JAMA Book Review, Vol. 285, Number 4, 1/24-31/01 (Journal of the American Medical Association)

Edited by Harvey Max Chochinov, 435 pp, $79.50,ISBN 0-19-509299-6, New York, NY, Oxford University Press, 2000.

Reviewed by Mary Hartshorn, MD

Edmund D. Pellegrino, in his chapter "Ethical Issues in Palliative Care," offers two very important orienting thoughts for the physician caring for a patient with terminal illness. He notes that (in Western culture especially), "The dying person intrudes on everyone else's pursuit of business or pleasure. In the modern world, dying is an obscenity, an experience to be avoided at all costs. And he reminds us that "The vulnerability of the patient and the inequality in knowledge, physical stamina, and power between patient and physician must always be a moral brake on doing harm so that good may come of it." Although we, as doctors, know these things intellectually, especially if we've had the good fortune to be exposed to a rigorous ethics course, the book is replete with examples and adjurations against our tendency to forget them as we go about our daily lives in practice, particularly when a crisis occurs and we are in the heat of battle with a medical emergency. Several of the authors acknowledge that our behavior at such times is wholly understandable, trained as we are to think of disease as "the enemy."

Thinking that we must do our utmost to overcome is well and good until the patient in our care has a terminal illness. But now, as multiple writers point out, we are more than ever called upon to be a doctor: to minister, if you will, to the patient's fears of abandonment, uncontrollable pain, being a burden on loved ones or even on non-family caretakers, spending the children's inheritance on medical care, etc. At such times the true mettle of a healer is tested: there is no cure for death but, contrary to what many of us saw during our training, there is much that can be done to alleviate suffering and isolation as the terminal person makes his or her final earthly journey.

Multiple authoritative contributors provide their expertise in the relatively new field of psychiatric intervention for the dying and for those who love them. Some, like Jimmie C. Holland, MD, have had much to do with inventing the field, and others, including the editors, have come up as protégés of the original pioneers. The book has seven parts: "Psychiatric Complications of Terminal Illness," "Symptom Management," "Psychotherapeutic Intervention and Palliative Care," "Pediatric Palliative Care," "Family and Staff Issues," "Ethical and Spiritual Issues," and "Research Issues."

Much is based on common sense ideas, for instance, that depression, although understandable in the face of a cancer diagnosis, may still require treatment. Other concepts may be new to the workaday physician not specializing in treatment of terminal patients, such as the meaning and practical application of the World Health Organization's "pain ladder" algorithm. Patients' involvement in making trade-offs during illness is also directly relevant to the daily practice of any physician who has terminal patients in his or her care; thus, one patient might prefer to tolerate a higher pain level for the sake of mental clarity; another might be more willing to accept some degree of sedation in exchange for less perception of pain. The sedation factor can be minimized in some types of pain patterns via local analgesic implants of various kinds.

Hospice is addressed, including whether and when to invoke hospice services (assuming one is locally available), whether to use home-based or free-standing facility care, and the understanding by patients and loved ones of exactly what hospice is and is not. For example, it is vital to know that, while all that's possible will be done to maximize comfort, temporary lifesaving measures will not be attempted in a crisis. Helping patient and family deal with the anxiety attendant upon removal of this (illusory) "safety net" requires both skill and tact.

The book deserves kudos for not polemicizing any particular point of view. Although touchy issues such as physician-assisted suicide are discussed openly, no sides are taken, and the discussion sheds far more light than heat, for a pleasant change. Alas, the only drawback this reviewer found was the occasionally sloppy editing (for instance, "laser report" for "last resort" [p 387] and "hasten the life" for "hasten the death"[p 53]), particularly disappointing from a distinguished publisher. But, in general, the book is cohesively written and rarely uneven, a remarkable feat in a multi-author work.

This reviewer commends the book to all physicians. Others in the palliative and hospice care setting will also find much of value, including social workers dealing with families, psychiatrists who may have some patients with dying loved ones, and nurses and aides who deal day in and day out with many frustrations.

Even the malpractice wary (and isn't that all of us?) will benefit. Not only is it becoming a legal standard of care in many jurisdictions to provide adequate pain control, but this text reminds us that our primary duty, even above offering the latest in new treatment technology and attempting to cure illness, is to relieve suffering. The many ways, both medical and person-to-person, of accomplishing this should bring comfort to readers who, when all is said and done, must recognize their own fallibility.