cannot cope or move through it. It is more common after a traumatic, violent or sudden death, the death of a partner, and the death of a child. Signs include long-lasting anxiety, symptoms of PTSDpost-traumatic stress disorderpohst-truh-MAT-ik STRES dis-OR-derA mental health condition that develops after a person lives through or sees a terrifying event.Full entry Close, survivor guilt, substance misusesubstance misuseSUB-stuns mis-YOOSUsing alcohol, drugs or medicines in a way that can cause harm, or using a medicine other than as prescribed.Full entry Close, sleep problems and an inability to manage daily tasks; a grief therapist may be needed.
• Disenfranchised grief is grief that others do not acknowledge or support, so the person feels they cannot grieve openly. Examples include the death of a former spouse, a death by suicide or homicide, a miscarriagespontaneous abortionspon-TAY-nee-us uh-BOR-shunThe loss of a pregnancy on its own, before the fetus can live outside the uterus, usually before 20 weeks; a miscarriage.Full entry Close or ended pregnancy, and a death from a stigmatized illness such as AIDSAIDSAYDZAcquired immunodeficiency syndrome: the most advanced stage of HIV infection, when the immune system is badly damaged.Full entry Close.

Children grieve too. Young children may not understand that death is permanent, and through magical thinking may believe a death was their fault. Use the word "death," never "went to sleep" or "went away."

Comforting the dying patient

Your contact with a dying patient in surgery may be brief, but every encounter is a chance to support them.

• Listen and watch. Notice facial expressions, gestures, changes in mood, and signs of fear or loneliness. Listening is often the greatest comfort, though not the easiest. A reply is not always needed, so do not force one.
• Acknowledge death. Never try to minimize, explain away or deny it, but never be blunt or careless either.
• Follow the patient's lead. Let their words and cuescueKYOOA piece of information about a client, such as a sign, symptom, lab value or remark, that the nurse notices and uses to make a judgment.Full entry Close guide you, rather than your guesses about what they feel.
• Never promise a cure. An operation on a dying patient may aim to shrink a tumor or relieve pain. You can speak of the hope of a good outcome, a longer or more comfortable life, without implying the surgery will cure them.

Supporting the family

Families often need help from health professionals, especially after a sudden death. Recognize when tension is building, accept strong emotions as normal, and point the family toward help that brings some order to the experience, such as a support group, the chaplain or counseling.

After a sudden, unexpected death, families first want to know what happened, and they need privacy. Only the physicians and nurses give information about the patient's condition. If a family member asks you, acknowledge the loss with a few kind words, offer to bring the surgeon or the nurse, and help in practical ways: show the way to a private consultation room and make sure it is ready.

Some family members want to touch or hold the person who has died; others do not. Let them choose, and give them the time with their loved one that facility policy allows.

11Quality and quantity of life

Medicine can now keep many people alive who would once have died. Whether to use that power is a personal decision, guided by each person's culture, faith and values: for some, a longer life comes first, and for others the quality of the life that remains matters more.

Self-determination

Self-determinationself-determinationself-dih-ter-mih-NAY-shunA person's right to make their own choices about their life and health care.Full entry Close is every person's right to make decisions about how they live and how they die. A patient may refuse treatment at any point, and may choose which comfort measurescomfort careKUM-fert KAIRCare that aims to relieve pain and distress and give the best quality of life, rather than to cure, usually near the end of life.Full entry Close they accept. When a patient can no longer speak for themselves, the decisions fall to the family or a chosen representative, and conflicts that the family and the team cannot settle may go to the hospital's ethics committeeethics committeeETH-iks kuh-MIT-eeA group in a health care facility that helps staff, clients and families work through difficult moral questions about care.Full entry Close.

