<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Psittacosis and can you explain it in depth? [/INST] Psittacosis—also known as parrot fever, and ornithosis—is a zoonotic infectious disease in humans caused by a bacterium called Chlamydia psittaci and contracted from infected parrots, such as macaws, cockatiels, and budgerigars, and from pigeons, sparrows, ducks, hens, gulls and many other species of birds. The incidence of infection in canaries and finches is believed to be lower than in psittacine birds.
In certain contexts, the word is used when the disease is carried by any species of birds belonging to the family Psittacidae, whereas ornithosis is used when other birds carry the disease.

In humans
Signs and symptoms
In humans, after an incubation period of 5–19 days, the symptoms of the disease range from inapparent illness to systemic illness with severe pneumonia.  It presents chiefly as an atypical pneumonia.  In the first week of psittacosis, the symptoms mimic typhoid fever, prostrating high fevers, joint pains, diarrhea, conjunctivitis, nose bleeds, and low level of white blood cells.  Rose spots called Horders spots can appear. Spleen enlargement is common towards the end of the first week. It may become a serious lung infection. Diagnosis can be suspected in case of respiratory infection associated with splenomegaly and/or epistaxis. Headache can be so severe that it suggests meningitis and some nuchal rigidity is not unusual.  Towards the end of the first week, stupor or even coma can result in severe cases.The second week is more akin to acute bacteremic pneumococcal pneumonia with continuous high fevers, headaches, cough, and dyspnea. X-rays show patchy infiltrates or a diffuse whiteout of lung fields.Complications in the form of endocarditis, liver inflammation, inflammation of the hearts muscle, joint inflammation, keratoconjunctivitis (occasionally extranodal marginal zone lymphoma of the lacrimal gland/orbit), and neurologic complications (brain inflammation) may occasionally occur. Severe pneumonia requiring intensive-care support may also occur. Fatal cases have been reported (less than 1% of cases).

Transmission route
The Chlamydia psittaci bacterium that causes psittacosis can be transmitted by mouth-to-beak contact, or through the airborne inhalation of feather dust, dried faeces, or the respiratory secretions of infected birds. Person-to-person transmission is possible, but rare.

Diagnosis
Blood analysis usually shows a normal white cell count, but marked leukocytosis is occasionally apparent. Liver enzymes are abnormal in half of the patients, with mild elevation of aspartate transaminase. The erythrocyte sedimentation rate and C-reactive protein can be markedly elevated. Differential diagnosis must be made with typhus, typhoid, and atypical pneumonia by Mycoplasma, Legionella, or Q fever. Exposure history is paramount to diagnosis.
Diagnosis involves microbiological cultures from respiratory secretions of patients or serologically with a fourfold or greater increase in antibody titers against C. psittaci in blood samples combined with the probable course of the disease. Typical inclusions called "Leventhal-Cole-Lillie bodies" can be seen within macrophages in BAL (bronchoalveolar lavage) fluid. Culture of C. psittaci is hazardous and should only be carried out in biosafety laboratories.

Treatment
The infection is treated with antibiotics; tetracyclines and chloramphenicol are the choice for treating patients. Most people respond to oral therapy doxycycline, tetracycline hydrochloride, or chloramphenicol palmitate. For initial treatment of severely ill patients, doxycycline hyclate may be administered intravenously. Remission of symptoms is usually evident within 48–72 hours. However, relapse can occur, and treatment must continue for at least 10–14 days after fever subsides.

Epidemiology
Psittacosis was first reported in Europe in 1879.In 1929, a highly publicized outbreak of psittacosis hit the United States.  Although not the first report of psittacosis in the United States, it was the largest up to that time.  It led to greater controls on the import of pet parrots.  The aftermath of the outbreak and how it was handled led to the establishment of the National Institutes of Health.From 2002 through 2009, 66 human cases of psittacosis were reported to the Centers for Disease Control and Prevention, and most resulted from exposure to infected pet birds, usually cockatiels, parakeets, and macaws. Many more cases may occur that are not correctly diagnosed or reported.
Bird owners, pet shop employees, zookeepers, and veterinarians are at risk of the infection. Some outbreaks of psittacosis in poultry-processing plants have been reported.

In birds
In birds, Chlamydia psittaci infection is referred to as avian chlamydiosis. Infected birds shed the bacteria through feces and nasal discharges, which can remain infectious for several months. Many strains remain quiescent in birds until activated under stress. Birds are excellent, highly mobile vectors for the distribution of chlamydial infection because they feed on, and have access to, the detritus of infected animals of all sorts.

Signs
C. psittaci in birds is often systemic and infections can be inapparent, severe, acute, or chronic with intermittent shedding. Signs in birds include "inflamed eyes, difficulty in breathing, watery droppings, and green urates."

Diagnosis
Initial diagnosis may be by symptoms, but is usually confirmed by an antigen and antibody test.  A polymerase chain reaction-based test is also available.  Although any of these tests can confirm psittacosis, false negatives are possible, so a combination of clinical and laboratory tests is recommended before giving the bird a clean bill of health. It may die within three weeks.

Epidemiology
Infection is usually by the droppings of another infected bird, though it can also be transmitted by feathers and eggs, and is typically either inhaled or ingested.C. psittaci strains in birds infect mucosal epithelial cells and macrophages of the respiratory tract. Septicaemia eventually develops and the bacteria become localized in epithelial cells and macrophages of most organs, conjunctiva, and gastrointestinal tract. It can also be passed in the eggs. Stress commonly triggers onset of severe symptoms, resulting in rapid deterioration and death </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is SIDS and can you explain it in depth? [/INST] Sudden infant death syndrome (SIDS) is the sudden unexplained death of a child of less than one year of age. Diagnosis requires that the death remain unexplained even after a thorough autopsy and detailed death scene investigation. SIDS usually occurs during sleep. Typically death occurs between the hours of midnight and 9:00 a.m. There is usually no noise or evidence of struggle. SIDS remains the leading cause of infant mortality in Western countries, contributing to half of all post-neonatal deaths.The exact cause of SIDS is unknown. The requirement of a combination of factors including a specific underlying susceptibility, a specific time in development, and an environmental stressor has been proposed. These environmental stressors may include sleeping on the stomach or side, overheating, and exposure to tobacco smoke. Accidental suffocation from bed sharing (also known as co-sleeping) or soft objects may also play a role. Another risk factor is being born before 39 weeks of gestation. SIDS makes up about 80% of sudden and unexpected infant deaths (SUIDs). The other 20% of cases are often caused by infections, genetic disorders, and heart problems. While child abuse in the form of intentional suffocation may be misdiagnosed as SIDS, this is believed to make up less than 5% of sudden death cases.The most effective method of reducing the risk of SIDS is putting a child less than one year old on their back to sleep. Other measures include a firm mattress separate from but close to caregivers, no loose bedding, a relatively cool sleeping environment, using a pacifier, and avoiding exposure to tobacco smoke. Breastfeeding and immunization may also be preventive. Measures not shown to be useful include positioning devices and baby monitors. Evidence is not sufficient for the use of fans. Grief support for families affected by SIDS is important, as the death of the infant is sudden, without witnesses, and often associated with an investigation.Rates of SIDS vary nearly tenfold in developed countries from one in a thousand to one in ten thousand. Globally, it resulted in about 19,200 deaths in 2015, down from 22,000 deaths in 1990. SIDS was the third leading cause of death in children less than one year old in the United States in 2011. It is the most common cause of death between one month and one year of age. About 90% of cases happen before six months of age, with it being most frequent between two months and four months of age. It is more common in boys than girls. Rates of SIDS have decreased in areas with "safe sleep" campaigns by up to 80%.

Definition
The syndrome only applies to infants under one. SIDS is a diagnosis of exclusion and should be applied to only those cases in which an infants death is sudden and unexpected, and remains unexplained after the performance of an adequate postmortem investigation, including:

an autopsy (by an experienced pediatric pathologist, if possible);
investigation of the death scene and circumstances of the death; and
exploration of the medical history of the infant and family.After investigation, some of these infant deaths are found to be caused by suffocation, hyperthermia or hypothermia, neglect or some other defined cause.Australia and New Zealand shifted to sudden unexpected death in infancy (SUDI) for professional, scientific, and coronial clarity.

The term SUDI is now often used instead of sudden infant death syndrome (SIDS) because some coroners prefer to use the term undetermined for a death previously considered to be SIDS. This change is causing diagnostic shift in the mortality data. In addition, the US Centers for Disease Control and Prevention have proposed that such deaths be called sudden unexpected infant deaths (SUID) and that SIDS is a subset of SUID.

