IAHPC Hospice and Palliative Care Newsletter

THE NATURE OF SUFFERING AND THE GOALS OF MEDICINE. Second Edition.

Eric J. Cassell. Oxford University Press, 2004. 313 pp. ISBN 0-19-515616-1. RRP $US24.95, £17.50

That the prevention and relief of suffering caused by human sickness should be the fundamental goal of medicine remains the central theme in this second edition of Cassell’s classic “The Nature of Suffering and the Goals of Medicine.”

Starting with historical views of the evolving theories underpinning medical practice and what might constitute the ideal physician, Cassell discusses what suffering is and what (whole) persons are. There are chapters on what he calls the “mysterious” doctor-patient relationship and on the interaction between the person and their sickness. The following chapters challenge you to think whether medical practice is about the pursuit of disease or the care of the sick, whether we are treating the disease, the body, or the patient. He provides compelling arguments that doctors have to know more about the sick person and the illness than just the name of the disease and its pathophysiology if they are to be successful in relieving suffering.

There are three new chapters in this edition regarding the mind-body interface, the social dimensions of illness and suffering, and how suffering arises from pain and other symptoms that are inevitably personalized.

This book is about how we could and should practice truly holistic care. Cassell’s arguments and discussions are clear and logical and his style makes it a pleasure to read. It is also clinically practical, with many case histories used to introduce and illustrate the discussion.

Highly recommended.

SURGICAL PALLIATIVE CARE

Geoffrey P. Dunn and Alan G. Johnson (Eds). Oxford University Press, 2004. 267pp. ISBN 019-851000-4. RRP $US75 £49.95

The stereotypical surgeon is portrayed as the expert technician, the “captain of the ship”, acting decisively, unrelenting in the fight against disease. To do otherwise would be to allow the patient no hope and constitute abandonment of care. Well, welcome to the 21st century, this book is about the appropriate integration of surgical skills into the comprehensive management of patients with advanced disease.

The first part of the book includes chapters on ethics and surgical decision-making in the context of advanced disease, and there are good discussions on spirituality, interdisciplinary care and quality of life. The second part reviews surgical interventions that may be of benefit to palliative care patients, although orthopaedic surgery seems to have been left out.

This pioneering book is a most welcome first step towards educating the surgical community about the broader aspects of patient-centered care. It clearly outlines how the surgeon can usefully participate in the team management of patients with advanced disease, and underlines the need for the surgeon to have a sympathetic understanding of the nonsurgical aspects of care, including psychosocial and spiritual suffering. But will surgeons read it? Some won’t, and they will remain stereotyped. Others will, and may discover a new dimension to the care they can offer their patients. The goal is not to turn surgeons into palliative care specialists, but knowing the basics of how to deal with patients with advanced disease and their families (patient-centered holistic care, good communication, working effectively in an interdisciplinary team, grief and bereavement skills, etc) should be as much a part of surgical training as learning to tie knots.

PALLIATIVE CARE PERSPECTIVES

James L. Hallenbeck. Oxford University Press, 2003. 232pp. ISBN 019-516578-0. RRP $US24.95 £19.95

This is one palliative care physician’s synthesis of both the art and science of palliative care. It is distinguished by the use of clinical stories to introduce or illustrate clinical problems, and by the inclusion of boxed “Palliative Care Notes”, which are clinical pearls.

Chapters cover the history and philosophy of palliative care, pain and symptom management, ethical issues, psychosocial and spiritual aspects of care, communication, and how to manage the final 48 hours.

This is not a palliative care treatment manual, but a discussion of palliative care that is both insightful and clinically practical. It will be particularly useful as an introduction for doctors and nurses coming to the field of palliative care, but will also be valuable to more experienced practitioners to ponder and to use in their teaching.

A FEW MONTHS TO LIVE. Different Paths to Life’s End

Jana Staton, Roger Shuy and Ira Byock. Georgetown University Press, 2001. 358pp. ISBN 0-8784-841-X. RRP $US26, £13.20

This book describes the palliative care Demonstration Project conducted by Dr. Ira Byock and his co-workers in their hometown of Missoula, tucked away in the breathtaking beauty of the mountains of Montana.

