Tuesday, 18 August 2015

Ancient Art of Dying

The ancient Art of Dying

Fear of Death

The time of our death is almost never in our control (except perhaps where suicide was achieved). The manner in which we die is also almost never within our control. The only fact is that death is inevitable. Thus the concept of the art of dying may not be relevant for an overwhelming majority of human beings. Having said that, every day we live takes us closer to the day we die, hence it is possible in a broad sense to ‘prepare’ for death. The art of dying is to psychologically prepare for death, the main component is to remove the fear of death.

Fear of death is common; humans often fear the unknown. The difference between most other unknowns and death is that a human will not have any perception of the unknown called death simply due to the fact that we will be dead after that and hence not be able to perceive the unknown as we normally do. So the first point is not to fear death from the perspective of our own body and our own mind.

The only other reason for fearing death is the issue of our duties and responsibilities towards our family and communities. This is a difficult one, we do have such commitments and though no one is really indispensable broadly speaking families can severely feel the negative impact of the death of a person who had ongoing responsibilities, typically persons with young children or very old parents. There may really be no resolution to this issue. The philosophical logic by which we may attempt to remove the fear of death in these circumstances are as already stated, we do not control the time or manner of death, death happens to anyone – fearing something that we have no control over and is inevitable is perhaps not rational. However human psychology is unlikely to accept this rationality and that is why the issue is difficult to resolve.

Fear of illness

It is possible, in fact likely, that most of us when we think we fear death, we may actually be fearing any precursors, pathways, process that lead to death, specifically we probably link that to acute or chronic ill health and their related effects, especially painful effects – no wonder it induces fear. To explain this in simplistic terms we are actually fearing illness but we include death into that spectrum and fear death as well. In some terminal illness situations where illness causes severe pain, death may actually provide relief.

Fear of illness in some contexts could be a motivator for some people to embark on action to attempt to improve their own health with the hope of preventing illness; that is possible in some types of illnesses and generally is a long term issue. While the trigger to act might be a good thing, if the fear persists it becomes very uncomfortable existence psychologically even in the presence of good health.

Good Death

The fear of death and fear of illness makes most of us wish that we have a ‘good death’. Many of us imagine that a good death is when ‘the time comes’ we will die in our sleep and that is what we wish for ourselves. That does happen sometimes. That does not happen sometimes.

Are there other descriptions of ‘good death’?

Quality of Death

Many healthcare professionals are aware of this concept of quality of death, which is when cure is no longer possible and death becomes a probably outcome within a short time span, healthcare professionals would aim for that short time span to be spent or lived in comfort where possible or at least with a lack of distress. Many aspects of terminal care is geared towards the quality of death.


Most of us would have heard the term Euthanasia – literally translates into good death (Eu meaning good or normal; Thanos meaning a wish to die). Currently, it has meandered about a bit and refers to one person helping another to die. In many or most parts of the world it is illegal for someone to help another to die. Where euthanasia is legal it is reserved for terminal illness situations where an individual explicitly desires to end his/her own life and seeks help from another to fulfill that desire. This could be counted as 'good death' in the limited circumstances. There are debates to be resolved in terms of the 'active' nature of this effort, the issue of a second person playing that active role and other related arguments.


Is a very large topic. Suicide is defined as the act of taking one’s own life. It is thus intentional and active. The drivers for suicide are complex and are significantly related to mental health issues and drug issues. Whether suicide counts as good death or comes within the ambit of the discussion of ancient art of dying is questionable and in my view probably not counted as ‘good death’.

In Euthanasia and in Suicide there is an act of commission, seen as possible violence against the soul, this could be the basis of potential arguments against them. 

The Ancient Art of Dying

The ancient art of death is separate and well away from the above concepts. The origins are from ancient Vedic or Hindu practices.