Age
SIDS has a four-parameter lognormal age distribution that spares infants shortly after birth — the time of maximal risk for almost all other causes of non-trauma infant death.
By definition, SIDS deaths occur under the age of one year, with the peak incidence occurring when the infant is two to four months old. This is considered a critical period because the infants ability to rouse from sleep is not yet mature.

Risk factors
The exact cause of SIDS is unknown. Although studies have identified risk factors for SIDS, such as putting infants to bed on their bellies, there has been little understanding of the syndromes biological process or its potential causes. Deaths from SIDS are unlikely to be due to a single cause, but rather to multiple risk factors. The frequency of SIDS does appear to be influenced by social, economic, or cultural factors, such as maternal education, race or ethnicity, or poverty. SIDS is believed to occur when an infant with an underlying biological vulnerability, who is at a critical development age, is exposed to an external trigger. The following risk factors generally contribute either to the underlying biological vulnerability or represent an external trigger:

Tobacco smoke
SIDS rates are higher in babies of mothers who smoke during pregnancy. Between no smoking and smoking one cigarette a day, on average, the risk doubles. About 22% of SIDS in the United States is related to maternal smoking. SIDS correlates with levels of nicotine and its derivatives in the baby. Nicotine and derivatives cause alterations in neurodevelopment.

Sleeping
Placing an infant to sleep while lying on the belly or side rather than on the back increases the risk for SIDS. This increased risk is greatest at two to three months of age. Elevated or reduced room temperature also increases the risk, as does excessive bedding, clothing, soft sleep surfaces, and stuffed animals in the bed. Bumper pads may increase the risk of SIDS due to the risk of suffocation. They are not recommended for children under one year of age, as this risk of suffocation greatly outweighs the risk of head bumping or limbs getting stuck in the bars of the crib.Sharing a bed with parents or siblings increases the risk for SIDS. This risk is greatest in the first three months of life, when the mattress is soft, when one or more persons share the infants bed, especially when the bed partners are using drugs or alcohol or are smoking. The risk remains, however, even in parents who do not smoke or use drugs. The American Academy of Pediatrics thus recommends "room-sharing without bed-sharing", stating that such an arrangement can decrease the risk of SIDS by up to 50%. Furthermore, the academy has recommended against devices marketed to make bed-sharing "safe", such as "in-bed co-sleepers".Room sharing as opposed to solitary sleeping is known to decrease the risk of SIDS.

Breastfeeding
Breastfeeding is associated with a lower risk of SIDS. It is not clear if co-sleeping among mothers who breastfeed without any other risk factors increases SIDS risk.

Pregnancy and infant factors
SIDS rates decrease with increasing maternal age, with teenage mothers at greatest risk. Delayed or inadequate prenatal care also increases risk. Low birth weight is a significant risk factor. In the United States from 1995 to 1998, the SIDS death rate for infants weighing 1000–1499 g was 2.89/1000, while for a birth weight of 3500–3999 g, it was only 0.51/1000. Premature birth increases the risk of SIDS death roughly fourfold. From 1995 to 1998, the U.S. SIDS rate for births at 37–39 weeks of gestation was 0.73/1000, while the SIDS rate for births at 28–31 weeks of gestation was 2.39/1000.Anemia has also been linked to SIDS (however, per item 6 in the list of epidemiologic characteristics below, extent of anemia cannot be evaluated at autopsy because an infants total hemoglobin can only be measured during life). SIDS incidence rises from zero at birth, is highest from two to four months of age, and declines toward zero after the infants first year.

Genetics
Genetics plays a role, as SIDS is more prevalent in males.  There is a consistent 50% male excess in SIDS per 1000 live births of each sex. Given a 5% male excess birth rate, there appears to be 3.15 male SIDS cases per 2 female cases, for a male fraction of 0.61. This value of 61% in the US is an average of 57% black male SIDS, 62.2% white male SIDS and 59.4% for all other races combined. Note that when multiracial parentage is involved, infant race is arbitrarily assigned to one category or the other; most often it is chosen by the mother. The X-linkage hypothesis for SIDS and the male excess in infant mortality have shown that the 50% male excess might be related to a dominant X-linked allele, occurring with a frequency of 1⁄3 that is protective against transient cerebral anoxia. An unprotected male would occur with a frequency of 2⁄3 and an unprotected female would occur with a frequency of 4⁄9.
About 10 to 20% of SIDS cases are believed to be due to channelopathies, which are inherited defects in the ion channels which play an important role in the contraction of the heart.Genetic evidence published in November 2020 concerning the case of Kathleen Folbigg, who is in prison over the death of four of her children, showed that at least two of the children had genetic mutations in the CALM2 gene that predisposed them to heart complications.

Alcohol
Drinking of alcohol by parents is linked to SIDS. One study found a positive correlation between the two during New Years celebrations and weekends. Another found that alcohol use disorder was linked to a more than doubling of risk.

Other
A 2022 study found that infants who died of SIDS exhibited significantly lower specific activity of butyrylcholinesterase, an enzyme involved in the brains arousal pathway, shortly after birth. This can serve as a biomarker to identify infants with a potential autonomic cholinergic dysfunction and elevated risk for SIDS.SIDS has been linked to cold weather, with this association believed to be due to over-bundling and thus, overheating. Premature babies are at four times the risk of SIDS, possibly related to an underdeveloped ability to automatically control the cardiovascular system.A 1998 report found that antimony- and phosphorus-containing compounds used as fire retardants in PVC and other cot mattress materials are not a cause of SIDS. The report also states that toxic gas cannot be generated from antimony in mattresses and that babies had SIDS on mattresses that did not contain the compound.
It has been suggested that some cases of SIDS may be related to Staphylococcus aureus and Escherichia coli infections.

Diagnosis
Differential diagnosis
Some conditions that are often undiagnosed and could be confused with or comorbid with SIDS include:

medium-chain acyl-coenzyme A dehydrogenase deficiency (MCAD deficiency);
infant botulism;
long QT syndrome (accounting for less than 2% of cases);
Helicobacter pylori bacterial infections;
shaken baby syndrome and other forms of child abuse;
overlaying, child smothering during carers sleepFor example, an infant with MCAD deficiency might die by "classical SIDS" if found swaddled and prone, with its head covered, in an overheated room where parents were smoking. Genes indicating susceptibility to MCAD and Long QT syndrome do not protect an infant from dying of classical SIDS. Therefore, the presence of a susceptibility gene, such as for MCAD, means the infant might have died either from SIDS or from MCAD deficiency. It is currently impossible for a pathologist to distinguish between them.
A 2010 study looked at 554 autopsies of infants in North Carolina that listed SIDS as the cause of death, and suggested that many of these deaths may have been due to accidental suffocation.  The study found that 69% of autopsies listed other possible risk factors that could have led to death, such as unsafe bedding or sleeping with adults.Several instances of infanticide have been uncovered in which the diagnosis was originally SIDS. The estimate of the percentage of SIDS deaths that are actually infanticide varies from less than 1% to up to 5% of cases.Some have underestimated the risk of two SIDS deaths occurring in the same family; the Royal Statistical Society issued a media release refuting expert testimony in one UK case, in which the conviction was subsequently overturned.

Prevention
A number of measures have been found to be effective in preventing SIDS, including changing the sleeping position to supine, breastfeeding, limiting soft bedding, immunizing the infant and using pacifiers. The use of electronic monitors has not been found to be useful as a preventative strategy. The effect that fans might have on the risk of SIDS has not been studied well enough to make any recommendation about them. Evidence regarding swaddling is unclear regarding SIDS. A 2016 review found tentative evidence that swaddling increases the risk of SIDS, especially among babies placed on their bellies or sides while sleeping.Measures not shown to be useful include positioning devices and baby monitors. In the United States, companies that sell the monitors do not have FDA approval for them as medical devices.

Sleep positioning
Sleeping on the back has been found to reduce the risk of SIDS. It is thus recommended by the American Academy of Pediatrics and promoted as a best practice by the US National Institute of Child Health and Human Development (NICHD) "Safe to Sleep" campaign. The incidence of SIDS has fallen in a number of countries in which this recommendation has been widely adopted. Sleeping on the back does not appear to increase the risk of choking, even in those with gastroesophageal reflux disease. While infants in this position may sleep more lightly, this is not harmful. Sharing the same room as the parents but in a different bed may decrease the SIDS risk by half.