Nine terminally ill patients and their carers were the subjects of the study. Information was prospectively collected by interview throughout the course of the illness. The material is presented according to the participants’ experience: hearing bad news, planning (or not planning) for their care, doctor-patient communication, understanding their illness, daily life and meaningful activities, the experience of caregivers, the final days of life, and memorials held after the patient’s death. The use of many direct quotations and recorded conversations greatly enhances the picture of terminal illness as seen from the patients’ and carers’ points of view.

Whilst this study involved only a small number of patients, it provides in-depth insights into the needs of the terminally ill and their carers that should be particularly useful for health care professionals and health care planners.

Cancer in Developing Countries: The Great Challenge for Oncology in the 21st Century

S. Tanneberger, F. Cavalli, F. Pannuti (eds.). Zuckschwerdt Verlag, 2004, . 177pp. ISBN 3-88603-830-0. RRP: 39,00 Euro

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This book compares and contrasts the problems of cancer control in developed and developing countries, outlining some of the differences in aetiological associations and clinical features. The enormity of the cancer problem in developing countries cannot be denied, but has largely been overlooked in favour of infectious diseases. But the problem is going to get much worse, not better. In 2020, the IARC estimates there will be 20 million new cases of cancer each year. Three-quarters of these will occur in developing or resource-poor countries where the great majority of patients present with advanced disease.

The book contains a number of essays or snapshots of innovative programs in oncology and palliative care from around the world. We read about Italians helping to develop paediatric haematology-oncology in Nicaragua, the plight of oncology in Serbia and Albania, and there is the wonderful story of the faith and perseverance required to establish the CanSupport program of free domiciliary palliative care in Delhi. There is a description of the development of the Pain and Palliative Care Society in Kerala, India that is managed by IAHPC Director Dr. Rajagopal. The lack of justice, in terms of access to effective treatment, at every level from global to community, is emphasized repeatedly.

What might be done about these problems is discussed in the third part of the book. Palliative care is described as the most urgent and most rapid way to lessen suffering. It is argued that the establishment of more domiciliary programs in the developing countries is feasible and cost effective, particularly given the continuing solidarity of the family structure in these countries.

This is a book that is both interesting and informative and underlines the great and urgent need for more palliative care in developing countries, whilst indicating that the requirements are going to escalate rapidly in the next two decades.

PALLIATIVE CARE AND COMMUNICATION. Experiences in the Clinic

Anne-Mei The. Open University Press, 2002. 254 pp. ISBN 0-335-21205-0. RRP £24, $US30.95, $AU59.95

This book is the result of a five-year ethnographic study in a Dutch clinic treating patients with small cell carcinoma of the lung. It describes, in narrative form, the communication the patients received at the various stages of their illness trajectory. Each section has a complementary discussion of what was said (or not said), how it was said, and what was understood. The important effects that each individual patient has on the results of doctor-patient communication are also discussed.

In her discussion of the overall study, Anne-Mei The makes many points which cause one to reflect on one’s own practices in communicating bad news. The importance of allowing other health care professionals to be present at these discussions and not just the specialist cannot be underestimated, as it is these nurses and counselors that will be looking after the patient and family after their few minutes with the doctor. She also raises even more fundamental questions about the validity of consent to treatment, and whether patients with relapsed disease would not be better off spending less time at the hospital having chemotherapy, and more time attending to those matters that will improve the final phase of their lives. Do patients suffer “somatization” and “medicalization” at the hands of specialist oncologists?

Although not written for the purpose, this book provides innumerable and compelling arguments in favor of comprehensive and coordinated interdisciplinary supportive care for patients with incurable cancer. I found it thought-provoking and written in an engaging style.

Roger Woodruff,

Director of Palliative Care, Austin Health, Melbourne, Australia

PALLIATIVE MEDICINE

Evidence-based symptomatic and supportive care for patients with advanced cancer. 4th edition.

Roger Woodruff. Oxford University Press, 2004. 497 pp

ISBN 019 551677 X. RRP $US 69.50 £29.95 $AU 79.95

Roger Woodruff has just completed the 4th edition of his classic PALLIATIVE MEDICINE book. This new edition has major improvements and it is likely to remain as one of the most successful, single-authored palliative book on the market.