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.

Euthanasia

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.

Suicide

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.

©M HEMADRI

Follow me on Twitter @HemadriTweets

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.

High Mortality Hospitals Cannot Afford To Pay

In a previous post I showed that most high mortality trusts did not pay bank holiday extra rates/wages to staff for the Queen’s diamond jubilee bank holiday, while most low mortality trusts paid higher wages. 

 

A friend of mine who is an academic wrote back to me and said he could not resist doing a chi square on the numbers and found the p=0.01. I am no don to argue or explain stats but irrespective of statistical significance it is important to probe if there might be a deeper meaning or relevance. 

 

It is important to understand why the high mortality trusts did not pay higher holiday rates. Are they ‘mean spirited’ as the Unite Union portrayed them?

In my mind the underlying reasons are very simple and here it is:

QUALITY IS INVERSELY PROPORTIONAL TO COST 

 

And a high HSMR is broadly speaking poor quality care.

Financial reasons?

It might be something as simple as they had no money left to pay. Now that would be a perfectly reasonable assumption to make. Trusts get paid for activity, things like hernia repairs, aneurysm repairs, cardiac stenting, the kinds of things that you do to make patients get better. As far as I know the NHS tariff system through which the trusts get paid does not include things like deaths or complications. 

But in-hospital deaths are very costly; in-hospital complications are very costly. There is no mechanism for payment for that. So a hospital/trust which has high deaths and complications will obviously not have money to do anything else.

Well, it therefore might turn out that their inability to pay higher wages had no a financial reason at all; it may well be a by product of poor quality. High cost, deficits, losses are all a function of poor quality. 

 

If you pushed them they will come out with something like ‘in this financial climate we would like to channel all our sparse finances directly into patient care’ and you know what, they sure do; their patient care must cost excessive amounts of money due to higher rates of standardised mortality and higher complications.

Cultural reasons?

Perhaps they were unwilling to pay higher rates; management might not have felt the need to 'reward' staff who are unable to produce high quality measured in terms of mortality. Another reason might have been that the money might be better spent in a high mortality hospital in trying to reduce the mortality rather than paying more to staff when the law does not demand that you do so. These are a part of the mental make up and cultural reasons of management. They are right, well, partly right. It is also just possible that well rewarded staff might be motivated to engage in improvement. Works both ways but always difficult to decide which one is right for the given circumstances.

Finally, here is some speculation

But, why did some high mortality hospitals pay staff bank holiday wages? Surely the above arguments apply to them as well. Why did some low mortality hospitals not pay higher bank holiday wages? 

 

Now I am moving into speculation something which I try not to do too often. My gut feeling is that the high mortality hospitals who paid a higher wage are probably going to find reduced mortality soon or at the best they may continue to stay where they without slipping and getting any worse and the low mortality hospitals who did not pay may find their mortality going up or at the best they may stay where they are without getting any better

 

My speculation is an extension of my theory about money in hospitals, the trusts who are doing clinically well might have the spare cash to spend it on staff. If that was indeed the case, the staff deserve it.

©M HEMADRI 

Follow me on twitter @HemadriTweets

HSMR

HSMR

Hospital Standardised Mortality Ratio

M HEMADRI

Preface

This is written on the basis of my understanding of the HSMR after attending a mini-course at the International Forum on Quality and Safety in Healthcare, Amsterdam 2011, taught by Sir Brian Jarman the original designer of HSMR, Paul Aylin of the Imperial College Dr Foster unit and Andre van der Veen (of de Praktijk index the Dutch collaborator of dr Foster). Their methodology and descriptions are publicly available and links are provided at the end.

Introduction

Death is a definite unarguable outcome; that includes deaths in hospitals. Though hospitals are essentially to provide care and save lives there will be some patients who will die in hospital despite the best possible care provided by the hospital and its staff. Using risk assessment models it is possible to calculate the number of patients who could be expected to die in hospital.

The number of actual patients who die in a hospital can obviously be accurately measured. The number of patients who are expected to die in the hospital can be calculated by risk assessment and risk adjustment models. These values are converted into a ratio and expressed as a value. That value would be the value of the Hospital Standardised Mortality Ratio.

In this write up, the basis of the calculation of the model is explained, some questions about the way it works are explained and the implications of the ratio are explored.