Pacifiers
The use of pacifiers appears to decrease the risk of SIDS, although the reason is unclear. The American Academy of Pediatrics considers pacifier use to prevent SIDS to be reasonable. Pacifiers do not appear to affect breastfeeding in the first four months, even though this is a common misconception.

Bedding
Product safety experts advise against using pillows, overly soft mattresses, sleep positioners, bumper pads (crib bumpers), stuffed animals, or fluffy bedding in the crib, and recommend instead dressing the child warmly and keeping the crib "naked."Blankets or other clothing should not be placed over a babys head.The use of a "baby sleep bag" or "sleep sack", a soft bag with holes for the babys arms and head can be used as a type of bedding that warms the baby without covering its head.

Vaccination
Infants typically receive several vaccinations between the ages of 2 and 4 months, which is also the peak age for SIDS. Due to this coincidence, a number of studies have investigated the possible role of vaccinations as a cause of SIDS. These have found either no relation between vaccinations and SIDS, or a reduction of the risk of SIDS following vaccination. A 2007 meta-analysis found that vaccinations were associated with a halving of the risk of SIDS, and argued that immunisation should be a part of SIDS prevention campaigns.

Epidemiology
Globally, SIDS resulted in about 22,000 deaths as of 2010, down from 30,000 deaths in 1990. Rates vary significantly by population from 0.05 per 1000 in Hong Kong to 6.7 per 1000 in Native Americans.SIDS was responsible for 0.54 deaths per 1,000 live births in the US in 2005. It is responsible for far fewer deaths than congenital disorders and disorders related to short gestation, though it is the leading cause of death in healthy infants after one month of age.
SIDS deaths in the US decreased from 4,895 in 1992 to 2,247 in 2004, a 54% decrease. During a similar time period, 1989 to 2004, SIDS as the cause of death for sudden infant death (SID) decreased from 80% to 55%, a 31% decrease. According to John Kattwinkel, chairman of the Centers for Disease Control and Prevention (CDC) Special Task Force on SIDS "A lot of us are concerned that the rate (of SIDS) isnt decreasing significantly, but that a lot of it is just code shifting".

Race
In 2013, there were persistent disparities in SIDS deaths among racial and ethnic groups in the U.S. In 2009, the rates of death range from 20.3 per 100,000 live births for Asian/Pacific Islander to 119.2 per 100,000 live births for Native Americans/Alaska Native. African American infants have a 24% greater risk of having a SIDS-related death, compared to the U.S. population as a whole, and experience a 2.5 greater incidence of SIDS than in Caucasian infants. Rates are calculated per 100,000 live births to enable more accurate comparison across groups of different total population size.
Research suggests that factors which contribute more directly to SIDS risk—maternal age, exposure to smoking, safe sleep practices, etc.—vary by racial and ethnic group and therefore risk exposure also varies by these groups. Risk factors associated with prone sleeping patterns of African American families include mothers age, household poverty index, rural/urban status of residence, and infants age. More than 50% of African American infants were placed in non-recommended sleeping positions, according to a 2012  study completed in South Carolina, indicating that cultural factors can be protective as well as problematic.The rate of SIDS per 1000 births varies among ethnic groups in the United States:
Central Americans and South Americans: 0.20
Asian/Pacific Islanders: 0.28
Mexicans: 0.24
Puerto Ricans: 0.53
Whites: 0.51
African Americans: 1.08
Native American: 1.24

Society and culture
The rate of SIDS varies vastly among different cultures and countries around the world, with SIDS rates lowest among Asian and Pacific Islander infants. Some evidence supports the hypothesis that SIDS is not an ancient phenomenon and that it appears more commonly in western societies.
Much of the popular media portrayals of infants shows them in non-recommended sleeping positions.

See also
Fading puppy syndrome
Failure to thrive
Neonatal isoerythrolysis
Newborn care and safety
Sudden unexpected death syndrome
Sudden unexplained death in childhood

References
Further reading
Ottaviani, G. (2014). Crib death – Sudden infant Death Syndrome (SIDS). Sudden infant and perinatal unexplained death: the pathologists viewpoint. Berlin Heidelberg, Germany: Springer. ISBN 978-3-319-08346-9.
Joan Hodgman; Toke Hoppenbrouwers (2004). SIDS </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Electrical injury and can you explain it in depth? [/INST] Electrical injury is a physiological reaction caused by electric current passing through the body. The injury depends on the density of the current, tissue resistance and duration of contact. Very small currents may be imperceptible or produce a light tingling sensation. A shock caused by low and otherwise harmless current could startle an individual and cause injury due to jerking away or falling. Stronger currents may cause some degree of discomfort or pain, while more intense currents may induce involuntary muscle contractions, preventing the person from breaking free of the source of electricity. Still larger currents result in tissue damage and may trigger ventricular fibrillation or cardiac arrest. Consequences of injury from electricity may  include amputations, bone fractures and orthopedic and musculoskeletal injuries. If death results from an electric shock the cause of death is generally referred to as electrocution.
Electric injury occurs upon contact of a body part with electricity that causes a sufficient current to pass through the persons tissue. Contact with energized wiring or devices is the most common cause. In cases of exposure to high voltages, such as on a power transmission tower, direct contact may not be necessary as the voltage may "jump" the air gap to the electrical device.
Following an electrical injury from household current, if a person has no symptoms, no underlying heart problems, and is not pregnant further testing is not required. Otherwise an electrocardiogram, blood work to check the heart, and urine testing for signs of muscle breakdown may be performed.Management may involve resuscitation, pain medications, wound management, and heart monitoring. Electrical injuries affect more than 30,000 people a year in the United States and result in about 1,000 deaths.

Signs and symptoms
Burns
Heating due to resistance can cause extensive and deep burns. When applied to the hand, electricity can cause involuntary muscle contraction, producing the "no-let-go" phenomenon, and increasing the risk for serious burns. Voltage levels of 500 to 1000 volts tend to cause internal burns due to the large energy (which is proportional to the duration multiplied by the square of the voltage divided by resistance) available from the source. Damage due to current is through tissue heating and/or electroporation injury. For most cases of high-energy electrical trauma, the Joule heating in the deeper tissues along the extremity will reach damaging temperatures in a few seconds.

Ventricular fibrillation
A domestic power supply voltage (110 or 230 V), 50 or 60 Hz alternating current (AC) through the chest for a fraction of a second may induce ventricular fibrillation at currents as low as 30 milliamperes (mA). With direct current (DC), 300 to 500 mA is required. If the current has a direct pathway to the heart (e.g., via a cardiac catheter or other kind of electrode), a much lower current of less than 1 mA (AC or DC) can cause fibrillation. If not immediately treated by defibrillation, fibrillation is usually lethal because all of the heart muscle fibres move independently instead of in the coordinated pulses needed to pump blood and maintain circulation. Above 200 mA, muscle contractions are so strong that the heart muscles cannot move at all, but these conditions prevent fibrillation.

Neurological effects
Electrical current can cause interference with nervous control, especially over the heart and lungs. Electric shock which does not lead to death has been shown to cause neuropathy at the site where the current entered the body. The neurologic symptoms of electrical injury may occur immediately, which traditionally have a higher likelihood for healing, though they may also be delayed by days to years. The delayed neurologic consequences of electrical injury have a worse prognosis.When the patch of electrical current proceeds through the head, it appears that, with sufficient current applied, loss of consciousness almost always occurs swiftly. This is borne out by some limited self-experimentation by early designers of the electric chair and by research from the field of animal husbandry, where electric stunning has been extensively studied.If ventricular fibrillation occurs (as above), the blood supply to the brain is diminished, which may cause cerebral hypoxia (and its associated neurologic consequences).

Mental health
There are a variety of psychiatric effects that may occur as a result of electrical injuries. Behavioral changes can occur as well, even if the path of electrical current did not proceed through the head. Symptoms may include:
Depression, including feelings of low self-esteem and guilt
Anxiety spectrum disorders, including posttraumatic stress disorder and fear of electricity
Moodiness, including a lower threshold for frustration and "losing ones temper"
Memory loss, decreased attention span, and difficulty learning

Arc-flash hazards
OSHA found that up to 80 percent of its electrical injuries involve thermal burns due to arcing faults. The arc flash in an electrical fault produces the same type of light radiation from which electric welders protect themselves using face shields with dark glass, heavy leather gloves, and full-coverage clothing. The heat produced may cause severe burns, especially on unprotected flesh. The arc blast produced by vaporizing metallic components can break bones and damage internal organs. The degree of hazard present at a particular location can be determined by a detailed analysis of the electrical system, and appropriate protection worn if the electrical work must be performed with the electricity on.

