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Osler’s “Study of the Act of Dying” (1900-1904): An Analysis of the Original Data

Osler’s “Study of the Act of Dying” (1900-1904): An Analysis of the Original Data. Paul S. Mueller, MD, MPH, FACP Associate Professor of Medicine Mayo Clinic Rochester. Disclosures. I am a member of the Boston Scientific Patient Safety Advisory Board

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Osler’s “Study of the Act of Dying” (1900-1904): An Analysis of the Original Data

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  1. Osler’s “Study of the Act of Dying” (1900-1904): An Analysis of the Original Data Paul S. Mueller, MD, MPH, FACP Associate Professor of Medicine Mayo Clinic Rochester

  2. Disclosures • I am a member of the Boston Scientific Patient Safety Advisory Board • I am an associate editor for Journal Watch • No off-label use of drugs or devices will be discussed

  3. Objectives • Explain why Osler did the study • Explain why certain data were gathered • Describe the results of the study • Draw conclusions from the study • Describe Osler’s post-study views of death

  4. Sir William Osler12 Jul 1849 - 29 Dec 1919 • Born in Canada • Widely-adored physician who practiced in Canada, the US, and the UK • Highly influential author, educator, researcher, reformer, and civil servant • Family man William Osler

  5. Science and Immortality1904 Ingersoll Lecture at Harvard University • Annual lecture on topic of immortality (still given today) • Osler invited to give lecture multiple times by then Harvard President Eliot • Osler eventually, yet reluctantly, agreed and gave lecture 18 May 1904 • Later published as a book

  6. Science and ImmortalityExcerpt “I have careful records of about five hundred death-beds...Ninety suffered bodily pain or distress of one sort or another, eleven showed mental apprehension, two positive terror, one expressed spiritual exaltation, one bitter remorse. The great majority gave no sign one way or the other; like their birth, their death was a sleep and a forgetting” (p.19).

  7. Why re-examine Osler’s“Study of the Act of Dying”? • A detailed manuscript describing the study and its results was never published, yet the brief quote from Science and Immortality continues to be cited • Analysis would shed light on the attitudes toward death and the dying experience and during Osler’s era • Few similar studies have been done

  8. Resources: Data collection cards and a spreadsheet used by Osler and stored at McGill University JHH administrative records Osler’s papers Methods: Data abstracted from cards and compared to data recorded on Osler’s spreadsheet Methods of the current analysis

  9. Features of Osler’s study • Done at the Johns Hopkins Hospital (JHH) 1900-1904 • Observations of 486 dying patients recorded on data collection cards • Data from cards transferred to a spreadsheet tallied by Osler William Osler (1900)

  10. Data collection card Name blocked out Purpose of the study

  11. Name blocked out Thomas McCrae

  12. Purpose of the study • Printed at bottom of data collection card • “The object of this investigation is to ascertain the relative proportion of cases in which (1) the death is sudden; (2) accompanied by coma or unconsciousness; (3) by pain, dread, or apprehension.”

  13. Osler’s spreadsheet Tallies written by Osler and cited by him in Science and Immortality (“Ninety suffered bodily pain…eleven showed mental apprehension…”)

  14. 429 (89%) cards were signed: 258 (60%) by nurses 139 (32%) by residents 32 (7%) unidentified None of the cards were signed by Osler 149 unique individuals signed the cards: 97 (65%) nurses 34 (23%) residents 18 (12%) unidentified Results: Who completed and signed the data cards?