There are a number of terminologies including Mahaprasthna (great journey), Samadhi-marana, Sanyasamarana, Samadhi, prayopavesha and others. The Jain religion has terms such as Sallekana (properly thinning out), Santharan,et al. Veer Savarkar pushed the concept by talking about aatma arpan (surrendering the soul) while the general agreement seems to be that he actually practised prayopavesa.

The modes are primarily two fold, one is literally setting out on a great journey during which death happens without the actual details being ever known (Mahaprasthna). The other more commonly known is by gradual withdrawal from food, by voluntary fasting (Prayopavesa or Sallekana). There are other modes but those are rare, unusual and no longer found in practice (e.g. jal-samadhi - where one simply walks calmly into deep waters).

There seem to be reasonable and clear conditions when one can embark on prayopavesa (or sallekana). The main condition seems to be that there is no purposeful use of the body and mind – i.e. the purpose of life is completed. It is voluntary (meaning that there is competence of the individual’s mind to contemplate and make such a decision). It also a slow process and often a gradual process. It must be announced. The end of natural life should be close e.g. terminal illness. It is overseen by the community (there seems to be no question of sanction or approval by any person or group).

The ancient Vedic based art of dying is thus very different and bears neither resemblance nor comparison to euthanasia, suicide or terminal care; the philosophy and ethical frameworks are almost poles apart; the relevance is also directed differently; we will not debate these right now. There are no external agents, there is only the self and if at all there is an act of omission (rather than an act of commission); it is even questionable whether there is an act of omission due to the gradually adjusted constantly decremental nature of the process.

The art of dying is the culmination of life long practice of renunciation leading on to some individuals deciding to renounce life itself. It happens to be the pinnacle of discipline after numerous varied long term practices based on discipline. Very few are actually able to achieve it, they achieve it by making a deliberate active decision to take up a slow voluntary process to end their physical living. They possibly see it as the ultimate union of the soul to the eternal by a directed effort.

The art of living is relatively easy by comparison to the art of dying. It seems that it is by learning the art of living we can even begin to comprehend the ancient art of dying.

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PS: The concept of the art of dying as written here is not applicable to many of us within the current contexts as it stands. I am hoping it will inform the important debate around death, dying, quality of death, pain before death, etc and we will in time be able to apply the concepts of the art of dying to the contemporary lives of a larger number of people.

Friday, 7 August 2015

Surgical Swab - tail it, tag it, secure - then let us see how many are lost

Retained Swab after surgical procedures

Surgical Swabs – tail it, tag it, secure it – and then let us see how many are retained.

Swabs retained in patients’ bodies after surgical procedures are thought to happen from 1 in 500 to 1 in 5000 patients. However, NHSLA data would suggest that it happens much less often (possibly rarer than 1 in 10000 during caesareans). The point is not about the numbers or frequency or other statistics. Firstly, a retained swab is a completely avoidable complication. More importantly, the impact on patients’ lives can be extremely profound when a swab is left behind with infections, difficulty in diagnosis of the complication, re-operation, all sorts of other complications and death.

The impact on the doctor is also serious though not as much as for the patient. It seems that an average surgeon could have a 1 in 3 or 1 in 4 chance of a retained swab happening by his/her hands.

The primary responsibility for all instruments, needles, swabs and in general, anything that happens during a surgical procedure belongs to the operating surgeon. The primary method now used to ensure that a swab is not left in a patient is operator memory, as we all know memory is a fallible method to ensure patient safety. The adjunct to memory is the intra-operative swab notes/notices where the surgeon tells the scrub nurse a swab is placed within a patient, the scrub nurse tells the runner nurse who writes on the theatre white board and at the surgeon tells the scrub nurse when the swab is removed, the scrub nurse tells the runner nurse who removes the note from the board. This six or eight step communication is prone for failure once again because the initiation point is the surgeon’s memory (remembering to mention) and then simply by the number of steps involved in the communication.  