Advance directives and DNR

Chapter 15 teaches the law of advance directivesadvance directivead-VANS dih-REK-tivA legal document in which a person states their wishes for medical care, for a time when they cannot speak for themselves.Full entry Close, living willsliving willLIV-ing WILA written legal document that says which medical treatments a person does or does not want if they cannot speak for themselves.Full entry Close and the durable power of attorney for health carehealth care proxyHELTH KAIR PROK-seeA person a client chooses in a legal document to make health care decisions for them if they cannot decide for themselves.Full entry Close, and the three choices for a DNRdo-not-resuscitate orderdoo-not-rih-SUS-ih-tayt OR-derA provider's order that CPR will not be started if the client's heart or breathing stops.Full entry Close order in the OR. In brief:

• An advance health care directive is a document in which a person gives instructions about their medical care in case they become unable to speak for themselves. The names of these documents differ by state.
• A living will states what end-of-life careend-of-life careEND-uv-LYF KAIRThe care given to a person and their family in the last days, weeks or months of life.Full entry Close the person wants or refuses, such as whether to be intubatedendotracheal intubationen-doh-TRAY-kee-ul in-too-BAY-shunPutting a breathing tube through the mouth or nose into the windpipe (trachea).endo- withintrache/o windpipe-al relating toFull entry Close, put on a ventilatormechanical ventilationmeh-KAN-ih-kul ven-tuh-LAY-shunBreathing support from a machine, a ventilator, that pushes air into the lungs through a tube or a mask.Full entry Close, given drugs to support the blood pressure, shocked for a dangerous heart rhythm, or fed by tube or IV. It is written while the person is still competent.
• A DNR ("do not resuscitate") order is an official request to withhold certain kinds of resuscitationresuscitationrih-sus-ih-TAY-shunEmergency treatment to restore breathing, heartbeat or blood circulation.Full entry Close, usually CPR. DNAR ("do not attempt resuscitation") says the same thing while stressing that the patient chooses to refuse the attempt. Neither means "no treatment": the patient still receives care for their condition. The order is signed and charted, and because a patient may change their wishes, DNR status is checked throughout care and always on admission for surgery.
• A DNIDNIdee-en-eye (said as letters)Do not intubate: an order that a breathing tube must not be placed, even if breathing fails.Full entry Close ("do not intubate") order refuses a breathing tube, and AND ("allow natural death") focuses on comfort while letting death come naturally.
• A POLSTPOLSTPOHLSTA medical order form, signed by a provider and the client, that states the client's wishes about life-sustaining treatment.Full entry Close (Physician Orders for Life-Sustaining Treatment) is a medical order, completed by a health care professional with a seriously ill or frail patient, that travels with the patient and is followed wherever they are. An advance directive, by contrastcontrastKON-trastA dye or other substance given before an imaging test so body parts show up more clearly.Full entry Close, is a legal document any adult can write.

Palliative and therapeutic care

Therapeutic procedures treat or manage a disease, whether elective, such as a pacemakerpacemakerPAYS-may-kerA small device that sends electrical pulses to the heart to keep it beating at a set rate; also the heart's own natural rhythm center.Full entry Close, or urgent. PalliativepalliativePAL-ee-uh-tivDescribing care that eases symptoms and improves comfort and quality of life rather than curing the disease.Full entry Close care relieves symptoms and suffering, to improve the quality of life, and it is not only for the dying. Palliative operations include shrinking (debulking) a tumor, debridingdebridementdih-BREED-muntThe removal of dead, damaged or infected tissue from a wound so it can heal.Full entry Close a pressure wound, placing a feeding tubeenteral feeding tubeEN-ter-ul FEE-ding toobA tube placed into the stomach or small intestine to give liquid food, water and drugs to a person who cannot eat enough by mouth.Full entry Close or dialysisdialysisdy-AL-ih-sisA treatment that removes wastes and extra fluid from the blood when the kidneys can no longer do it.dia- through, apart-lysis separation, looseningFull entry Close access, and placing a stentstentstentA small tube, often of metal mesh, placed inside a vessel or duct to hold it open.Full entry Close to reopen a blocked bile ductbile ductbyle duktOne of the tubes that carry bile from the liver and gallbladder to the small intestine.Full entry Close.