  15. Osler and nurse Bessie Boley (1904)

  16. Life on the JHH wards1898 Nursing Annual Report, Mary A. Nutting “The head nurses are responsible for the general management of the wards…They are held responsible for every detail in connection with their wards, of which they do not and cannot do the actual work. They are an essential feature of a properly organized and equipped ward.” M.A. Nutting

  17. Results: Acquisition of cases • First case 3 Jan 1900 • Last case 29 Mar 1904 (just 6 weeks before Osler gave the Ingersoll Lecture) • >1-year gaps between card 400 (dated 18 Feb 1901) and card 401 (dated 26 Feb 1902) and between card 463 (dated 20 Jan 1903) and card 464 (dated 5 Feb 1904)

  18. Results: Acquisition of cases †Mortality 6.6% (1449 deaths/21926 patients)

  19. Results: Gender • No place on the data card to record gender; however, gender-specific descriptors (eg, “he”) and names (eg, “Mary”) used for most patients • Breakdown: • Male: 308 (63%) • Female: 169 (35%) • Unknown: 9 (2%)

  20. Nationality: American: 360 (78%) German: 44 (9%) Unknown: 18 (4%) Irish: 13 (3%) Polish: 13 (3%) Other 38 (7%) Religion: Protestant: 171 (35%) Catholic: 69 (14%) Jewish: 19 (4%) “None”: 1 Unknown: 226 (47%) Results: Nationality and religion

  21. Results: Age at death • Recorded for 477 (98%) patients (440 adults, 47 children) • Overall median (range) age at death: 39.0 (0.3-83) years • Gender: female 39.0 (0.8-75), male 40.0 (0.3-83) • Race: black 36.0 (0.3-82), nonblack 40.0 (0.8-83)

  22. Results: Length of illness before death • Recorded for 428 (88%) patients • Overall median (range) length of illness before death: 0.8 (0-81) months • Gender: female 0.8 (0-81), 0.9 (0-48) • Race: black 0.8 (0-26), nonblack 0.8 (0-81) • Age: child 0.3 (0-24), adult 1.0 (0-81)

  23. Results: Cause of death • At the start of the study, the data card had no place to record diagnosis; place added later (first: #288 dated 6 Apr 1901) • Overall, a diagnosis was recorded for 188 (39%) patients From card #288

  24. All (N=188): Infection: 60 (32%) CV: 33 (18%) Surgical: 31 (17%) Cancer: 21 (11%) Nephritis: 16 (9%) Trauma/burns: 13 (7%) Other: 14 (7%) Children only (N=17): Infection: 9 (53%) CV: 1 (6%) Surgical: 2 (12%) Cancer: 1 (6%) Burns: 4 (24%) Results: Cause of death

  25. Men (N=110): Infection: 37 (34%) CV: 27 (25%) Surgical: 9 (8%) Cancer: 11 (10%) Nephritis: 11 (10%) Trauma/burns: 5 (9%) Other: 10 (9%) Women (N=58): Infection: 14 (24%) CV: 5 (9%) Surgical: 19 (33%) Cancer: 9 (16%) Nephritis: 5 (9%) Trauma/burns: 3 (5%) Other: 3 (5%) Results: Cause of deathBy gender (adults only)

  26. Results: “The act of dying”“If sudden” • Recorded for 472 (97%) patients • Sudden: 340 (70%) • Observers specifically wrote “gradual” next to “if sudden” for 46 patients and “quiet” next to “The act of dying” for 42

  27. Results: “The act of dying”“Did respiration stop before pulse?” • Recorded for 330 (68%) patients • Respirations before pulse: 119 (24%) • Time available for 100 patients; median (range) 1 (0.1-10) minutes • Pulse before respirations: 187 (38%) • Time available for 145 patients; median (range) 3 (0.1-240) minutes • Same time: 24 (5%)

  28. Results: “The act of dying”“Coma or unconsciousness” • Recorded for 458 (94%) patients • Coma affected 311 (64%) patients • Length of coma recorded for 296 patients • Median (range) length of coma 3 (0-168) hours • Alert: 147 (30%) patients

  29. Results: “The act of dying”Number of unique patients experiencing discomforts *†41% higher than recorded on Osler’s spreadsheet †79% higher than reported in Science and Immortality

  30. Results: “The act of dying”Number of discomforts experienced by patients *Excludes 24 patients for whom “fear” column marked “yes” *34% higher than reported by Osler †107% higher than reported by Osler; p<0.05 v. spreadsheet

