With the hospice movement having become so popular, however, more and more terminally ill people are choosing to die in their own homes or in those of family members, as opposed to in the antiseptic settings of hospital rooms. Hospice nurses and other caregivers are usually present when such a death occurs, or they are quickly summoned if needed. A death in hospice care at a private residence is not considered “death without medical attendance.” For example, when someone is found deceased at home and not under hospice care, the coroner or medical examiner almost always will examine the case. Some counties require a pronouncement of death by a physician. On many occasions I have had to transport a deceased loved one from his or her place of residence to a hospital, so that one of the doctors on duty could come out to the transport vehicle and pronounce the patient dead. Nine times out of ten, the doctor looks briefly at the deceased and then at his or her wristwatch and says, “Let’s call it 2:45 a.m.” That is declared the official time of death, even though the patient more than likely expired an hour or so earlier.
Very rarely do doctors come out to a funeral home vehicle completely equipped to make a death pronouncement—no flashlight to shine into the eyes and no stethoscope to detect a heartbeat.
It is important, though, to make sure that the patient is actually dead! I have heard of cases of nursing home patients being transported to funeral homes only to “come to life” during the trip. A colleague once told me that he had an elderly man on his preparation room table and was in the process of removing the man’s clothing when the “dead” man suddenly began to moan and move. After a few seconds of freaking out, my colleague called for an ambulance. The old man was very much alive; he was transferred to a hospital to stay overnight and the next day he returned to the nursing home.
Sometimes I have been just about to roll up the cot to the wrong bed in a nursing home, only to hear the person still breathing. Obviously, I needed to attend the bedside of his or her late roommate. At some older nursing homes, patients are bedded in wards, and there are three or four non-ambulatory people in one large room, which is separated into sections by a floor-to-ceiling privacy curtain. Arriving in the dark in the middle of the night, a kindly nurse in charge once commented to me, “Take your pick,” as we surveyed a row of four elderly patients, all of whom appeared to be dead.
Before the invention of the stethoscope, there were some interesting tests for death. The fire test involved holding an open flame to the skin of the potentially deceased. If the skin blistered, then the patient was not dead—skin cannot blister after death. For the mirror test, a small handheld mirror was positioned under the nose or mouth. If the mirror fogged, then there was obviously breath. The water test was administered by placing a glass of water on the chest to detect any motion in the water from the rise and fall of breathing.
Even such fail-safe tests were not trustworthy; that is why the term wake came to be. Today a wake is a visitation period for offering sympathy and support, but originally a wake involved staying awake with the deceased to make sure he or she was in fact dead. If a moan, a twitch, or any other movement took place, then obviously the person was still alive. I imagine such things occurred quite frequently in the late 1800s and early 1900s, when a comatose patient or even someone who had fainted was often assumed to be deceased.
An autopsy may be required for medical or legal reasons—suspected homicide, accident, suicide, or other probable unnatural death. Many teaching hospitals, such as those with a degreed nursing program, or hospitals owned and operated by a university, are required by hospital associations to conduct a certain number of autopsies for teaching purposes.
As an orderly during my college days, I witnessed hundreds of autopsies. As a result, I fervently hope that such a procedure is never performed on anyone in my family. Before proceeding, the pathologist would hand me a notepad and pencil, both already stained with blood from his earlier notations on height, weight, and general appearance. I was the designated stenographer, assigned to note the weight and condition of each organ and any abnormalities detected. I perused the initial notations of the pathologist so that I could be equally descriptive—I didn’t want to appear inexperienced. Standard initial commentary was already present: “A fifty-four-year-old white female, eyes brown in color, natural hair, streaked in gray. Well nourished, with all natural teeth present. Surgical scar on abdomen suggests past hysterectomy, with no other scars or anomalies noted.”
First, a Y incision is made with a scalpel on the chest of the decedent. A large knife pares away the muscle and fatty tissue to expose the ribs. The ribs are cut away with a cast saw to expose the thoracic and abdominal organs for the pathologist’s inspection.
The initial sight of exposed human organs always takes everyone aback. My first glimpse reassured me that there is a God, because all of those organs must work together in perfect synchronization to sustain life, and that’s something so complex that only God could make it possible.
After the initial reaction to the sight comes the shock of odor. Blood reeks after death, as do stomach contents and the contents of the colon. Then you note the vivid colors of human organs: the mottled, black-specked appearance of a lung; the reddish-purple hue of a heart; the grayish-blue tint and the glistening wet appearance of a kidney; the three-lobed liver the color of any calf liver in a supermarket meat case.
The pathologist then used a large knife to open the pericardial sac, the structure that surrounds the heart. With a qualified, deft slice, he released the heart from its moorings. The dripping heart was placed in a stainless-steel basket attached to a ceiling-mounted scale. The heart’s weight is critical; if a heart is heavier than normal, that’s an obvious red flag and probably the cause of death. An enlarged, and heavier, heart sometimes pinches off the nearby arteries, dramatically decreasing the blood flow.
After being weighed, the heart was placed on a cutting board, where the pathologist sectioned it to meticulously search for any abnormality, such as scars from past or recent coronary disease.
The remaining organs were removed and examined in the same fashion, with a few exceptions. The stomach was removed and the contents poured into a stainless-steel container for inspection. The first time I witnessed this procedure I was close to nausea. Stomach acids that had ceased working nonetheless carried the familiar odor of vomit. Certain foods do not digest quickly. Salad greens, broccoli, and baked potato skins are clearly recognizable among stomach contents, as are drug capsule remains. I was once instructed to use a screened ladle, much like a net used in fishbowls, to dip into the stomach of a patient who had potentially ingested many chloral hydrate capsules to commit suicide. It was amazing to know the death was on purpose, which I knew as soon as I scooped out more than forty capsules, some dissolved but some very recognizable.
Probably the most unpleasant part of an autopsy is the procedure called running chitlins: several feet of intestines curled up in the abdomen are pulled out a foot or so at a time by an assistant (me) and then handed to the pathologist, who slices open the structures and inspects the interiors for tumors, restrictions, or any other abnormalities. Part of my duty was also to squeeze the exterior of the intestine to force fecal material out of the way so the pathologist could obtain a clearer view. That particular procedure took a little getting used to, but after a few times, I thought nothing of it.