Pathophysiology
The minimum current a human can feel depends on the current type (AC or DC) as well as frequency for AC. A person can sense electrical current as low as 1 mA (rms) for 60 Hz AC and as low as 5 mA for DC. At around 10 mA, DC current passing through the arm of a 68-kilogram (150 lb) human can cause powerful muscle contractions; the victim is unable to voluntarily control muscles and cannot release an electrified object. This is known as the "let go threshold" and is a criterion for shock hazard in electrical regulations.
The current may, if it is high enough and is delivered at sufficient voltage, cause tissue damage or fibrillation which can cause cardiac arrest; more than 30 mA of AC (rms, 60 Hz) or 300–500 mA of DC at high voltage can cause fibrillation. A sustained electric shock from AC at 120 V, 60 Hz is an especially dangerous source of ventricular fibrillation because it usually exceeds the let-go threshold, while not delivering enough initial energy to propel the person away from the source. However, the potential seriousness of the shock depends on paths through the body that the currents take. If the voltage is less than 200 V, then the human skin, more precisely the stratum corneum, is the main contributor to the impedance of the body in the case of a macroshock—the passing of current between two contact points on the skin. The characteristics of the skin are non-linear however. If the voltage is above 450–600 V, then dielectric breakdown of the skin occurs. The protection offered by the skin is lowered by perspiration, and this is accelerated if electricity causes muscles to contract above the let-go threshold for a sustained period of time.If an electrical circuit is established by electrodes introduced in the body, bypassing the skin, then the potential for lethality is much higher if a circuit through the heart is established. This is known as a microshock. Currents of only 10 µA can be sufficient to cause fibrillation in this case with a probability of 0.2%.

Body resistance
The voltage necessary for electrocution depends on the current through the body and the duration of the current. Ohms law states that the current drawn depends on the resistance of the body. The resistance of human skin varies from person to person and fluctuates between different times of day. The NIOSH states "Under dry conditions, the resistance offered by the human body may be as high as 100,000 ohms. Wet or broken skin may drop the bodys resistance to 1,000 ohms," adding that "high-voltage electrical energy quickly breaks down human skin, reducing the human bodys resistance to 500 ohms".The International Electrotechnical Commission gives the following values for the total body impedance of a hand to hand circuit for dry skin, large contact areas, 50 Hz AC currents (the columns contain the distribution of the impedance in the population percentile; for example at 100 V 50% of the population had an impedance of 1875Ω or less):

Skin
The voltage-current characteristic of human skin is non-linear and depends on many factors such as intensity, duration, history, and frequency of the electrical stimulus. Sweat gland activity, temperature, and individual variation also influence the voltage-current characteristic of skin. In addition to non-linearity, skin impedance exhibits asymmetric and time varying properties. These properties can be modeled with reasonable accuracy. Resistance measurements made at low voltage using a standard ohmmeter do not accurately represent the impedance of human skin over a significant range of conditions.
For sinusoidal electrical stimulation less than 10 volts, the skin voltage-current characteristic is quasilinear. Over time, electrical characteristics can become non-linear. The time required varies from seconds to minutes, depending on stimulus, electrode placement, and individual characteristics.
Between 10 volts and about 30 volts, skin exhibits non-linear but symmetric electrical characteristics. Above 20 volts, electrical characteristics are both non-linear and symmetric. Skin conductance can increase by several orders of magnitude in milliseconds. This should not be confused with dielectric breakdown, which occurs at hundreds of volts. For these reasons, current flow cannot be accurately calculated by simply applying Ohms law using a fixed resistance model.

Point of entry
Macroshock: Current across intact skin and through the body. Current from arm to arm, or between an arm and a foot, is likely to traverse the heart, therefore it is much more dangerous than current between a leg and the ground. This type of shock by definition must pass into the body through the skin.
Microshock: Very small current source with a pathway directly connected to the heart tissue. The shock is required to be administered from inside the skin, directly to the heart i.e. a pacemaker lead, or a guide wire, conductive catheter etc. connected to a source of current. This is a largely theoretical hazard as modern devices used in these situations include protections against such currents.

Lethality
Electrocution
The earliest usage of the term "electrocution" cited by the Oxford English Dictionary was an 1889 newspaper reference to the method of execution then being considered. Shortly thereafter, in 1892, the term was used in Science to refer generically to death or injury caused by electricity.

Factors in lethality of electric shock
The lethality of an electric shock is dependent on several variables:

Current. The higher the current, the more likely it is lethal. Since current is proportional to voltage when resistance is fixed (ohms law), high voltage is an indirect risk for producing higher currents.
Duration. The longer the duration, the more likely it is lethal—safety switches may limit time of current flow
Pathway. If current flows through the heart muscle, it is more likely to be lethal.
High voltage (over about 600 volts). In addition to greater current flow, high voltage may cause dielectric breakdown at the skin, thus lowering skin resistance and allowing further increased current flow.
Medical implants. Artificial cardiac pacemakers or implantable cardioverter-defibrillators (ICD) are sensitive to very small currents.
Pre-existing medical condition.
Age and sex.Other issues affecting lethality are frequency, which is an issue in causing cardiac arrest or muscular spasms. Very high frequency electric current causes tissue burning, but does not penetrate the body far enough to cause cardiac arrest (see electrosurgery). Also important is the pathway: if the current passes through the chest or head, there is an increased chance of death. From a main circuit or power distribution panel the damage is more likely to be internal, leading to cardiac arrest. Another factor is that cardiac tissue has a chronaxie (response time) of about 3 milliseconds, so electricity at frequencies of higher than about 333 Hz requires more current to cause fibrillation than is required at lower frequencies.
The comparison between the dangers of alternating current at typical power transmission frequences (i.e., 50 or 60 Hz), and direct current has been a subject of debate ever since the war of the currents in the 1880s. Animal experiments conducted during this time suggested that alternating current was about twice as dangerous as direct current per unit of current flow (or per unit of applied voltage).
It is sometimes suggested that human lethality is most common with alternating current at 100–250 volts; however, death has occurred below this range, with supplies as low as 42 volts. Assuming a steady current flow (as opposed to a shock from a capacitor or from static electricity), shocks above 2,700 volts are often fatal, with those above 11,000 volts being usually fatal, though exceptional cases have been noted. According to a Guinness Book of World Records comic, seventeen-year-old Brian Latasa survived a 230,000 volt shock on the tower of an ultra-high voltage line in Griffith Park, Los Angeles on November 9, 1967. A news report of the event stated that he was "jolted through the air, and landed across the line", and though rescued by firemen, he sustained burns over 40% of his body and was completely paralyzed except for his eyelids. The shock with the highest voltage reported survived was that of Harry F. McGrew, who came in contact with a 340,000 volt transmission line in Huntington Canyon, Utah.

Prevention
Grounding the electrical enclosure of high-voltage machinery.
Use of insulated gloves, insulated boots, mats and tools.
Protecting electrical circuit with a residual-current device (RCD).

Epidemiology
There were 550 reported electrocutions in the US in 1993, 2.1 deaths per million inhabitants. At that time, the incidence of electrocutions was decreasing. Electrocutions in the workplace make up the majority of these fatalities. From 1980–1992, an average of 411 workers were killed each year by electrocution. Workplace deaths caused by exposure to electricity in the U.S. increased by nearly 24% between 2015 and 2019, from 134 to 166. However, workplace electrical injuries dropped 23% between 2015 and 2019 from 2,480 to 1,900. In 2019, the top 5 states with the most workplace electrical fatalities were: (1) Texas (608); (2) California (451); (3) Florida (306); (4) New York (273); and (5) Georgia (207).A recent study conducted by the National Coroners Information System (NCIS) in Australia has revealed 321 closed case fatalities (and at least 39 case fatalities still under coronial investigation) that had been reported to Australian coroners where a person died from electrocution between July 2000 and October 2011.In Sweden, Denmark, Finland and Norway the number of electric deaths per million inhabitants was 0.6, 0.3, 0.3 and 0.2, respectively, in the years 2007–2011.People who survive electrical trauma may develop a host of injuries including loss of consciousness, seizures, aphasia, visual disturbances, headaches, tinnitus, paresis, and memory disturbances. Even without visible burns, electric shock survivors may be faced with long-term muscular pain and discomfort, exhaustion, headache, problems with peripheral nerve conduction and sensation, inadequate balance and coordination, among other symptoms. Electrical injury can lead to problems with neurocognitive function, affecting speed of mental processing, attention, concentration, and memory. The high frequency of psychological problems is well established and may be multifactorial. As with any traumatic and life-threatening experience, electrical injury may result in post traumatic psychiatric disorders. There exist several non-profit research institutes that coordinate rehabilitation strategies for electrical injury survivors by connecting them with clinicians that specialize in diagnosis and treatment of various traumas that arise as a result of electrical injury.