HospicehospiceHOS-pisCare for people expected to live about six months or less, focused on comfort and quality of life rather than cure.Full entry Close is comfort care at the end of life, for patients expected to live six months or less, with no treatment aimed at a cure. Palliative carepalliative carePAL-ee-uh-tiv KAIRCare that relieves pain, other symptoms and stress for people with serious illness, at any stage and alongside other treatment.Full entry Close, by contrast, can begin at any stage of a serious illness and can go on alongside curative treatment.

Life support and life-sustaining therapy

Life-support systems and life-sustaining therapy keep a patient alive when the body cannot: mechanical ventilation, feeding tubes, IV fluids and IV nutrition, dialysis, drugs to support failing organs, defibrillationdefibrillationdee-fib-ruh-LAY-shunAn electric shock given to the heart to stop a chaotic, life-threatening rhythm so a normal rhythm can return.Full entry Close and heart-lung bypass. Care that adds no undue burden is sometimes called "ordinary" means, and care whose burdens outweigh its benefits, or that is simply futile, "extraordinary" means.

Families find it very hard to decide when to continue life support and when to stop it, and stopping fluids and feeding is often the most painful choice. The team explains what withdrawing care will mean without taking away the family's right to decide. Removing a ventilator or other life support when it can no longer help, and only prolongs dying, is sometimes called terminal weaning.

The right to die and euthanasia

Some people believe they have a right to die, and they may refuse treatment to claim it. Not treating a dying patient is very different from acting to cause death.

• Euthanasia is helping a person die. Active euthanasia is a deliberate act that ends the life of someone who is suffering, such as giving a lethal dose of a drug. Passive euthanasia is withholding or withdrawing life-sustaining treatment so the patient dies of their disease.
• Voluntary euthanasia is done at the clear request of the person; involuntary euthanasia violates the person's own right to decide.
• In medical aid in dying (provider-assisted death, also called assisted suicide), a provider prescribes the means and a terminally ill, mentally competent patient takes it themselves. It is legal only where a law allows it, under strict conditions: in the District of Columbia and a number of states, and in some other countries. The US Supreme Court has left the question to the states, and the list changes, so know your own state's law.

When you disagree

Health workers often disagree, privately, with the choices patients and families make. You are still obliged to honor them. In an extreme conflict you may ask to be excused from the patient's care; chapter 15 covers when and how you may step aside. In the end, every health professional has to settle their own ethicsethicsETH-iksThe study of right and wrong, and the principles that guide good conduct and decisions.eth/o custom, character-ics the study ofFull entry Close and accept that others see things differently.

12A death in the operating room

A patient's death in surgery is rare. When it happens, the team follows set steps. They can feel clinical, but they protect the patient's dignity, keep order and meet the law. Every facility writes its own protocol, built on state and federal law, and the details differ between states, hospitals and organ procurement organizations, so learn your facility's before you need it.

Determining death

When a patient dies in surgery, the surgeon and the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close determine death, and the time of death and the actions taken are recorded.

Under The Joint Commission'sThe Joint Commissionthuh JOYNT kuh-MISH-unAn independent US organization that inspects and accredits hospitals and other health care organizations against safety and quality standards.Full entry Close policy, a sentinel eventsentinel eventSEN-tih-nul ee-VENTAn unexpected event in health care that causes a client's death, permanent harm or severe temporary harm.Full entry Close is a patient safety event, not mainly due to the natural course of the patient's illness or condition, that reaches the patient and causes death, permanent harm or severe harm. So a death in the OR is a sentinel event only when a patient safety event, not the patient's illness or injury, led to it. After a sentinel event the hospital must carry out a comprehensive analysis, such as a root cause analysisroot cause analysisroot kawz uh-NAL-uh-sisA structured review after a serious error or harmful event that looks for the underlying system problems that let it happen.Full entry Close; reporting the event to The Joint Commission's Sentinel Event Database is voluntary. Your facility's policy sets how each death is reviewed, and chapter 15 covers incident reportsincident reportIN-sih-dent rih-PORTA written record of an unexpected event in a health care setting that caused or could have caused harm.Full entry Close and sentinel events. One reference calls every death in the OR a sentinel event.

Is it a coroner's case?