  31. Results: “The act of dying”Specific discomforts experienced by patients Total number of discomforts: 215

  32. Results: Discrepant discomfort data • Most discrepancies are not subtle • 76 (16%) cards had data (84 discomforts) discrepant with Osler’s spreadsheet • Physical discomforts: 37 (pain 22, dyspnea 23) • Mental discomforts: 47 (fear 17, anxiety 15, irrational 12)

  33. Physical (N=37) Pain: 22 (for 4 patients, pain was marked as “yes” on Osler’s spreadsheet, but not on the cards) Dyspnea: 12 Convulsions: 3 Mental (N=47) Fear: 17 Anxiety: 15 Irrational: 12 Mental “yes”: 2 Depression: 1 Results: Discrepant discomfort data

  34. Specific spreadsheet-data card discrepanciesCard #47

  35. Specific spreadsheet-data card discrepanciesCard #194

  36. Specific spreadsheet-data card discrepanciesCard #314

  37. Specific spreadsheet-data card discrepanciesCard #408 “For about 10 minutes before death the patient was in a condition of acute mania. He fought with the orderlies, bit one and was restrained with difficulty.” Osler’s spreadsheet also marked “none” for each

  38. What conclusions can be drawn from the study results? • Nurses played a major role in the study; Osler had little direct involvement • Data collected suggest nearly constant bedside presence of observers who completed the data cards • Dying patients were young • Median length of illness before death was brief; shorter for children

  39. What conclusions can be drawn from the study results? • Most common cause of death infectious diseases; causes differed by gender • A majority experienced coma before death; median duration of coma brief • More patients (38%) experienced discomforts (mostly physical) than reported by Osler (21%) in Science and Immortality

  40. What prompted Osler to do a study of dying?Personal interest • 1872: to investigate causes of death among the “highest objects” of the physician • Entries in his pocket “day books” • Plans for lectures and essays (eg, “On the Hour of Death”) • Numerous volumes on death, dying and related topics in his personal library

  41. What prompted Osler to do a study of dying?Popular opinion and fears Death viewed as the “King of Terror.” Why? • Decline of religious faith • Reduced death rates, especially due to infectious diseases; death primarily affects elders with chronic diseases • Rise of science, and hospitals; death medicalized and moved from home to hospital • Death becomes “foreign” to most

  42. What prompted Osler to do a study of dying?Osler openly disputed the popular opinion • Osler, like many physicians of his era, refuted the popular opinion that death was accompanied by suffering: • 1888 article: death a “sleep and forgetting” • 1893 lecture: death “accompanied with pleasure rather than with pain” • Nevertheless, empirical data about death were sparse; Osler was a naturalist

  43. Why were certain data gathered? • Popular concerns about “apparent death,” the nature of the exact moment of death and about discomforts associated with the dying process • Physician interest in modes of death: • Sudden versus gradual • Cardiac versus respiratory • Presence or absence of coma

  44. Why were the results reported by Osler inaccurate? Possible reasons: • Osler did not carefully examine data cards (he did not sign any of them) • Confusing layout of data cards • Osler did not complete the spreadsheet • Osler inaccurately tallied the spreadsheet • Haste

  45. Confusing layout of data cardsCard #41

  46. Confusing layout of data cardsCard #164

  47. Inaccurate tallying of spreadsheet by Osler __ ___ __ __ Actual figures: 24 131 9 1 None of these 24 included in the “mental” column

  48. Possible role of haste • Short interval between last case (29 Mar 1904) and lecture (18 May 1904) • Hectic time for Osler: • Very busy with consultative practice and scholarly activities • Great Baltimore Fire of February 1904 nearly consumed Osler’s home • Observations of others and comments by Osler

  49. The Great Baltimore FireFebruary 1904 View from Calvert and Baltimore Streets

  50. Observations of others and comments by Osler Possible role of haste: • Cushing1: lecture written “in a single morning” • Cushing biography notes2: lecture “written in some haste...misquoted sources” • Osler letter to Miss Jewett2: “a rash production” 1Ann Med Hist (Summer, 1919) 2Cushing folders at McGill University Harvey Cushing

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