2015; Volume 16, No 10, October

IAHPC Book Reviews

By Dr. Roger Woodruff

Palliative Care Book of the Month

Jeanne Van Bronkhorst has worked with people facing life-threatening illness for twenty years, including ten years as a hospice social worker and bereavement counselor. And it shows.

Working as a social worker and counselor, Van Bronkhorst was conscious of asking about pain and eating and sleeping, but avoiding the bigger questions and hoping that they were being taken care of by the patient and family. But many terminally ill patients and their families cannot bring themselves to talk about their deeper emotions. But when Van Bronkhorst asked them about their dreams, she found it could lead easily to conversations about their most pressing concerns as well as the larger questions of life. And knowing what mattered most to them made it easier to know what help they needed.

So what’s special about dreams at the end of life? Van Bronkhorst says they are richer, more meaningful and more helpful because end of life is one of the most intense, stressful, meaningful and sacred times we will ever face.

The first part of the book deals with dreams that can help the dying and the bereaved at the end of life. Van Bronkhorst does not have any rigid classification of dreams but, for example, says any dream that helps someone grieve can be a grief dream, regardless of the dream images. There are dreams about unfinished business and unresolved relationships. Dreams that prepare the dreamer for a journey. Visitation dreams of long dead loved ones. Dreams that lead to those important and meaningful conversations within families. And a lot more. There is also a chapter about nightmares and how they might not be all bad.

I liked Van Bronkhorst’s approach of keeping it simple. Make it safe for them to tell you about their dream. Ask simple questions to encourage them – ‘What happened?’, ‘How did you feel?’ And never to offer any interpretation of their dream, for that is something owned by the dreamer. I thought this was important, because you were not being a therapist and didn’t need a degree in dream analysis, but were simply using it to let them express their innermost hopes and concerns. And some of that information could be used to improve the palliative care services offered to them.

The second part of the book gives ideas on how to listen to the dreams of loved ones and how to find your own dreams more easily. Most healthcare professionals ignore dreams, their patients’ and their own. Driving to work in the past few days, I have found myself thinking about the previous night’s dreams, something I cannot remember doing before.

This book was a bit of a revelation to me. It was as if someone had shown me a piece of the palliative care jigsaw puzzle that I had not realized was missing. I would recommend this book to anyone who works in palliative care. It may help you improve the care you give, as allowing patients to talk about their dreams is non-obtrusive. And it may help the care of yourself.

Other Reviews

This book is described as a core, introductory text for grief counseling courses that combines the knowledge and skills of counseling psychology with current theory and research in grief and bereavement. Not that I feel qualified to judge, but the book seems to cover the field. What I particularly admired was the almost conversational style, which allowed even me to comprehend the points they were making.

The book is divided into three sections – to do with the theoretical underpinnings of grief counseling, the practice and process, and current issues or trends. In the first section, I was drawn to the chapter on the Social Context of Loss, which highlights the importance of social (and cultural) norms in the grieving response. The opening chapter of the second section – on the Practice of Presence – is a bit of a gem that has implications throughout communication in palliative care.

There is discussion about the recently published Diagnostic and Statistical Manual of Mental Disorders (DSM-5), in which the caveat to not diagnose a major depressive disorder (MDD) if the symptoms were better accounted for by bereavement and lasted less than two months has been removed. I agree with those who say this is placing a medical diagnosis on a normal, albeit emotionally difficult, life transition.

This book will interest anyone who works in palliative care and has an interest in grief and bereavement. It seemed well written and understandable. My only criticism would be the abbreviations. I got hung up with CG, TG and CG/TG. I know what PTSD means. Was CG chronic grief or complicated grief? And STUG? I suggest that the next printing should have a one-page list of the abbreviations related to clinical situations (I don’t care about the abbreviated names of organizations).

Vanderpool says that the story of medical palliation (euthanasia [meaning ‘a good death’] as it was known then, and palliative care as we know it today) starts with the proclamation of Sir Francis Bacon in 1605. Bacon challenged physicians to offer and continually improve palliative medical care and treatment for dying persons. We are then treated to a procession of important figures in the fields of medical ethics and palliative care in England and America over the following 250 years, brought alive by the liberal use of quotations, which show a continuing evolution towards what we call palliative care. Florence Nightingale is amongst them, after which there is regular mention of the role played by nurses in palliative care, as well as the outstanding contributions of a number of individual nurses in the development of palliative care in America.

My amble down the history of palliative care was interrupted when I read that it was an English schoolmaster, one S. D. Williams, who after an address to The Speculative Club in Birmingham, England in 1870 is credited with reversing the meaning of the word euthanasia.

‘In all cases of hopeless and painful illness, it should be the recognized duty of the medical attendant, whenever so desired by the patient, to administer chloroform…so as to destroy consciousness at once, and put the sufferer to a quick and painless death.’

The admonitions to the contrary from William Monk (of whom I had heard) provide some balance.