A coroner is an official who investigates deaths from unknown or violent causes; depending on the state, the coroner may or may not be a physician. A medical examinermedical examinerMED-ih-kul eg-ZAM-ih-nerA doctor, appointed by the government, who investigates deaths that are sudden, unexpected, violent or unexplained.Full entry Close is a physician trained in pathologypathologypuh-THOL-uh-jeeThe study of disease and its causes and effects, or the disease changes found in a person or tissue.path/o disease-logy study ofFull entry Close and forensic medicine who investigates the cause and circumstances of a death on behalf of the government.

A coroner's case is a death that the coroner or medical examiner must investigate, with an autopsyautopsyAW-top-seeAn exam of a body after death to find the cause of death or to study a disease.Full entry Close. State law sets the criteria, and they are much alike from state to state. They may include:

• a death in the operating room or the emergency department
• an unwitnessed death, a death soon after admission, or a death after transfer from another facility
• a death in which a crime is suspected, whether the patient was the victim or the offender, such as a homicide
• a suicide, an accident such as a crash or a fall, or a drug overdose
• the death of a person in custody
• a death from an infectious disease that may threaten public health

A coroner's case needs the body exactly as it was at death: every tube, line, drain, catheter and implanted or invasive device stays in place. In some facilities the body stays on the OR table, untouched, until the decision about the coroner is made.

Every specimen taken during the operation becomes the coroner's property. Identify each one with special care and send it straight from the OR as hospital protocol directs, with Standard Precautions. The patient's belongings may also go to the coroner instead of the family. If a crime may be involved, preserve and document the evidence as described under Physical or mental trauma, above, and follow the procedures of the police and the facility.

Finishing the case

The surgeon closes the wound as the facility's protocol directs, and it is dressed. The drapes come off, unless they were already removed during resuscitationresuscitationrih-sus-ih-TAY-shunEmergency treatment to restore breathing, heartbeat or blood circulation.Full entry Close, and the instruments and supplies are handled as at the end of any case (chapter 30).

A sudden death shakes everyone in the room, and it will shake you. You still have duties to finish: keep your attention on the counts, the specimens and the field until they are done, then let yourself feel what happened (see When death touches the team, below).

Documentation

The records of the operation are completed as for any case, with an accurate account of the chain of events: the operative record, the anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close record, the counts and every usual form. The attending physician and the anesthesia provider document the death itself, and the death is registered on a separate legal document, the death certificate, completed by the attending physician or the coroner or medical examiner. When death is pronounced in the OR, the members of the team are named in the documentation.

The records of a death also show who was told and when, any tubes and lines left in the body, the belongings and who received them, and where the identification tags were placed.

Who is told

The Core Curriculum names four groups to notify, and federal rules add a fifth:

• The perioperativeperioperativepair-ee-OP-er-uh-tivRelating to the whole time around a surgery: before, during and after it.peri- aroundoperative relating to surgeryFull entry Close manager. The OR supervisor is told right away and calls the people who must act, alerting the morgue, the coroner or the PACU.
• The family and significant others. The surgeon tells them, in a quiet, private room near the department or the PACU.
• The chaplain and clergy. Calling the family's own clergy is usually left to the family. Hospital staff call the chaplain, or the patient's religious leader if the family has not already.
• The organ procurement organization. Federal rules require the hospital to report every death, and every death expected soon, to the organ procurement organization (see Organ and tissue donation, below).
• The mortician. The family chooses a funeral home, often with the staff's help, and the funeral director takes the body once any examination or donation is complete.

If a patient dies in the PACU instead, the family is told, the surgeon meets with them, and a staff member stays with them for support.

Preparing the body

Postmortem carepostmortem carepohst-MOR-tum KAIRThe care given to a person's body after death, preparing it with respect for the family and for transport.Full entry Close is the physical care of the body that prepares it for the family to view and for the mortuary. Every facility defines exactly how it is done, a coroner's case has its own protocol, and everyone who does it must know the protocol well. The patient may be moved to the PACU or another room for it, and the surgical team may do the first steps of preparing the body for the family.

