All humans share at least two experiences: birth and death.

What comes after birth marks our time on earth. What happens after death is more a mystery — even though we face it daily. 

In obituaries posted at the Homer Post Office and printed in the Homer News, we read of revered elders, distinguished artists and adventurers, who die of old age, terminal diseases and accidents. Unless we have seen immediate family or close friends die, however, we might not know the details of dying.

What happens after death remains a mystery, a matter of faith and spirituality. But the experience of dying raises several practical questions and issues:

• What happens when someone dies outside of a hospital?

• How do doctors and nurses provided care for dying patients and their families in hospitals?

• How do funeral homes and others care for the bodies of loved ones?

• How do families and friends cope with grief?

In the recent past, gravely ill people often died at a hospital, but with the rise of the modern hospice movement, more people expecting death have chosen to die at home. That presents challenges for officially declaring someone dead, particularly in rural communities.

Under Alaska law, the State Medical Examiner investigates deaths that are sudden and when a person is in apparent good health; when someone isn’t under the care of a physician; when the death is suspicious, unusual or unexplained; and when deaths are the result of an accident, homicide or a suicide.

Police blotter logs tell the most common of these deaths, an unattended, nonviolent death at home. 

Sometimes a person living alone doesn’t show up at work or a person misses an appointment. Sometimes a family member dies in his sleep. “Unattended” doesn’t mean the person dies alone, but that no doctors or nurses are present.

Sometimes a person has been expected to die, as with a terminally ill cancer patient. The patient might be in hospice care, too. If a patient and doctor signs a do-not-resuscitate, or DNR, order under Alaska’s Comfort One Program, doctors, nurses and medics will not administer cardiopulmonary resuscitation. Comfort One forms are on file at the patient’s home, the hospital and with fire departments.

Patients at hospitals with DNR orders still get comfort, care and dignity, said Kenny Rogers, manager of the South Peninsula Hospital emergency department. Patients might also get medication like antibiotics.

In an unattended death at home with a Comfort One form on file, unless there’s suspicion of foul play, the State Medical Examiner’s office doesn’t need to sign off on a death, said Stephen Hoage, a State Medical Examiner investigator in Anchorage.

“Other than that, any unattended deaths are required to be reported to the medical examiner,” he said.

That includes patients who die at a hospital within 24 hours of being admitted. In an unattended death, police or troopers would be called.

In Anchorage, investigators like Hoage would go to the scene, but in rural Alaska, “We’re depending on law enforcement to be our eyes, ears on scene,” Hoage said.

Under the direction of the medical examiner, police would take photos of the body and look for injuries. They would look at the patient’s medical history. Police can’t pronounce death and under state law that has to be done by a medical professional. If nothing seems suspicious, the medical examiner would release the body to the family.

“It’s rough enough for a family with an unattended death,” Hoage said. 

Sometimes police don’t have enough information or further tests need to be done. The medical examiner might release a body to a funeral home, but put a hold on the body while the investigation continues so the person wouldn’t be buried or cremated.

“We try as much as possible to work with families in situations like that, to meet what they need as well,” Hoage said.

In the case of an unidentified body or anything suspicious, the body will be sent to Anchorage for further examination or an autopsy.

Death in hospitals can involve the tragedy of a sudden death from accident or the expected death of the elderly or terminally ill. How medical teams handle a dying patient can be made easier with advance directives. When patients are admitted, staff will talk with them about an advance directive.

An advance directive is different from a DNR or Comfort One order and ideally would be done when a patient is healthy. An advance directive spells out the patient’s wishes regarding levels of care if the patient is unable to make decisions, such as being unconscious with no hope of recovery. The challenge with an advance directive can be if the patient has spelled out one course of action and the family wants to change it.

Declaring someone dead and stopping treatment gets done on a case-by-case basis, Rogers said.

South Peninsula Hospital uses various guidelines, such as how sick the patient has been, how long efforts have been done to revive the patient and how well the patient responds, said Shara Sutherlin, director of patient care services.

“It’s very much a team approach,” Rogers said, “We have said, ‘Is there anything else anybody can think of?’”

In deciding death, medical teams look at factors like if the patient has a heart beat, if there is electrical activity in the heart, if there is a pulse and if there is breathing.

“You have to say, ‘Enough is enough,’” Rogers said. “Sometimes it’s the family who says, ‘Enough is enough.’”

The hospital also follows a humane principle, Rogers said: “We try not to let somebody die alone.”

Even after a patient has died, “They are still a patient,” Rogers said. “They’re going to be treated with the same respect when they were alive.”

In thinking about dying, it’s also important to know what a loved one’s wishes are regarding organ donation, Rogers said.

The question of organ donation also is raised in an advance directive. South Peninsula Hospital staff used to be trained to talk to families about organ donations, but now refer families to Life Alaska Donor Services, an agency that coordinates organ donations. A team might come to the hospital to recover organs and tissues or the patient might be flown to a Lower 48 facility. The body won’t be disfigured and if the family wishes there can still be an open casket viewing, Rogers said.

After a person dies at the hospital, the body will be cleaned and prepared for a vigil, Sutherlin said. That’s the point at which a funeral home gets called.

Next week: The solemn duty of preparing bodies for burial or cremation, and how families cope with grief and continue the relationship with someone who has died.

Michael Armstrong can be reached at michael.armstrong@homernews.com.