PALLIATIVE CARE CONSULTATIONS IN GYNAECOLOGY

Palliative Care Consultations in Gynaeoncology (Palliative Care Consultations)

Sara Booth and Eduardo Bruera (Eds). Oxford University Press, 2004. 176 pp. ISBN 019-852806-X. RRP £29.95  $US45 More Info

This is the second volume in the Palliative Care Consultations series and I found it particularly informative and useful.  As a medical oncologist, I saw less and less gynaecological malignancy as the specialty of gynaecological oncology grew.  But now, as a palliative care physician, I am seeing more and more women with advanced and terminal disease, which makes this book very welcome.

This book starts with overviews of the management of advanced cancer of the cervix, endometrium and ovary.  Then there are useful chapters on pelvic pain, odours and discharges, fistulae, and psychosexual problems.  There is a good chapter on thrombosis and bleeding, although I think there is sufficient evidence to advocate the continued use of LMWH in patients with advanced disease and a short life expectancy, rather than subjecting them to warfarin, which may be ineffective and is always difficult to manage.

This book contains a wealth of information pertinent to the good symptomatic care of patients with advanced gynaecological malignancy and will be a welcome addition to the palliative care unit bookshelf. 


DEATH FORETOLD. Prophecy and Prognosis in Medical Care

Nicholas Christakis. University of Chicago Press, 1999. 328 pp. ISBN 0-226-10470-2. RRP $US 30. £21 More Info

This book is about "the use physicians make of prognosis, the symbolism it contains, and the practical and emotional difficulties it involves."  Christakis believes that "cogent and compassionate prognostication "could decrease the prevalence of bad deaths in our society."  How true!

Successive chapters describe the decline in the use of prognosis with the increasing availability of therapies, how prognoses are used in contemporary medicine, the inaccuracy of prognostication, the stresses involved, and the "ritualization of optimism".  The final chapter argues that individual physicians and the profession as a whole have a duty to prognosticate.

To people who work in palliative care, this book brings no surprises.  The discussion of the origins and perpetuation of some of the rituals makes for interesting reading, and clearly calls for a change to the way physicians are taught and practice.  For the sake of their patients.


A GOOD ENOUGH LIFE. The Dying Speak

Susan Gabori. Goose Lane, 2002. 323pp. ISBN 0-86492-352-X. RRP $Can24.95 $US 24  £14 More Info

We teach that good palliative care allows personal growth in the final phase of one's life.  But I sometimes worry about that when I see patients who are angry or bitter, miserable or depressed, or just in total denial.  So it was a particular pleasure to read this collection of interview "portraits" of twelve terminally ill people collected by Montreal writer, Susan Gabori.  They demonstrate how genuine growth is possible, in many different ways.  In attitude, in feelings, in needs, in reviewing their lives and their relationships.  Perhaps this growth is the positive dividend of suffering.  As Dianne said "If you have not healed your life then dying must be very frightening."

Anyone who works in hospice and palliative care will enjoy reading this book and will be richer for it.  I was left wondering what we can do to help more of the terminally ill patients we look after to grow like this.


PALLIATIVE MEDICINE SECRETS

Palliative Medicine Secrets

Suresh Joishy. Hanley & Belfus, 1999. 244 pp. ISBN 1-56053-304-8. RRP $US 34, £30 More Info

This book is about the philosophy and practice of palliative care.  There are good descriptions of what palliative care is, the interdisciplinary team, and the role of each of the members of the team.  Patient-centered care is emphasized and there are good discussions on communication and ethics.  Dr. Joishy has written well over half of the book, although a variety of other health care professionals have contributed fifteen of the thirty-four chapters.  The book does not set out to be a symptom control manual and, whilst the management of pain is reasonably well covered, only a relatively small number of other physical symptoms are discussed.

This book gives a good account of what palliative care is all about and I found the question and answer format made reading it more interesting.



EUTHANASIA, ETHICS AND PUBLIC POLICY.
An Argument Against Legalisation

John Keown. Cambridge University Press, 2002. 318 pp. ISBN 0-521-00933-2. RRP $A59.95  $US 25  £17 More Info

As indicated by the subtitle, this book is unashamedly against the legalization of euthanasia and physician-assisted suicide, but it is written in a moderate and reasoned tone and in a manner easily understood whether you are a health care professional, lawyer, politician or just an interested member of the public.

Keown first explores the inexactitudes and ambiguities that abound in the euthanasia debate, and then dissects the arguments for and against.  This includes a description of the doctrine of double effects, although more recently published information suggests that it may not need to be invoked; Sykes et al. (Lancet Oncology 2003; 4:312) found no evidence that initiation of opioid or sedative therapy is associated with the precipitation of death.

The second part of the book is an in-depth assessment of the practices in The Netherlands, the Northern Territory of Australia, and the U.S. State of Oregon, and includes a clear illumination of the inadequacy of the much-vaunted legal safeguards against abuse.  Despite all their talk, the most recent data published by the Dutch (Onwuteaka-Philipsen et al. Lancet 2003;362:395) shows no sign of any reduction in the incidence of non-voluntary euthanasia or euthanasia without request.  It is to be hoped that Cambridge University Press will invite Keown to prepare an up-dated edition as more information and data becomes available from The Netherlands and Oregon.  The third part of the book critically reviews the findings of various expert committees, associations and the courts. 

By no means everyone will agree with the conclusions and opinions expressed in this book, but it should be required reading for anyone who intends to make a public statement in the euthanasia debate.



THE DYING PROCESS. Patients' Experiences of Palliative Care

Julia Lawton, Routledge, 2000. 229pp. ISBN 0-415-22679-1 . RRP £18, $US 29 More Info

This book is meant to be about patients' experiences of palliative care.  But it is really about Julia Lawton's (educational background and training not disclosed) interpretation and analysis of those experiences.  And I found some of them pretty difficult to follow.

In her fieldwork in a hospice, she discovered that dying patients frequently undergo progressive physical deterioration leading to increasing dependency. To the point, she says, that there is "loss of self".

Now if this is the case, she argues, then palliative care workers who talk about "living well until you die" are not telling the truth.  And those of us who talk about "dignified deaths" are hypocrites.  Well, I mean, how can you talk about dignity when, having relieved a patient of terrible pain, they become more despondent about their incontinence? Are hospices, she asks, just a place to hide this "dirty dying".

Described as a "subtle ethnographic study" by the publisher, I found it both convoluted and confronting.


DYING WELL. A Guide to Enabling a Good Death

Julia Neuberger, Radcliffe Medical Press, 1999. 171pp. ISBN 1-898507-26-0. RRP £25  $US25 More Info

Brilliant!  In 171 clearly-written pages, I found out about the origins of the attitudes to death and bereavement with which I grew up; I learned about the teachings and customs regarding death of the world's great religions and how palliative care professionals can best deal with them; I was treated to an erudite discussion on the meaning of a "good death", covering everything from common sense to euthanasia; and how we, whether we are health care professionals, family members, clergy, or friends, can help people achieve it; and finally, a description of our society's approach to grief and bereavement that does not shy away from pointing out what is wrong and why. 

Anyone who works in hospice and palliative care should read this book.  And, as it is written both for health care professionals and the general public, it should be available to be loaned out to people caring for loved ones through a terminal illness.

Highly recommended. 


Roger Woodruff
Director of Palliative Care, Austin Health, Melbourne, Australia