Changes in the body after death. Death brings changes you will see:

• The body begins to cool (algor mortis).
• The sphincterssphincterSFINGK-terA ring of muscle that tightens to close an opening or passage in the body and relaxes to open it.Full entry Close relax, so urine and stool may pass. The eyes stay open and the jaw drops.
• Blood pools in the lowest parts of the body and colors the skin purple or red (livor mortis). The color cannot be reversed by embalming, and the face is protected from it by raising the head. Areas under pressure, such as over the sacrumsacrumSAY-krumThe large, triangle-shaped bone at the base of the spine, between the two hip bones.sacr/o sacrumFull entry Close, fill with fluid, and the tissue can break down.
• The muscles stiffen (rigor mortis). It begins about 3 to 4 hours after death, lasts about 24 hours, and then fades as enzymesenzymeEN-zimeA protein that speeds up a chemical reaction in the body without being used up.Full entry Close break down the cross-bridges in the muscle. It starts at the head, at the eyelids, and moves down to the feet. References give different times: one says it begins about 15 minutes after death, another that it peaks at 12 to 18 hours and is gone by 48.

Postmortem care, when it is allowed. Use the facility's postmortempostmortempohst-MOR-temAfter death.post- aftermortem deathFull entry Close kit and follow its protocol. Typical steps:

1. Confirm that the provider has pronounced death, and find out whether an autopsy, a coroner's investigation or a donation is planned, because each one limits what you may remove.
2. Identify the patient with two identifiers. Wear gloves, and a gown if body fluids may splash.
3. Handle the body gently and with respect at all times.
4. Raise the head on a pillow as soon as you can, so blood does not pool in the face and discolor it.
5. Gently close the eyes, and leave dentures in the mouth to keep the shape of the face.
6. Remove tubes and lines only as the policy allows, and never in a coroner's case, before an autopsy or for a donation unless you are told to.
7. Clean any soiled areas, put on clean linen, comb the hair, and cover any wounds or signs of trauma. Ask whether the family wants to help, or has requests, such as special clothing or a religious item.
8. Make the space clean, quiet and private, with soft light, and offer the family the chance to view the body and say goodbye in their own way.
9. Keep the belongings that stay with the body, such as a wedding ring, give the rest to the family, and document who received what. Attach the identification tags and the shroud as policy directs, and cover the body for transport.

Law and policy

State laws define death, set what makes a coroner's case, and govern autopsy; federal rules require every death to be referred to the organ procurement organization; and hospital policy turns these into the steps you follow. Know the conditions for a coroner's case in your own state.

13Organ and tissue donation

Organ recovery is the removal, preservation and use of organs and tissues from a person who has just died, for transplant into a living person. One donor can help many people, and every day patients suffer or die because no organ or tissue is available for them. AST fully supports organ donor programs.

What can be given

• Organs: the heart, lungs, liver, kidneys, pancreaspancreasPAN-kree-usA long, flat gland behind the stomach that makes digestive enzymes and the hormones insulin and glucagon.pan- allcreas fleshFull entry Close and intestine, most often the kidneys, liver, heart and lungs. Even hands and faces can be transplanted.
• Tissues: the corneascorneaKOR-nee-uhThe clear, dome-shaped layer at the front of the eye, over the iris and pupil.Full entry Close, skin, bone, cartilagecartilageKAR-tih-lijFirm, smooth, rubbery tissue that cushions joints and gives shape to parts such as the ear, nose and windpipe.chondr/o cartilageFull entry Close, tendons and ligaments, heart valves, blood vessels and the small bones of the middle ear.
• From a living donor: most often a kidney, or part of a liver or a lung, given with informed consentinformed consentin-FORMD kun-SENTA person's agreement to a treatment or procedure, given freely after the risks, benefits and other choices have been explained to them.Full entry Close.

Death comes first

• The dead donor rule: no vital organ is removed until the patient has been declared dead.
• The first priority is always to save the patient's life. Donation is never a reason to give up on a patient or to withdraw care.
• The patient's own care team declares death. The recovery surgeons and the transplant team take no part in declaring death, or in a decision to withdraw care, because their interest in the organs would be a conflict of interest.
• When life support is to be withdrawn, that decision is made before donation is discussed.