Deliberate uses
Medical uses
Electric shock is also used as a medical therapy, under carefully controlled conditions:

Electroconvulsive therapy or ECT, a psychiatric therapy for mental disorders
As a surgical tool for cutting or coagulation. An electrosurgical unit (ESU) uses high currents (e.g. 10 amperes) at high frequency (e.g. 500 kHz) with various schemes of amplitude modulation to cut or coagulate
As a treatment for fibrillation or irregular heart rhythms: see Defibrillation and Cardioversion
As a method of pain relief: see Transcutaneous electrical nerve stimulation (TENS)
As a treatment for excessive sweating with a process called iontophoresis
Electrodiagnosis, for example nerve conduction studies and electromyography
Electroporation for gene delivery

Entertainment
Mild electric shocks are also used for entertainment, especially as a practical joke for example in such devices as a shocking pen or a shocking gum. However devices such as a joy buzzer and most other machines in amusement parks today only use vibration that feels somewhat like an electric shock to someone not expecting it.
It is also used entertainingly for sex stimulation.  This is usually done via the use of an erotic electrostimulator which induces erotic electrostimulation.  These devices may include a violet wand, transcutaneous electrical nerve stimulation, electrical muscle stimulation, and made-for-play units.

Policing and personal defense
Electroshock weapons are incapacitant weapons used for subduing a person by administering electric shock to disrupt superficial muscle functions. One type is a conductive energy device (CED), an electroshock gun popularly known by the brand name "Taser", which fires projectiles that administer the shock through a thin, flexible wire. Although they are illegal for personal use in many jurisdictions, Tasers have been marketed to the general public. Other electroshock weapons such as stun guns, stun batons ("cattle prods"), and electroshock belts administer an electric shock by direct contact.
Electric fences are barriers that use electric shocks to deter animals or people from crossing a boundary. The voltage of the shock may have effects ranging from uncomfortable, to painful or even lethal. Most electric fencing is used today for agricultural fencing and other forms of animal control purposes, though it is frequently used to enhance security of restricted areas, and there exist places where lethal voltages are used.

Torture
Electric shocks are used as a method of torture, since the received voltage and current can be controlled with precision and used to cause pain and fear without always visibly harming the victims body.
Electrical torture has been used in war and by repressive regimes since the 1930s. The United States Army is known to have used electrical torture during World War II. During the Algerian War electrical torture was used by French military forces. Amnesty International published a statement that Russian military forces in Chechnya tortured local women with electric shocks by attaching wires onto their breasts.The parrilla (Spanish for grill) is a method of torture whereby the victim is strapped to a metal frame and subjected to electric shock. It has been used in a number of contexts in South America. The parrilla was commonly used at Villa Grimaldi, a prison complex maintained by Dirección de Inteligencia Nacional, a part of the Pinochet regime. In the 1970s, during the Dirty War, the parrilla was used in Argentina. Francisco Tenório Júnior (known as Tenorinho), a Brazilian piano player, was subjected to the parrilla during the military dictatorship in Brazil.Advocates for the mentally ill and some psychiatrists such as Thomas Szasz have asserted that electroconvulsive therapy (ECT) is torture when used without a bona fide medical benefit against recalcitrant or non-responsive patients.The Judge Rotenberg Center in Canton, Massachusetts has been condemned for torture by the United Nations special rapporteur on torture for its use of electric shocks as punishment as part of its behavior modification program.Japanese serial killer Futoshi Matsunaga used electric shocks to control his victims.

Capital punishment
Electric shock delivered by an electric chair is sometimes used as an official means of capital punishment in the United States, although its use has become rare from the 1990s onward due to the adoption of lethal injection </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Foreign body aspiration and can you explain it in depth? [/INST] Foreign body aspiration occurs when a foreign body enters the airway which can cause difficulty breathing or choking. Objects may reach the respiratory tract and the digestive tract from the mouth and nose, but when an object enters the respiratory tract it is termed aspiration. The foreign body can then become lodged in the trachea or further down the respiratory tract such as in a bronchus. Regardless of the type of object, any aspiration can be a life-threatening situation and requires timely recognition and action to minimize risk of complications. While advances have been made in management of this condition leading to significantly improved clinical outcomes, there were still 2,700 deaths resulting from foreign body aspiration in 2018.  Approximately one child dies every five days due to choking on food in the United States, highlighting the need for improvements in education and prevention.

Signs and symptoms
Signs and symptoms of foreign body aspiration vary based on the site of obstruction, the size of the foreign body, and the severity of obstruction. 20% of foreign bodies become lodged in the upper airway, while 80% become lodged in a bronchus. Signs of foreign body aspiration are usually abrupt in onset and can involve coughing, choking, and/or wheezing; however, symptoms can be slower in onset if the foreign body does not cause a large degree of obstruction of the airway. With this said, aspiration can also be asymptomatic on rare occasions.Classically, patients present with acute onset of choking. In these cases, the obstruction is classified as a partial or complete obstruction. Signs of partial obstruction include choking with drooling, stridor, and the patient maintains the ability to speak. Signs of complete obstruction include choking with inability to speak or absence of bilateral breath sounds among other signs of respiratory distress such as cyanosis. A fever may be present. When this is the case, it is possible the object may be chemically irritating or contaminated.Foreign bodies above the larynx often present with stridor, while objects below the larynx present with wheezing. Foreign bodies above the vocal cords often present with difficulty and pain with swallowing and excessive drooling. Foreign bodies below the vocal cords often present with pain and difficulty with speaking and breathing. Increased respiratory rate may be the only sign of foreign body aspiration in a child who cannot verbalize or report if they have swallowed a foreign body.If the foreign body does not cause a large degree of obstruction, patients may present with chronic cough, asymmetrical breath sounds on exam, or recurrent pneumonia of a specific lung lobe. If the aspiration occurred weeks or even months ago, the object may lead to an obstructive pneumonia or even a lung abscess. Therefore, it is important to consider chronic foreign body aspiration in patients whose histories include unexplained recurrent pneumonia or lung abscess with or without fever.In adults, the right lower lobe of the lung is the most common site of recurrent pneumonia in foreign body aspiration. This is due to the fact that the anatomy of the right main bronchus is wider and steeper than that of the left main bronchus, allowing objects to enter more easily than the left side. Unlike adults, there is only a slight propensity towards objects lodging in the right bronchus in children. This is likely due to the bilateral bronchial angles being symmetric until about 15 years of age when the aortic knob fully develops and displaces the left main bronchus.Signs and symptoms of foreign body aspiration in adults may also mimic other lung disorders such as asthma, COPD, and lung cancer.
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Causes
Most cases of foreign body aspiration are in children ages 6 months to 3 years due to the tendency for children to place small objects in the mouth and nose. Children of this age usually lack molars and cannot grind up food into small pieces for proper swallowing. Small, round objects including nuts, hard candy, popcorn kernels, beans, and berries are common causes of foreign body aspiration. Latex balloons are also a serious choking hazard in children that can result in death. A latex balloon will conform to the shape of the trachea, blocking the airway and making it difficult to expel with the Heimlich maneuver. In addition, if the foreign body is able to absorb water, such as a bean, seed, or corn, among other things, it may swell over time leading to a more severe obstruction.
In adults, foreign body aspiration is most prevalent in populations with impaired swallowing mechanisms such as the following: neurological disorders, alcohol use, advanced age leading to senility (most common in the 6th decade of life), and loss of consciousness. This inadequate airway protection may also be attributed to poor dentition, seizure, general anesthesia, or sedative drug use.

Diagnosis
The most important aspect of the assessment for a clinician is an accurate history provided by an event witness. Unfortunately, this is not always available.

Physical examination
A physical examination by a clinician should include, at a minimum, a general assessment in addition to cardiac and pulmonary exams. Auscultation of breath sounds may give additional information regarding object location and the degree of airway obstruction. The presence of drooling and dysphagia (drooling) should always be noted alongside the classic signs of airway obstruction as these can indicate involvement of the esophagus and impact management.

