2015; Volume 16, No 11, November

IAHPC Book Reviews

By Dr. Roger Woodruff

Palliative Care Book of the Month

I can remember back in 1989 or 1990 when I received my copy of Holland et al’s Handbook of Psycho-Oncology. The psychological and psychosocial problems of the patient with malignant disease and their families had always been paramount since my training days but here, for the first time, it was set out in a clear and orderly manner. Since then, the field has gone from strength to strength, this being the third edition of the Holland et al’s textbook, Psycho-Oncology (previously published by OUP in 1998 and 2010). The influence of Jimmie Holland and her editorial teams on the education and attitudes of oncology professionals over the last 25 years, to the benefit of patients and their families, is enormous.

The third edition is big and impressive. Sixteen sections and 102 chapters, covering just about every aspect you can think of; 204 contributors with many familiar names.

The opening sections are about behavioral and psychological factors in cancer risk and screening. Then there is a section on psychological issues related to the site of the cancer that covers 11 frequent cancers and HIV/AIDS. The section on physical symptoms covers pain, nausea and vomiting, fatigue, sleep and anorexia. A good chapter addresses cognitive changes associated with cancer and cancer treatment, showing there are numerous influences, rather than the catchy ‘chemobrain’ popularized in the lay and professional press. I thought the section on palliative and terminal care was a bit light, and I felt there was room for a lot more material about reactions and difficulties that were not abnormal or pathological. The section on psychiatric disorders is comprehensive, except the chapter on suicide included only a short discussion of physician-assisted death. The section on screening and assessment in psychosocial oncology underlines that we should be asking about this in the same way other vital signs are recorded. The sections on psychotropic management, both pharmaceutical and non-pharmaceutical, are comprehensive. Then there are sections on geriatric psycho-oncology, psychological issues for the family, cross-cutting issues, survivorship, professional education and health policy.

There is a real wealth of information in this book that covers an enormous range of psychosocial difficulties from the time of screening to survivorship. But my experience is that the real psychosocial crunch for the patient and their family comes when the patient is dying. Using the index or table of contents, I can quickly access information about how to deal with obviously pathological psychosocial and psychiatric problems, but I had trouble finding information about how to deal with ‘ordinary’ psychosocial problems suffered by ‘ordinary’ patients. I am sure there are lots of pearls hidden away in the chapters about more severe problems, but a busy oncologist doesn’t have time to read all these. David Kissane’s chapter about bereavement was welcome, but I felt there was far too little about the ‘normal’ psychosocial problems surrounding dying and bereavement. I wondered if Psycho-oncology had gone down the over-pathologization path of DSM 5.

Which brings me to the chapter on DSM 5. The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders was published in 2013. It has been criticized because it seems to pathologize normal behavior. Of particular importance to those of us who work in palliative care, the recommendation in DSM-IV that a diagnosis of major depressive disorder (MDD) be deferred for two months after the death of a loved one (the ‘bereavement exclusion’), has been removed. I’m not a psychiatrist and it certainly doesn’t make sense to me, but it is calmly defended here.

Overall, this is an excellent textbook. It certainly deserves a place on the library shelf in any oncology unit and should be required reading for any trainees in oncology. I guess I have to wait a few years for American psychiatrists to recognize that normal human reactions are not necessarily pathological.

And a big thank you, from the profession at large, to Jimmie Holland.

Other Reviews

The night her father unexpectedly died in his sleep, he paid a visit to her sister who was suffering advanced breast cancer, to comfort her. In another city. And when she later died, a number of her relatives, some thousands of miles away, were awakened in their beds.

That is the jumping off point for this exploration of parapsychological phenomena surrounding death by Canadian journalist and writer, Patricia Pearson.

In her search for information, she starts with what the dying do and see. Visitations by long-dead relatives seem relatively common. Some are a little more extraordinary: when a dying man is visited by a long-dead uncle, he asks him what it’s like after you die. The uncle reassures him that everything will be OK and suggests he asks Dianne what it’s like. Dianne was the dying man’s palliative care nurse, and when he asked her it turns out she had had a near death experience of her own and had perhaps glimpsed the other side. There is also the foreknowledge of death (the Nearing Death Experience), which is frequently announced by talk of traveling and leaving. And we have all seen the patient who has been unconscious, mute and immobile for days or weeks, who suddenly moves purposively or speaks lucidly. It may only last for a few moments, but what is the explanation for it? And the terminally ill who become blissfully serene, as Pearson’s sister did?

She then turns to the bereaved. Haraldsson’s 340 cases where the bereaved saw the deceased or conversed with them or suffered similar symptoms to them, either at the time of death or within 24 hours. In 86% of cases they had not been notified of the death. Do 49% of the bereaved experience presences, voices and touches? Many years ago, Freud apparently classified this as unhealthy. But it is important today if it means the bereaved cannot discuss their post-bereavement hallucinations in grief therapy.

Her description of The Third Man phenomenon is intriguing. The sensed presence by endangered soldiers, injured climbers, desperate Antarctic explorers (Shackleton), and others of an invisible presence that guided them to safety.

Near Death Experiences (NDEs), with or without Out of Body Experiences (OBEs), are other incompletely explained phenomena. Originally thought to be rare, it is said that 17% of the American population have experienced them. Seems the light is the core essence of the mystical experiences encountered in NDEs, a light that is intensely bright, but comfortable to gaze at, and one that seems to cut across, historical, cultural and religious boundaries. That the light was a core tenet of Christianity and other major religions was interesting. I also noted that those who have NDEs have a significant 40% fall in those that call themselves religious, but interests in spirituality doubled.