Consent

A person can decide ahead of time to be a donor, usually by joining their state's donor registry, often when they get a driver's license, or in an advance directiveadvance directivead-VANS dih-REK-tivA legal document in which a person states their wishes for medical care, for a time when they cannot speak for themselves.Full entry Close. That is called first-person consent.

When the person left no decision, the family is asked. The organ procurement coordinator contacts the spouse or domestic partner, an adult child, a parent, an adult sibling, a legal guardian or another person allowed to decide, and the consent form is signed by the authorized next of kin and a representative of the hospital.

Patients have the right to refuse donation after their death, and that wish is written in the chart. Some faiths and cultures forbid or limit donation, and some people refuse because they fear their organs could be taken before they are truly dead. Most religions support donation.

Since the Omnibus Budget Reconciliation Act of 1986, federal law has required hospitals to have organ procurement protocols to receive Medicare and Medicaid funds. Today federal rules require every hospital to report every death, and every death expected soon, to its organ procurement organization (OPO), and the family of every potential donor learns that donation is possible. A specially trained person, such as an OPO nurse or a transplant coordinator, makes the request to the family; other staff do not raise donation themselves, and most hospitals have staff nurses wait for the OPO. If a family member asks you about donation, bring the nurse; never start that conversation on your own.

Donation costs the family nothing from the time of death, and recovery does not disfigure the body in a way that interferes with viewing or funeral rituals.

Types of recovery

The Core Curriculum names two kinds of recovery, with and without life support. A donor who dies after circulatory death can give organs too, if life support is withdrawn in a planned way:

1. Recovery on life support: donation after brain death. A patient declared dead by brain criteria stays on a ventilatormechanical ventilationmeh-KAN-ih-kul ven-tuh-LAY-shunBreathing support from a machine, a ventilator, that pushes air into the lungs through a tube or a mask.Full entry Close, with drugs and fluids, so blood and oxygen keep reaching the organs. The donor arrives in the OR with the heart beating, and the ventilator is turned off as the organs are flushed with cold preservation solution. The body can look alive, which confuses many families: the machines only keep the organs alive. Most organ donors in the United States donate after brain death. Older references call this donor a heart-beating cadaver.
2. Recovery after circulatory death: donation after circulatory death (DCD). A patient who is not brain dead, most often after a brain injury they cannot survive, may have life support withdrawn, by their own directive or their family's decision. Withdrawalwithdrawalwith-DRAW-ulThe physical and mental symptoms that occur when a person stops or cuts down a substance the body has come to depend on.Full entry Close is planned, in the ICU or the OR by hospital policy. When the heart and breathing stop, the team waits, usually 5 minutes, without touching the patient, to be sure the heart does not start again on its own, and then the patient's care team declares death. Only then does the recovery team begin, and it works fast, because organs are damaged without blood flow. The protocol sets how long the team waits for death after life support is withdrawn, usually about 60 minutes (one reference gives 90): if the heart has not stopped by then, organ recovery is called off, which happens in about 1 in 5 cases. Because the death is anticipated and planned, this is called controlled donation after circulatory death. When the heart stops without warning, as in a patient who arrives dead in the emergency department, donation is uncontrolled, and organ damage usually limits it to the kidneys, or rules it out. About a third of deceased donors give after circulatory death. Older references call it donation after cardiac death, and some call this donor a non-heart-beating donor.
3. Tissue recovery without life support. After a death without support, the organs cannot be used, but tissues that do not need blood flow can be: the corneas, skin, bone, heart valves and blood vessels. They are recovered as soon as possible after death, some in the OR and some in the morgue. One reference calls this donor a non-heart-beating cadaver.

The recovery team and your part

The process runs through organ procurement organizations and tissue banks, which find donors, register the people waiting, and organize each recovery, on call around the clock. A transplant coordinator manages the donor's care until the recovery teams arrive and finds recipients during the procedure.