The next two chapters cover the period 1895 to 1959, during which great advances in medicine led to less appropriate care for the dying, leading to interesting discussions about the ethics of treating the dying, and again with liberal quotations from the major players. The next period (1960-1981), Vanderpool describes as times of momentous transition. The development of cardiopulmonary resuscitation (CPR) and other medical advances led to concern about excessive attempts at life prolongation. The influence of Elisabeth Kübler-Ross and Cicely Saunders emerged, as did the issues of bioethics and patients’ rights. The last two chapters provide a good summary of what has happened to palliative care in America in the last 35 years with good discussions of patients’ rights, excessive treatment, barriers to accessing palliative care, and the ethical arguments that go with them.

This is a scholarly treatise about the history of palliative care over the last 400 years. It is enjoyable to read, particularly due to the frequent use of quotations that bring the argument of the day into better focus. Although Vanderpool chooses to start in 1605, I would have loved to hear what he had to say about palliative care from the days of Hippocrates to 1605, even if just by way of background. He stands aloof from the Physician Assisted Suicide business in Oregon, reporting what has happened, but offering no opinion. He makes no mention of the goings-on in The Netherlands.

If you have an interest in the history of palliative care, you will enjoy this book.

Harold Vanderpool is emeritus professor of history and philosophy of medicine in the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston.

This is the pediatric counterpart to Palliative Care Consultant, reviewed here last month. It also provides a mass of accessible information focused primarily on matters related to medications.

The opening section provides an overview of pediatric palliative care, with an emphasis on issues related to medications. The second part, which makes up the bulk of the book (250 pp), presents the Guidelines for Effective Management of Symptoms (PediGEMS) for 26 different symptoms or symptom complexes. Each topic includes material on the causes and risk factors, clinical characteristics, assessment, non-pharmacological treatment, and pharmacotherapy. The drug information includes the detailed dosing schedules that are part of pediatric practice. Each topic finishes with a list of clinical pearls, a treatment algorithm and references. All the material is presented as lists and tables, which I think makes the information more accessible. The third section is about Disease State Management with sections on life-limiting pediatric diseases, cystic fibrosis and neurodevelopmental disorders. There is an additional section on neonatal hospice considerations. Following this are some useful appendices, including tables on benzodiazepine equivalence, glucocorticoid equivalence, an insulin comparison chart, and lists of drugs that may cause extrapyramidal side effects, anticholinergic symptoms, prolongation of the QT interval, and those affected by cytochrome P450 metabolism.

I think this would be a very useful reference to have on the shelf in any pediatric palliative care unit, when questions regarding medications arise. It is written for the North American market, but the material in it is applicable anywhere (a few name changes aside).

Something Different

Clive James is the acclaimed memoirist, poet, critic and broadcaster. Known to be suffering from leukaemia, the pre-publication publicity for this volume promised ‘his evocative musings…on living and dying.’ I have never shared all his views, but have always admired his intelligence and industry.

But James is reticent to share any musings he has had regarding his own mortality. Mention is made of the regular infusions of intravenous immunoglobulin and the fact that the leukaemia flared up but responded well to subsequent therapy, but little else. The closest we get is ‘…when you start the slide to nowhere. The air is lit by a shimmering tangle of all the reasons you are sad to go and all the reasons you are glad to leave.’

So what do you get? A rollicking romp through (nearly) everything to do with the written word. He talks about the books he is reading or re-reading, offering insights into the literature of the last century, as well as commentaries on war, politics and politicians, class and social hierarchy, Hollywood and a lot more. I found interesting little facts on nearly every page. Did Florence Nightingale turn down the proposal of Richard Monckton Miles, and not vice versa as depicted by Hollywood? Was Ernest Hemingway brought up as a girl? His comments reflect his considerable knowledge and experience, perhaps honed or focused by the shadow of a life-limiting illness. He accepts that the world of the written word, as he knew it, is coming to an end and offers some interesting thoughts about what may happen in the future. You have to smile at his admissions to bibliomania (or being ‘book crazy’), complete with techniques for book smuggling by individuals forbidden to bring any new books into their own homes.

After finishing the book, I re-read the blurb. ‘In 2010,… terminal leukaemia.’ One could suspect that his disease has been controlled by one of the new Bruton-type tyrosine kinase drugs. And long may it last.

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Roger Woodruff, MD (Australia)
Dr. Woodruff is a Lifetime Member of the IAHPC Board and Past Chair. His bio may be found here.

Note for authors and publishers: If you wish to have your book reviewed, please send to:

Dr Roger Woodruff
IAHPC Bookshop Editor
210 Burgundy St, Suite 9
Heidelberg, Victoria 3084
AUSTRALIA

Note: Review copies become property of IAHPC and are not returned to the author. Only palliative care related books, which are previously approved, and which have an ISBN, will be reviewed. Due to the large number of requests, we can’t provide exact dates of when books will be reviewed.

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