Diagnostic Imaging
Radiography is the most common form of imaging used in the initial assessment of a foreign body presentation. Most patients receive a chest x-ray to determine the location of the foreign body. Lateral neck, chest, and bilateral decubitus end-expiratory chest x-rays should be obtained in patients suspected of having aspirated a foreign body. However, the presence of normal findings on chest radiography should not rule out foreign body aspiration as not all objects can be visualized. In fact, up to 50% of cases can have normal findings on radiography. This is because visibility of an object depends on many factors, such as the objects material, size, anatomic location and surrounding structures, as well as the patients body habitus. X-ray beams only show an object if that objects composition blocks the rays from traveling through, making it radiopaque and appearing lighter or white on the image. This also requires it to not be stuck behind something that blocks the beams first. Objects that are radiopaque include items made of most metals except aluminum, bones except most fish bones, and glass. If the material does not block the x-ray beams it is considered radiolucent and will appear dark which prevents visualization. This includes material such as most plastics, most fish bones, wood, and most aluminum objects.Other diagnostic imaging modalities, such as magnetic resonance imaging, computed tomography, and ventilation perfusion scans play a limited role in the diagnosis of foreign body aspiration.Signs on x-ray that are more commonly seen than the object itself and can be indicative of foreign body aspiration include visualization of the foreign body or hyperinflation of the affected lung. Other x-ray findings that can be seen with foreign body aspiration include obstructive emphysema, atelectasis, and consolidation.While, x-ray can be used to visualize the location and identity of a foreign body, rigid bronchoscopy under general anesthesia is the gold-standard for diagnosis since the foreign body can be visualized and removed with this intervention. Rigid bronchoscopy is indicated when two of the three following criteria are met: report of foreign body aspiration by the patient or a witness, abnormal lung exam findings, or abnormal chest x-ray findings.

Management
See also:  Choking § Treatment, Basic Life Support, Advanced Cardiovascular Life Support
Treatment of foreign body aspiration is determined by the age of the patient and the severity of obstruction of the airway involved.

Basic management
An airway obstruction can be partial or complete. In partial obstruction, the patient can usually clear the foreign body with coughing. In complete obstruction, acute intervention is required to remove the foreign body.If foreign body aspiration is suspected, finger sweeping in the mouth is not recommended due to the increased risk of displacing the foreign object further into the airway.For choking children less than 1 year of age, the child should be placed face down over the rescuers arm. Back blows should be delivered with the heel of the hand, then the patient should be turned face-up and chest thrusts should be administered. The rescuer should alternate five back blows followed by five chest thrusts until the object is cleared. The Heimlich maneuver should be used in choking patients older than 1 year of age to dislodge a foreign body. If the patient becomes unresponsive during physical intervention, cardiopulmonary resuscitation (CPR) should be started.

Advanced management
In the event that the basic measures do not remove the foreign body, and adequate ventilation cannot be restored, need for treatment by trained personnel becomes necessary. Laryngoscopy should be performed in unresponsive patients if non-invasive airway clearance techniques are unsuccessful. Laryngoscopy involves placing a device in the mouth to visualize the back of the airway. If the foreign body can be seen, it can be removed with forceps. An endotracheal tube should then be placed in order to prevent airway compromise from resulting inflammation after the procedure. If the foreign body cannot be visualized, intubation, tracheotomy, or needle cricothyrotomy can be done to restore an airway for patients who have become unresponsive due to airway compromise.If non-invasive measures do not dislodge the foreign body, and the patient can maintain adequate ventilation, rigid bronchoscopy under general anesthesia should be performed. Supplemental oxygen, cardiac monitoring, and a pulse oximeter should be applied to the patient. Efforts should be made to keep the patient calm and avoid agitating the patient to prevent further airway compromise. Flexible rather than rigid bronchoscopy might be used when the diagnosis or object location are unclear. When flexible bronchoscope is used, rigid bronchoscope is typically on standby and readily available as this is the preferred approach for removal. Rigid bronchoscopy allows good airway control, ready bleeding management, better visualization, and ability to manipulate the aspirated object with a variety of forceps. Flexible bronchoscopy may be used for extraction when distal access is needed and the operator is experienced in this technique. Potential advantages include avoidance of general anesthesia as well as the ability to reach subsegmental bronchi which are smaller in diameter and further down the respiratory tract than the main bronchi. The main disadvantage of using a flexible scope is the risk of further dislodging the object and causing airway compromise. Bronchoscopy is successful in removing the foreign body in approximately 95% of cases with a complication rate of only 1%.After the foreign body is removed, patients should receive nebulized beta-adrenergic medication and chest physiotherapy to further protect the airway. Steroidal anti-inflammatories and antibiotics are not routinely administered except in certain scenarios. These include situations such as when the foreign body is difficult or impossible to extract, when there is a documented respiratory tract infection, and when swelling within the airway occurs after removal of the object. Glucocorticoids may be administered when the foreign body is surrounded by inflamed tissue and extraction is difficult or impossible. In such cases, extraction may be delayed for a short course of glucocorticoids so that the inflammation may be reduced before subsequent attempts. These patients should remain under observation in the hospital until successful extraction as this practice can result in dislodgement of the foreign body. Antibiotics are appropriate when an infection has developed but should not delay extraction. In fact, removal of the object may improve infection control by removing the infectious source as well as using cultures taken during the bronchoscopy to guide antibiotic choice. When airway edema or swelling occur, the patient may have stridor. In these cases, glucocorticoids, aerosolized epinephrine, or helium oxygen therapy may be considered as part of the management plan.Patients who are clinically stable with no need for supplemental oxygen after extraction may be discharged from the hospital the same day as the procedure. Routine imaging such as a follow-up chest x-ray are not needed unless symptoms persist or worsen, or if the patient had imaging abnormalities previously to verify return to normal. Most children are discharged within 24 hours of the procedure.

Complications
Many complications can develop if a foreign body remains in the airway. There are also complications that may occur after removal of the object depending on the timeline of events.  Cardiac arrest and death are possible complications if a sudden complete obstruction occurs and immediate medical care is not performed. The most common complication from a foreign body aspiration is a pulmonary infection, such as pneumonia or a lung abscess. This can be more difficult to overcome in the elderly population and lead to even further complications. Patients may develop inflammation of the airway walls from a foreign body remaining in the airway. Airway secretions can be retained behind the obstruction which creates an ideal environment for subsequent bacterial overgrowth. Hyperinflation of the airway distal to the obstruction can also occur if the foreign body is not removed </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is End-of-life care and can you explain it in depth? [/INST] End-of-life care (EoLC) refers to health care provided in the time leading up to a persons death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a persons mental and emotional needs, physical comfort, spiritual needs, and practical tasks.EoLC is most commonly provided at home, in the hospital, or in a long-term care facility with care being provided by family members, nurses, social workers, physicians, and other support staff. Facilities may also have palliative or hospice care teams that will provide end-of-life care services.  Decisions about end-of-life care are often informed by medical, financial and ethical considerations.In most advanced countries, medical spending on people in the last twelve months of life makes up roughly 10% of total aggregate medical spending, while those in the last three years of life can cost up to 25%.

Medical
Advanced care planning
Advances in medicine in the last few decades have provided us with an increasing number of options to extend a personss life and highlighted the importance of ensuring that an individuals preferences and values for end-of-life care are honored. Advanced care planning is the process by which a person of any age is able to provide their preferences and ensure that their future medical treatment aligns with their personal values and life goals. It is typically a continual process, with ongoing discussions about a patients current prognosis and conditions as well as conversations about medical dilemmas and options. A person will typically have these conversations with their doctor and ultimately record their preferences in an advance healthcare directive. An advance healthcare directive is a legal document that either documents a persons decisions about desired treatment or indicates who a person has entrusted to make their care decisions for them. The two main types of advanced directives are a living will and durable power of attorney for healthcare. A living will includes a persons decisions regarding their future care, a majority of which address resuscitation and life support but may also delve into a patients’ preferences regarding hospitalization, pain control, and specific treatments that they may undergo in the future. The living will will typically take effect when a patient is terminally ill with low chances of recovery. A durable power of attorney for healthcare allows a person to appoint another individual to make healthcare decisions for them under a specified set of circumstances. Combined directives, such as the "Five Wishes", that include components of both the living will and durable power of attorney for healthcare, are being increasingly utilized. Advanced care planning often includes preferences for CPR initiation, nutrition (tube feeding), as well as decisions about the use of machines to keep a person breathing, or support their heart or kidneys. Many studies have reported benefits to patients who complete advanced care planning, specifically noting the improved patient and surrogate satisfaction with communication and decreased clinician distress. However, there is a notable lack of empirical data about what outcome improvements patients experience, as there are considerable discrepancies in what constitutes as advanced care planning and heterogeneity in the outcomes measured. Advanced care planning remains an underutilized tool for patients. Researchers have published data to support the use of new relationship-based and supported decision making models that can increase the use and maximize the benefit of advanced care planning.