The OPO brings the recovery surgeons, and a team from a transplant center may travel to recover an organ for its own patient. The hospital may supply scrub and circulating staff, and the recovery can take several hours. You keep strict sterile techniquesurgical asepsisSUR-jih-kul ay-SEP-sisPractices that keep an area or object completely free of microorganisms; also called sterile technique.a- withoutsepsis decay, infectionFull entry Close, as for any operation, and traffic in the room is limited to essential people.

Ice-cold preservation solution to flush each organ, and sterile containers to receive them, are ready before the first cut; the steps of the operation itself are on the Organ Procurement card.

For eye donation, the donor's head is raised on a pillow to limit swelling near the eyes, and the procurement team recovers the eyes within several hours of death.

The donor's body deserves the same respect and dignity as a living patient's. Some perioperativeperioperativepair-ee-OP-er-uh-tivRelating to the whole time around a surgery: before, during and after it.peri- aroundoperative relating to surgeryFull entry Close staff find donation after circulatory death an ethical dilemmaethical dilemmaETH-ih-kul dih-LEM-uhA situation in which a person must choose between two or more actions that each have moral reasons for and against them.Full entry Close; a staff member whose beliefs forbid taking part may decline, and that choice is respected, but it must never stand in the way of the patient's own decision. Many agencies later tell the hospital how the gifts helped their recipients.

Transplantation and its ethics

Organs from deceased donors are allocated by the policies of the national Organ Procurement and Transplantation Network, never swayed by money, political influence, national origin, ethnicity, gender, religion, or citizenship or residency.

Transplantation raises hard ethicalethicalETH-ih-kulHaving to do with what is morally right, or acting in line with accepted moral principles.Full entry Close questions:

• When is a person dead? Law and medicine set criteria for death, yet some people still question them, and donation after circulatory death keeps the question alive.
• Who decides? When the person left no clear wishes, family members may disagree, and some ask whether the family should decide for the person at all.
• Who receives a scarce organ? For example, alcohol-related liver diseaseliver diseaseLIV-er dih-ZEEZAny condition that damages the liver or keeps it from working normally.hepat/o liverFull entry Close is the leading reason for liver transplant in the United States, and it is debated whether people with a recent history of alcohol or drug use should receive organs.
• What does a living donor risk? The donor accepts the risks of an operation, such as bleeding, infection and even death, to help someone else.

Chapter 15 teaches the ethical principles behind these questions, and the transplant operations are taught in their procedure chapters.

Kidney Transplant32 instruments · 2 photos

14Suicide

Suicide is causing one's own death on purpose, by self-inflicted injury, with the intent to die. Depression, abuse, emotional trauma and other mental health disorders are closely tied to it.

What suicide means in surgery

• For the patient. A patient may come to surgery after a suicide attempt, with an injury or an overdose; attempted suicide is considered in every drug overdose, and suicide precautionssuicide precautionsSOO-ih-side prih-KAW-shunzThe safety measures used to protect a client who is at risk of harming or killing themselves.Full entry Close protect the patient from harming themselves again. Care for them with the same respect as any patient, without judgment; follow the facility's suicide precautions, and never leave a patient at risk alone.
• For the law. A death by suicide is usually a coroner's case. A suicide in a health care setting, or within 7 days of leaving inpatient care, the emergency department or certain behavioral health programs, is a sentinel eventsentinel eventSEN-tih-nul ee-VENTAn unexpected event in health care that causes a client's death, permanent harm or severe temporary harm.Full entry Close under The Joint Commission'sThe Joint Commissionthuh JOYNT kuh-MISH-unAn independent US organization that inspects and accredits hospitals and other health care organizations against safety and quality standards.Full entry Close policy.
• For the family. A suicide is sudden and often traumatic, and it leaves families with questions that cannot be answered, along with hurt, anger and deep sadness. Many feel they cannot grieve openly because of how the person died, so the grief is often disenfranchised, and it can become complicated grief.
• For the team. Like any sudden or violent death, a patient's suicide can hit the team hard, with shockshockshokA life-threatening state in which blood flow is too low to bring enough oxygen to the body's tissues.Full entry Close and denialdenialdih-NY-ulRefusing to accept or believe a painful fact or situation, often without being aware of doing so.Full entry Close (see When death touches the team, below).