The current next step currently taken is the end of procedure swab count – this happens at the end of the procedure when swabs are counted and confirmed as matching the number of swabs that were opened for use during the procedure. This is actually not a prevention method, this is technically a detection method to confirm that a swab has not been missed, at the best a secondary method of ‘prevention’. 

When a swab count shows a missing swab x-ray is used to detect if a swab is retained within a patient. Surgical swabs these days have a radio-opaque line so that a retained swab can be detected by an on-table x-ray when the swab count detects a missing swab; this is a tertiary or third order issue for detection of a missed or retained swab and does not prevent the swab going missing in the first place. The x-ray method has a known but rare rate of failure in detecting a retained swab.

We know that the current methods are failure prone. The primary prevention methods are memory based – hence fallible under stressful complex conditions.

The swab count, is post-hoc (post procedure), after the event, hence a swab count does not act as prevention, it only acts as a detection method in an area where primary prevention method is highly fallible.

It is known that mechanical methods are better than memory alone. It is best to agree on a single mechanical primary prevention method so as to either enhance the effectiveness of the secondary prevention or to make it a luxurious yet essential redundant detection mechanism.


In the context of retained swabs, surgical swabs during intra-operative use are of two kinds:

Held swab: one that does not leave the surgeons’ (or the assistant’s hand). The swab can be held in two ways a) directly held (surgeons’ hands) b) indirectly held (swab on a stick)

Free swab: is one that is placed within the patient by the surgeon and does not have contact with the surgeons’ hands for any period of time.

A directly held swab has no risk of being left in the patient – by definition a directly held swab does not end up being a retained swab.

An indirectly held swab has a small risk of ending up retained in the patient if the swab slips unnoticed (this is especially possible in the case of pledgets).

A free swab has the highest risk of being retained in the patient. Hence a primary mechanical prevention method is essential for a free swab, irrespective of the swab’s size or the anatomical site of use. Let us look at a method that could prevent a swab from being retained in the first place.


Tail-Tag-Secure is a must for Free Swabs

TAIL: Free swab must always have a tail (taped swabs) which extends outside the wound/incision. This tail could be part of the swab which is extending out of the wound or a formal tail from the swab.

TAG: At the end of the tail which is outside the wound the tail must always have a tag (clip/artery forceps or other instrument holding on it) so that it does not migrate inadvertently into the wound. 

SECURE (the tag): The purist is welcome to secure this tag (clip/artery forceps or other instrument) to the drape as a third level safety procedure, using another instrument. 

TAIL-TAG-SECURE means there is a constant visual reminder about the swab inside the abdomen and a mechanical hindrance to closing the wound acting as a second level safety mechanism. 

The recommendation is that all Free Swabs (any swab that is within a patient and does not have contact with the surgeons’ hand at any point of time), irrespective of the size of the swab or the anatomical site of its use must have a tail (tape), must be tagged (with a clip, artery forceps or other instrument) and most often be secured (to the drape using another instrument or an adhesive sticker). 

This makes the swab count a needed redundancy in the system which is what a detection method should be rather than the surgeons’ memory or a multi-point communication system both of which are potentially highly unreliable as a prevention methods.

A number of surgeons are already using this method. Obviously when these methods are insisted upon, there will be resistance and arguments that may sound valid; however, we know the current method does not work, we know that a retained swab is completely avoidable, we know that a retained swab is designated as a never event. It is time to look for and implement a different and a better solution – the tail-tag-secure is hence essential.

Electronic chip embedded swabs and routine scanning of patients before closure of the wound would be a technology intensive (and possibly costlier) solution. We may be far away, if at all, from completely absorbable swabs. We don’t know if these would have their own problems.

Current Method of primary prevention
Suggested Method of primary prevention
Memory based (fallible): Surgeon’s memory
Visual and Mechanical methods (more reliable)  
Tail (tape) – Tag – Secure the swab

Multi-person Communication based (fallible): Notes on the theatre board

Detection methods (swab counts, x-ray) remain essential
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