Founder/creator of HSMR

Prof Brian Jarman was an exploration geophysicist who worked at Shell and later became a doctor. He is a qualified physician, general practitioner and public health doctor. He developed the HSMR in 1999 at the Imperial College. He was a Senior Fellow at the IHI (where he looked into American HSMRs). He was a panel member of the Bristol Enquiry. He is a former president of the BMA. He is of course the author of innumerable papers, book chapters, member of various committees and boards

Calculating the HSMR

HSMR = (observed mortality/expected mortality) X 100

Observed mortality is the actual number of deaths that happen in the hospital. The expected mortality is based on a reference population. The standardisation is the risk adjustment that is taken into account for the reference population.

In England, the HSMR is based on HES (Hospital Episode Statistics) data with 14 million records and 300 fields of information. The risk adjustments are made for numerous factors including but not limited to age, sex, elective status, socio-economic status, diagnostic subgroup, procedure subgroup, some co-morbidity palliative care, source of admission, ethnicity, month, number of prior emergency admissions and so on.

Clinical risk adjustment takes into account specific biometric data some of the models are Euroscore, ASA, APACHE, POSSUM and so on. But the HSMR risk adjustment model takes into account sociological and operational data. HSMR uses the 56 diagnostic groups which contribute to 80% of in-hospital deaths in England

THE DEBATES AND ARGUMENTS

PALLIATIVE CARE CODING IS INACCURATE AND DISTORTS HSMR

The arguments about HSMR are about not including some of the preferred or favourite variables of some users. For instance, some hospitals feel that they have a palliative care/hospice ward within their premises and that could make their mortality rates high, some hospitals feel that there are no adequate hospice facilities in their area and hence more patients could come into hospital to die thus distorting their mortality rates by increasing it.

Research shows that firstly that the coding of palliative care is unreliable (more about it in an example below) and secondly that HSMR adjusted and non-adjusted for palliative care showed good correlation (i.e. no difference)

HSMR IS BASED ON HES DATA AND NOT ON SPECIFIC CLINICAL RISK DATA

Another argument is that HSMR risk adjustments are based on HES data which does not include specific clinical data on co-morbidity and hence does not account for the clinical complexity of the patients who died. Interestingly, HSMR adjusted and unadjusted for co-morbidity still has a good correlation (i.e. no difference).

In the instance of vascular society data the data showed 8462 cases whereas the HES data showed 32242 cases.

In the case of the ACPGBI (colo-rectal), the database showed 7635 cases when the HES data showed 16346 cases. The ACPGBI/NBOCAP audit was voluntary (it has since then thought to be biased due to under reporting by the latest article on bowel cancer outcomes in Gut on 11 April 2011.)

It seems that the HES data is more complete.

In the ACPGBI database 39% of patients had missing data for risk factors. It seems that the HES data is more accurate for its (HSMR) parameters. (In the same article in GUT published on 11 April 2011 where they analyse cancer survival/mortality they admit they had Duke’s classification missing in 15% of cases – to show that even within the parameters/data they set themselves clinical databases seem to have incomplete data; whereas there was incomplete post code information only in 0.25%).

Research shows that HES-drFoster is as good as or better than clinical models/databases.

COST

The cost of a clinical data base is up to £60 per patient whereas the HES general database is about £5 per patient.

THE ADMISSION DIAGNOSIS IS A POOR INDICATOR WHEN CALCULATING HSMR

Another common feeling is that admission diagnosis based coding could distort HSMR. Again interestingly in UK HES data apparently has no admission diagnosis and hence that is not taken into account in calculating HSMR.

IN SPECIALTIES WITH SMALL VOLUMES OF DEATHS THE HSMR IS NOT VERY USEFUL

Broadly speaking an increase or decrease in the HSMR in specialties with a small number of deaths may not indeed be a very useful way of understanding the issues – hospitals would be better off looking at the outcomes of specific process measures (and their compliance) within those deaths to obtain a better understanding on whether appropriate care was offered.

But for specialties with larger volumes, death as an outcome (increased or decreased deaths) is valid.

CODING IS POOR

That is certainly possible. However change of coding could result in actually increasing the HSMR (due to change in the denominators of the new code)

HSMR AND NON-NHS BEDS

One of the things we hear is mortality in private hospitals and mortality in private beds in NHS hospitals not being considered seriously.

Only 2% of bed usage in UK is non-NHS.

So obviously there is a substantial case for focussing on the NHS.

SOME INSIGHTS FROM SIR BRIAN JARMAN'S TALK

MORTALITY ALERTS & MID-STAFFS

Mid Staffs were sent mortality alerts like dr Foster would do for any other hospital.

Mid Staffs internally looked into 200 deaths and explained it as coding errors – they may well might have been – but subsequently took no notice of overall deaths or HSMR.

At the same time or thereabouts dr Foster looked into coding and found it was average.

Mid Staffs were doing regular clinical audits.