Medical aid in dying, sometimes called assisted suicide, is a separate legal and ethicalethicalETH-ih-kulHaving to do with what is morally right, or acting in line with accepted moral principles.Full entry Close question, covered under Quality and quantity of life, above.

Warning signs

These raise the risk that a person will consider or attempt suicide: a mental health condition, a substance use disordersubstance use disorderSUB-stuns yoos dis-OR-derA condition in which a person keeps using alcohol or another drug even though it is causing them harm.Full entry Close, hopelessnesshopelessnessHOPE-less-nessA feeling that things will not get better and that nothing a person does can change that.Full entry Close, impulsiveness, isolation, a past attempt or a family history of suicide, the loss of a job, money or a relationship, access to lethal means, and exposure to someone else's suicide.

Warning signs that a person may be about to attempt it include:

• talking about wanting to die, or having no reason to live
• looking for a way to do it
• talking about feeling trapped, or being a burden to others
• drinking or using drugs more
• acting anxious, agitated or reckless, sleeping too much, talking about revenge, or having extreme mood swings
• pulling away from other people

What to do

Whether the person is a patient, a coworker, a friend or a member of your family:

1. Take it seriously, and get help now. For a patient, tell the patient's nurse or the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close at once. If the danger seems immediate, call 911.
2. Ask directly whether they are thinking about killing themselves. Asking does not put the idea into a person's head; many people feel relief at being able to talk about it.
3. Listen without judging, and show that you care.
4. Stay with them, or make sure another caring person does, and remove anything that could be used for self-harmself-harmself-HARMHurting one's own body on purpose, such as by cutting, burning or hitting oneself.Full entry Close.
5. Connect them with help, such as the crisiscrisisKRY-sisA time when a person's usual ways of coping fail and they cannot manage a stressful event.Full entry Close line below.

The same help is there for you. Caring for patients who die, or who try to die, wears on health workers, and many employers offer confidential counseling through an employee assistance program. If you are struggling, reach out.

15When death touches the team

Health workers react to a patient's death in different ways, shaped by their past experience with death, the support around them, their beliefs and values, what they know about dying, and their own emotional health. They may feel what the family feels: shockshockshokA life-threatening state in which blood flow is too low to bring enough oxygen to the body's tissues.Full entry Close and denialdenialdih-NY-ulRefusing to accept or believe a painful fact or situation, often without being aware of doing so.Full entry Close are common after a sudden death, especially when the patient was young or the death was violent.

Sadness, a sense of loss and even frustration are normal parts of caring for the dying. But for some health workers, a death stirs up an old, unresolved loss or a clash of values, and it leads to depression or another serious reaction that affects their life and their ability to cope with stress at work. The emotional toll of caring for others is called compassion fatigue.

So the team needs a structured way to cope: a planned debriefing after the death, spontaneous support from teammates, and organized support groups. Chapter 16 covers the debriefing as a team habit, and chapter 30 as a step at the end of a case.

Coping skills that other health workers have found helpful:

• Talk it through. Going over exactly what happened and why helps the team see the limits of medicine: people cannot control every outcome, especially in the face of a death that could not be prevented.
• Acknowledge your feelings. It often helps to say out loud the sadness, shock or anger you feel, so others can understand and comfort you. Some people prefer to keep their feelings private, and that is respected: no one is pushed to share.
• Take a break from it. The effects of a tragic death in the OR can last for weeks. Lighter talk, or plans that have nothing to do with the death, give the team time to step away, without making the death matter less.
• Look after yourself. Ask yourself whether your coping is keeping up with the stress of the work, and talk with someone you trust, such as a mentor, a counselor or a religious leader.
• Use the help offered. Counseling services, peer support groups, stress management programs and employee assistance programs are there for you.

In a disaster with many deaths, keep working for the patients who can still be saved; chapter 17 covers disaster planning, including support for the staff.

For many health workers, caring for the dying turns out to be deeply rewarding: it teaches them what they value, and it shows them a gift for comforting others that is often why they chose health care in the first place.

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