End-of-life care conversations
End-of-life care conversations are part of the treatment planning process for terminally ill patients requiring palliative care involving a discussion of a patients prognosis, specification of goals of care, and individualized treatment planning. Current studies suggest that many patients prioritize proper symptom management, avoidance of suffering, and care that aligns with ethical and cultural standards.  Specific conversations can include discussions about cardiopulmonary resuscitation (ideally occurring before the active dying phase as to not force the conversation during a medical crisis/emergency), place of death, organ donation, and cultural/religious traditions. As there are many factors involved in the end-of-life care decision-making process, the attitudes and perspectives of patients and families may vary. For example, family members may differ over whether life extension or life quality is the main goal of treatment. As it can be challenging for families in the grieving process to make timely decisions that respect the patients wishes and values, having an established advanced care directive in place can prevent over-treatment, under-treatment, or further complications in treatment management.Patients and families may also struggle to grasp the inevitability of death, and the differing risks and effects of medical and non-medical interventions available for end-of-life care. A systematic literature review reviewing the frequency of end-of-life care conversations between COPD patients and clinicians found that conversations regarding end-of-life care often occur when a patient has advanced stage disease and occur at a low frequency. To prevent interventions that are not in accordance with the patients wishes, end-of-life care conversations and advanced care directives can allow for the care they desire, as well as help prevent confusion and strain for family members.

Signs of dying
The National Cancer Institute in the United States (US) advises that the presence of some of the following signs may indicate that death is approaching:
Drowsiness, increased sleep, and/or unresponsiveness (caused by changes in the patients metabolism).
Confusion about time, place, and/or identity of loved ones; restlessness; visions of people and places that are not present; pulling at bed linen or clothing (caused in part by changes in the patients metabolism).
Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased blood flow, and mental preparation for dying).
Changes in breathing (indicate neurologic compromise and impending death) and accumulation of upper airway secretions (resulting in crackling and gurgling breath sounds)
Decreased need for food and fluids, and loss of appetite (caused by the bodys need to conserve energy and its decreasing ability to use food and fluids properly).
Decreased oral intake and impaired swallowing (caused by general physical weakness and metabolic disturbances, including but not limited to hypercalcemia)
Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area).
Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or decreased fluid intake).
Skin becoming cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities).
Rattling or gurgling sounds while breathing, which may be loud (death rattle); breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs).
Turning of the head toward a light source (caused by decreasing vision).
Increased difficulty controlling pain (caused by progression of the disease).
Involuntary movements (called myoclonus), increased heart rate, hypertension followed by hypotension, and loss of reflexes in the legs and arms are additional signs that the end of life is near.

Symptoms management
The following are some of the most common potential problems that can arise in the last days and hours of a patients life:
Pain
Typically controlled with opioids, like morphine, fentanyl, hydromorphone or, in the United Kingdom, diamorphine. High doses of opioids can cause respiratory depression, and this risk increases with concomitant use of alcohol and other sedatives. Careful use of opioids is important to improve the patients quality of life while avoiding overdoses.
Agitation
Delirium, terminal anguish, restlessness (e.g. thrashing, plucking, or twitching).  Typically controlled using clonazepam or midazolam,antipsychotics such as haloperidol or levomepromazine may also be used instead of, or concomitantly with benzodiazepines. Symptoms may also sometimes be alleviated by rehydration, which may reduce the effects of some toxic drug metabolites.
Respiratory tract secretions
Saliva and other fluids can accumulate in the oropharynx and upper airways when patients become too weak to clear their throats, leading to a characteristic gurgling or rattle-like sound ("death rattle").  While apparently not painful for the patient, the association of this symptom with impending death can create fear and uncertainty for those at the bedside. The secretions may be controlled using drugs such as hyoscine butylbromide, glycopyrronium, or atropine.  Rattle may not be controllable if caused by deeper fluid accumulation in the bronchi or the lungs, such as occurs with pneumonia or some tumours.
Nausea and vomiting
Typically controlled using haloperidol, metoclopramide, ondansetron, cyclizine; or other anti-emetics.
Dyspnea (breathlessness)
Typically controlled with opioids, like morphine, fentanyl or, in the United Kingdom, diamorphineConstipation

Low food intake and opioid use can lead to constipation which can then result in agitation, pain, and delirium. Laxatives and stool softeners are used to prevent constipation. In patients with constipation, the dose of laxatives will be increased to relieve symptoms. Methylnaltrexone is approved to treat constipation due to opioid use.Other symptoms that may occur, and may be mitigated to some extent, include cough, fatigue, fever, and in some cases bleeding.

Medication Administration
Subcutaneous injections are one preferred means of delivery when it has become difficult for patients to swallow or to take pills orally, and if repeated medication is needed, a syringe driver (or infusion pump in the US) is often likely to be used, to deliver a steady low dose of medication. In some settings, such as the home or hospice, sublingual routes of administration may be used for most prescriptions and medications.Another means of medication delivery, available for use when the oral route is compromised, is a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route. The catheter was developed to make rectal access more practical and provide a way to deliver and retain liquid formulations in the distal rectum so that health practitioners can leverage the established benefits of rectal administration. Its small flexible silicone shaft allows the device to be placed safely and remain comfortably in the rectum for repeated administration of medications or liquids. The catheter has a small lumen, allowing for small flush volumes to get medication to the rectum. Small volumes of medications (under 15mL) improve comfort by not stimulating the defecation response of the rectum and can increase the overall absorption of a given dose by decreasing pooling of medication and migration of medication into more proximal areas of the rectum where absorption can be less effective.

Integrated pathways
Integrated care pathways are an organizational tool used by healthcare professionals to clearly define the roles of each team-member and coordinate how and when care will be provided. These pathways are utilized to ensure best practices are being utilized for end-of-life care, such as evidence-based and accepted health care protocols, and to list the required features of care for a specific diagnosis or clinical prolem. Many institutions have a predetermined pathway for end of life care, and clinicians should be aware of and make use of these plans when possible. In the United Kingdom, end-of-life care pathways are based on the Liverpool Care Pathway. Originally developed to provide evidence based care to dying cancer patients, this pathway has been adapted and used for a variety of chronic conditions at clinics in the UK and internationally. Despite its increasing popularity, the 2016 Cochrane Review, which only analyzed one trial, showed limited evidence in the form of high-quality randomized clinical trials to measure the effectiveness of end-of-life care pathways on clinical outcomes, physical outcomes, and emotional/psychological outcomes. The BEACON Project group developed an integrated care pathway entitled the Comfort Care Order Set, which delinates care for the last days of life in either a hospice or acute care inpatient setting. This order set was implemented and evaluated in a multisite system throughout six United States Veterans Affairs Medical Centers, and the study found increased orders for opioid medication post-pathway implementation, as well as more orders for antipsychotic medications, more patients undergoing palliative care consultations, more advance directives, and increased sublingual drug administration. The intervention did not, however, decrease the proportion of deaths that occurred in an ICU setting or the utilization of restraints around death.

Home-based end-of-life care
While not possible for every person needing care, surveys of the general public suggest most people would prefer to die at home. In the period from 2003 to 2017, the number of deaths at home in the United States increased from 23.8% to 30.7%, while the number of deaths in the hospital decreased from 39.7% to 29.8%. Home-based end-of-life care may be delivered in a number of ways, including by an extension of a primary care practice, by a palliative care practice, and by home care agencies such as Hospice. High-certainty evidence indicates that implementation of home-based end-of-life care programs increases the number of adults who will die at home and slightly improves their satisfaction at a one-month follow-up. There is low-certainty evidence that there may be very little or no difference in satisfaction of the person needing care for longer term (6 months). The number of people who are admitted to hospital during an end-of-life care program is not known. In addition, the impact of home-based end-of-life care on caregivers, healthcare staff, and health service costs is not clear, however, there is weak evidence to suggest that this intervention may reduce health care costs by a small amount.

Disparities in end-of-life care
Not all groups in society have good access to end-of-life care. A systematic review conducted in 2021 investigated the end of life care experiences of people with severe mental illness, including those with schizophrenia, bipolar disorder, and major depressive disorder. The research found that individuals with a severe mental illness were unlikely to receive the most appropriate end of life care. The review recommended that there needs to be close partnerships and communication between mental health and end of life care systems, and these teams need to find ways to support people to die where they choose. More training, support and supervision needs to be available for professionals working in end of life care; this could also decrease prejudice and stigma against individuals with severe mental illness at the end of life, notably in those who are homeless. In addition, studies have shown that minority patients face several additional barriers to receiving quality end-of-life care. Minority patients are prevented from accessing care at an equitable rate for a variety of reasons including: individual discrimination from caregivers, cultural insensitivity, racial economic disparities, as well as medical mistrust.