Mid Staffs palliative care coding ('not curable' categorisation) went up from 2% to 60%

CAN HOSPITALS REPORTED AS GOOD BY REGULATORS HAVE PROBLEMS?

Of all the assessments and inspections reports 96% are dependent on self-reported quality measures and only 4% are by external/independent assessment and inspection.

2/3rds of self-reported quality measures are incorrect.

WHAT CAN WE DO TO GET A START ON REDUCING MORTALITY

ADVERSE EVENT REPORTING

Hospitals with high adverse event reporting have low mortality. When hospitals start looking a mortality they start by encouraging increased adverse event reporting which then goes up by 4 times.

CARE BUNDLE APPROACH

We will all recall the hospital where trial patients developed severe organ failure. That was as a result of a private company hiring the hospital facilities for their drug trial. The NHS hospital itself at that time was doing just about okay. One of the senior nurses there took the care bundle approach to move to the hospital with the lowest mortality in England.

FINALLY AN ASIDE

Looking into mortality can be a threat to longevity.

Sir Brian says that there were assassination threats to the Bristol enquiry panel of which he was a member. Apparently there were people very upset that the panel refused to look into morbidity and stuck only to mortality investigation.

PERSONAL VIEWS

All the above is 'as heard' from the mini-course that I attended. My personal observations/views follow below from this point and hence cannot be attributed to the speakers of the course.

HSMR is a valid way of looking at mortality and is an excellent indicator of quality of healthcare provided by any healthcare organisation. Ignoring or explaining away HSMR and its related alerts have a huge underlying risk which may come back and bite very severely.

PROCESS MEASURES AND OUTCOME MEASURES

Michael Porter says measuring process is servitude and measuring outcome is liberation.

We should have a clear understanding of process measures and outcome measures. The new white paper's core theme is better outcome.

If we are achieving 4 hours, 31/62, 18 weeks, NPSA alert implementation, CQC points, Monitor requirements and so on; good for us but they are process measures.

Process measures have meaning only if they lead to improved outcome measures such as reduced mortality and reduced complications.

WHERE TO FOCUS

Hospitals that are at the higher end of the mortality ratio need to realise and accept that they do have the resources to deal with it. Having self confidence is the first and the best place to start.

That has to be followed by a very deep reflection on the activity, its explanations and results in the context of mortality.

Hospitals need to accept that the HSMR is mostly and broadly right and the alerts are relevant. When there is activity on internal validation of HSMR alerts it cannot be enough to explain coding issues/data validity; internal validation of HSMR alerts can only be accepted if they include a plan to reduce the subspecialty mortality (or risk as the case may be).

What should not be said is 'we are already doing this' or 'we are doing something even better’ when the mortality is not showing a downward trend.

If the mortality is high but regulator's ratings are good the questions to ask are about the accuracy/correctness of the internal reporting mechanisms – however uncomfortable those questions are. Similarly if care bundles are not working and the assumption should be that there is perhaps nothing wrong with the bundles or the patients, perhaps it is the way it is being done. If clinical audits are showing good results and but HSMR is increasing or procedure risk alerts are increasing that should trigger a reflection on whether the hospital is actually looking in the right direction.

A month on month continuous reduction in mortality (HSMR) should be the only acceptable proof. It looks like arguing with the data and explaining it away is no longer an option. If activity does not match the outcome data there may not be much point in attacking the data.

BY THE WAY WHAT ABOUT OTHER PROVIDERS

Dr Foster is not the only provider of analytical and comparative information; there are CHKS and others. It may or may not matter who the provider is; the point is to use the information in a way that makes a meaningful difference to the patients.


© HEMADRI

Follow me on twitter @HemadriTweets

Check out blog posts on 
Why High Mortality hospitals cannot afford to pay staff well (http://successinhealthcare.blogspot.co.uk/2012/06/any-links-between-bank-holiday-pay-and.html)
What your hospital mortality was in 1998 and if it is any different now?  http://successinhealthcare.blogspot.co.uk/2012/01/mortality-1998-now-what-can-we-learn.html

Links:

Imperial College Dr Foster Unit http://www1.imperial.ac.uk/publichealth/departments/pcph/research/drfosters/

NHS Choices: http://www.nhs.uk/NHSEngland/Hospitalmortalityrates/Documents/090424%20MS%28H%29%20-%20NHS%20Choices%20HSMR%20Publication%20-%20Presentation%20-%20Annex%20C.pdf

Brian Jarman http://www1.imperial.ac.uk/medicine/people/b.jarman/

Mid Staffs public enquiry: http://www.midstaffspublicinquiry.com/