Slide1We fear our own death, and see death as the ultimate defeat of our medical care for our patients. In “Diagnosing Dying” Papadimos and colleagues observe that physicians often fail to diagnose that a patient is literally dying, and thus fail to provide appropriate care and guidance. In their accompanying editorial (Anesthesiologists and the Quality of Death), Shander and colleagues eloquently note that by diagnosing dying “we can address the basic needs of patients who need us most… This is our duty as guardians of the life and well-being of our patients.”

In 2011 Lindholm and colleagues published their finding of no increased risk of malignant disease within 5 postoperative years with regard to duration of general anesthesia and time with Bispectral Index (BIS) under 45 in patients without a history of malignancy. In this issue of Anesthesia & Analgesia these authors investigated cancer risk in patients with previous or existing malignant disease at the time of surgery. (Surgery, General Anesthesia and Cancer) Neither duration of anesthesia nor cumulative time with “deep” sevoflurane anesthesia was associated with an increased risk for new cancer or death within 5 years after surgery. Based on these data, monitoring “depth of anesthesia” is not expected to alter the risk of cancer proliferation after surgery.

Delirium is a common and serious complication in geriatric surgical patients. In a substudy of the BAG-RECALL trial, Whitlock and colleagues (Postoperative Delirium in Cardiothoracic Surgical Patients) report a nonsignificant difference in postoperative delirium between patients managed intraoperatively with end-tidal anesthetic concentration or BIS-guided protocols. In their accompanying editorial, Berger and colleagues (Preventing Delirium after Cardiothoracic Surgery) note that these findings are consistent with prior work suggesting BIS-guided titration may reduce delirium, but even with these additional data the conclusions are not yet definitive.

Investigators have speculated that decreased finger circulation could contribute to inaccuracy of oximetry-based hemoglobin determination. Miller and colleagues (Noninvasive Hemoglobin Monitoring and Finger Physiology) investigated the effects of digital nerve block on the perfusion index determined by oximetry. They found that lidocaine and bupivacaine both increased the perfusion index, improving the accuracy of oximetric hemoglobin determination.

On the Cover

Predicated on the topic of death, it may seem entirely appropriate to invoke the style of Edward Gorey for the journal’s cover art. Anyone amongst the journal’s readership who grew up familiar with the animated introduction to public television’s Mystery! series knew his work. Gorey’s style implied a macabre context, though it was not overtly morbid visually. The brief narrative accompaniments to his images would teasingly amplify the grim innuendo. His work typified a mainstream conceptualization of death in the developed world, one that is vilified and emblematic of the extreme endpoint of human decay.

Cast aside any illusions that the journal’s cover panders to the same. Rather, it is an existential ruse that aims to turn our instinctive and conditioned response to mortality on its head. Death appears as a dimensionless entity that casts no shadow and is transcendent of time as informed by the closed pocket watch. It brings an umbrella, an object conferring a sense of protection and safe passage. It succeeds in illuminating the dying figure where the light of the external world has extinguished. Death, it seems, asks us to understand it not as an inevitability, but an opportunity.

Anesthesiologists, critical care physicians and pain management specialists are uniquely poised to coordinate the amelioration of suffering at the time of their patient’s death. To whatever degree one may romanticize the ideal passing of their loved one beyond the embrace of their living arms, this representation likely does not include an audible cadence of their pulse or the innumerable tentacles of wires that hold them captive. Ironically though, it is in this very clinical domain that we may acknowledge death in the most important hand-off we ever engage.