Non-medical
Family and friends
Family members are often uncertain as to what they should be doing when a person is dying.  Many gentle, familiar daily tasks, such as combing hair, putting lotion on delicate skin, and holding hands, are comforting and provide a meaningful method of communicating love to a dying person.Family members may be suffering emotionally due to the impending death.  Their own fear of death may affect their behavior.  They may feel guilty about past events in their relationship with the dying person or feel that they have been neglectful.  These common emotions can result in tension, fights between family members over decisions, worsened care, and sometimes (in what medical professionals call the "Daughter from California syndrome") a long-absent family member arrives while a patient is dying to demand inappropriately aggressive care.
Family members may also be coping with unrelated problems, such as physical or mental illness, emotional and relationship issues, or legal difficulties.  These problems can limit their ability to be involved, civil, helpful, or present.

Spirituality and Religion
Spirituality is thought to be of increased importance to an individuals wellbeing during a terminal illness or toward the end-of-life. Pastoral/spiritual care has a particular significance in end of life care, and is considered an essential part of palliative care by the WHO. In palliative care, responsibility for spiritual care is shared by the whole team, with leadership given by specialist practitioners such as pastoral care workers. The palliative care approach to spiritual care may, however, be transferred to other contexts and to individual practice.Spiritual, cultural, and religious beliefs may influence or guide patient preferences regarding end-of-life care. Healthcare providers caring for patients at the end of life can engage family members and encourage conversations about spiritual practices to better address the different needs of diverse patient populations. Studies have shown that people who identify as religious also report higher levels of well-being. Religion has also been shown to be inversely correlated with depression and suicide. While religion provides some benefits to patients, there is some evidence of increased anxiety and other negative outcomes in some studies. While spirituality has been associated with less aggressive end-of-life care, religion has been associated with an increased desire for aggressive care in some patients. Despite these varied outcomes, spiritual and religious care remains an important aspect of care for patients. Studies have shown that barriers  to providing adequate spiritual and religious care include a lack of cultural understanding, limited time, and a lack of formal training or experience.Many hospitals, nursing homes, and hospice centers have chaplains who provide spiritual support and grief counseling to patients and families of all religious and cultural backgrounds.

Attitudes of healthcare professionals
End-of-life care is an interdisciplinary endeavor involving physicians, nurses, physical therapists, occupational therapists, pharmacists and social workers. Depending on the facility and level of care needed, the composition of the interprofessional team can vary. Health professional attitudes about end-of-life care depend in part on the providers role in the care team.
Physicians generally have favorable attitudes towards Advance Directives, which are a key facet of end-of-life care. Medical doctors who have more experience and training in end-of-life care are more likely to cite comfort in having end-of-life-care discussions with patients. Those physicians who have more exposure to end-of-life care also have a higher likelihood of involving nurses in their decision-making process.A systematic review assessing end-of-life conversations between heart failure patients and healthcare professionals evaluated physician attitudes and preferences towards end-of-life care conversations. The study found that physicians found difficulty initiating end-of-life conversations with their heart failure patients, due to physician apprehension over inducing anxiety in patients, the uncertainty in a patients prognosis, and physicians awaiting patient cues to initiate end-of-life care conversations.Although physicians make official decisions about end-of-life care, nurses spend more time with patients and often know more about patient desires and concerns. In a Dutch national survey study of attitudes of nursing staff about involvement in medical end-of-life decisions, 64% of respondents thought patients preferred talking with nurses than physicians and 75% desired to be involved in end-of-life decision making.

End-of-life care around the globe
Canada
In 2012, Statistics Canadas General Social Survey on Caregiving and care receiving found that 13% of Canadians (3.7 million) aged 15 and older reported that at some point in their lives they had provided end-of-life or palliative care to a family member or friend. For those in their 50s and 60s, the percentage was higher, with about 20% reporting having provided palliative care to a family member or friend. Women were also more likely to have provided palliative care over their lifetimes, with 16% of women reporting having done so, compared with 10% of men. These caregivers helped terminally ill family members or friends with personal or medical care, food preparation, managing finances or providing transportation to and from medical appointments.

United Kingdom
End of life care has been identified by the UK Department of Health as an area where quality of care has previously been "very variable," and which has not had a high profile in the NHS and social care.  To address this, a national end of life care programme  was established in 2004 to identify and propagate best practice, and a national strategy document published in 2008. The Scottish Government has also published a national strategy.In 2006 just over half a million people died in England, about 99% of them adults over the age of 18, and almost two-thirds adults over the age of 75. About three-quarters of deaths could be considered "predictable" and followed a period of chronic illness – for example heart disease, cancer, stroke, or dementia.  In all, 58% of deaths occurred in an NHS hospital, 18% at home, 17% in residential care homes (most commonly people over the age of 85), and about 4% in hospices.  However, a majority of people would prefer to die at home or in a hospice, and according to one survey less than 5% would rather die in hospital.  A key aim of the strategy therefore is to reduce the needs for dying patients to have to go to hospital and/or to have to stay there; and to improve provision for support and palliative care in the community to make this possible. One study estimated that 40% of the patients who had died in hospital had not had medical needs that required them to be there.In 2015 and 2010, the UK ranked highest globally in a study of end-of-life care. The 2015 study said "Its ranking is due to comprehensive national policies, the extensive integration of palliative care into the National Health Service, a strong hospice movement, and deep community engagement on the issue." The studies were carried out by the Economist Intelligence Unit and commissioned by the Lien Foundation, a Singaporean philanthropic organisation.The 2015 National Institute for Health and Care Excellence guidelines introduced religion and spirituality among the factors which physicians shall take into account for assessing palliative care needs. In 2016, the UK Minister of Health signed a document which declared people "should have access to personalised care which focuses on the preferences, beliefs and spiritual needs of the individual." As of 2017, more than 47% of the 500,000 deaths in the UK occurred in hospitals.In 2021 the National Palliative and End of Life Care Partnership published their six ambitions for 2021–26. These include fair access to end of life care for everyone regardless of who they are, where they live or their circumstances, and the need to maximise comfort and wellbeing. Informed and timely conversations are also highlighted. Research funded by the National Institute for Health and Care Research (NIHR) has addressed these areas of need. Examples highlight inequalities faced by several groups and offers recommendations. These include the need for close partnership between services caring for people with severe mental illness, improved understanding of barriers faced by Gypsy, Traveller and Roma communities, the provision of flexible palliative care services for children from ethnic minorities or deprived areas.Other research suggests that giving nurses and pharmacists easier access to electronic patient records about prescribing could help people manage their symptoms at home. A named professional to support and guide patients and carers through the healthcare system could also improve the experience of care at home at the end of life. A synthesised review looking at palliative care in the UK created a resource showing which services were available and grouped them according to their intended purpose and benefit to the patient. They also stated that currently in the UK palliative services are only available to patients with a timeline to death, usually 12 months or less. They found these timelines to often be inaccurate and created barriers to patients accessing appropriate services. They call for a more holistic approach to end of life care which is not restricted by arbitrary timelines.

United States
As of 2019, physician-assisted dying is legal in eight states (California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont, Washington) and Washington D.C.Spending on those in the last twelve months accounts for 8.5% of total aggregate medical spending in the United States.When considering only those aged 65 and older, estimates show that about 27% of Medicares annual $327 billion budget ($88 billion) in 2006 goes to care for patients in their final year of life. For the over-65s, between 1992 and 1996, spending on those in their last year of life represented 22% of all medical spending, 18% of all non-Medicare spending, and 25 percent of all Medicaid spending for the poor. These percentages appears to be falling over time, as in 2008, 16.8% of all medical spending on the over 65s went on those in their last year of life.Predicting death is difficult, which has affected estimates of spending in the last year of life; when controlling for spending on patients who were predicted as likely to die, Medicare spending was estimated at 5% of the total.

See also
Advance health care directive
Death midwife
Hospice
Liverpool Care Pathway
Palliative care
Childrens palliative care
Physician assisted suicide
Robert Martensen

References
Further reading
External links
"End of Life Issues". MedlinePlus.
"EndLink - Resource for End of Life Care Education". Robert H. Lurie Comprehensive Cancer Center. Northwestern University </s>