So where are we with these psychic phenomena or psi – cognitive abilities that can’t be accounted for through identified senses, including clairvoyance, telepathy and prerecognition? Pearson has collected an impressive number of reports, as well as some very educated opinion. There is some evidence of psychic communication in primitive tribes who are isolated from the modern world and in the animal kingdom. The famous Hans Eysenck theorized that psi might be a primitive form of perception antedating cortical developments in the course of evolution, and that later developments in cortical arousal might suppress psi functioning.

When I picked up this book, I was a little skeptical. When I finished it, I think I said ‘Wow!’ We spend our professional lives with death and dying. Read it!

Produced and edited by the Chaplaincy Team at the Birmingham Children’s Hospital (UK), ‘this book seeks to address issues of care in our increasingly multifaith cultural context. It is written with awareness that being sensitive and attentive to the religious and spiritual needs of a child and family are intrinsic to holistic care.’ There is apparently a dearth of worthy published material focused on pediatric religious and spiritual care.

In the first chapter, Paul Nash sets out his list of key values and objectives, but notes that it continues to evolve with experience and time. They cover the different but overlapping types of care – religious, spiritual, pastoral and cultural. Then follow chapters regarding care within the context of each of the six major world faiths, (arranged alphabetically) – Buddhist, Christian, Hindu, Jewish, Muslim and Sikh. These chapters are packed with information that may allow you to offer better care: the basic beliefs and rituals, where the religion stands in the 21st century, family life and attitudes to children, information about food and prohibited products, modesty and hygiene, and taboos. Also discussed are age-specific considerations, views of suffering and attitudes to medical care, understanding of and preparation for a death, the funeral, and what on-going contact and support is appropriate. The text is enriched with little side boxes that explain the origin of particular beliefs or why a certain attitude is the way it is.

I was left a little in awe at what these people were managing to do. I was pleased to see Nash’s statement that his team’s work was not in the interests of some multicultural political correctness, but because they believed their pediatric patients and their families would get better care. This book has got a lot to offer anybody who works in palliative care in a multifaith setting, not just the chaplaincy team.

This second edition of Palliative Care, published after an interval of 13 years, is a core text about the fundamentals of palliative care directed at medical and nursing undergraduates and recent graduates.

There are chapters on principles, assessment, communication, decisions and care around the end of life, and physical symptom control. I particularly liked Chapter 8, which invited self-assessment in the core competences in end-of-life care – communication skills, assessment and care planning, symptom management, advance care planning, and ‘overarching values and knowledge’.

I liked the way the material was presented. There were lots of lists, as well as boxes of Key Points, Chapter Summaries, Learning Exercises, and numerous explanatory cartoons (not intended to be humorous).

I would be comfortable using this as an introductory text on palliative care for young doctors and nurses. The material presented is well organized and has been thought through. I also thought it might be a useful ‘introductory’ text for primary care physicians or GPs who find themselves called back into the field of palliative care.

Complementary and alternative medicine (CAM) has continued to grow, including in the fields of oncology and palliative care. This book is a scholarly discussion, primarily from the viewpoints of sociology and the law, of all the things that have been unjustly holding it back. A number of the chapters relate to original research (about sociological, regulatory and legal matters, not clinical effectiveness), which I respect. But it contains essentially no information about the clinical efficacy of any of the modalities discussed.

The book is divided into four sections. The first provides historical, sociological and legal discussions about professionalism and regulation. The second discusses the diversity of CAM, with sections on naturopathy, Ayurveda, Shamanism, and the use of Cam in obstetrics and infertility. The third is about risk and regulation, with reports from a number of different countries. The last is about the ‘knowledge base’ on which CAM practices are based. I had to remember there was knowledge, as well as knowledge viewed from different perspectives, and that ‘with a simple social science analysis, it is possible to see that knowledge is socially produced in many places, such as the research process, the experience of social actors and the pedagogies in formal and informal learning spaces.’

This book goes to great length to describe the numerous barriers preventing the wider practice of CAM, from charlatan practitioners that give it a bad name to those nasty biomedical scientists and doctors who won’t listen. But I didn’t find any discussion about money. The orthodox medical industry, Big Pharma in particular, will do whatever to stop revenues being diverted away from them, particularly when so little of CAM has a clinical evidence base. The review of coverage of herbal medicines by the Australian media raises questions about the portrayal of both benefits and risks, but doesn’t directly question the propriety of either the publisher or the manufacturer. Articles about the magic weed of the month sell publications, and the annual sales figure for the herbal medicine industry in Australia has topped $A550 million.

I found the text in this book a bit dense and difficult to read. I am not much into sociology or governmental regulation and I’m a bit ignorant about law, but I did not come across anything that swayed me to the cause of CAM. The editors will probably say that I missed the point altogether and should think in broader terms, from a wider range of perspectives, particularly the rights of the patient. My answer? Show me the evidence of benefit to the patients, following which, all these sociological, regulatory and legal issues may largely disappear.

Nicola Gale is a health sociologist at the Health Services Management Centre at the University of Birmingham in the UK. Jean McHale is Professor of Healthcare Law and Director of the Centre for Health Law Science and Policy, also at the University of Birmingham.

A classic

Somebody gave me a copy of one of the newer editions of this classic, and I could not help but read it again. For the uninitiated, it is the recollections of a Viennese psychiatrist imprisoned in the Nazi concentration camps in the Second World War. Frankl’s contribution comes to a little over 100 pages, although I think most editions have forewords and afterwords. Written in nine days in 1945, the first part is his recollection of his psychological (and physical) experiences in the camps; the second, shorter part, is about the type of psychotherapy he developed (primarily before the war), that he calls logotherapy (‘logos’ being Greek for ‘meaning’). The book offers some profound psychological advice for those who find themselves in a life-threatening situation, and secondarily for those associated with them or having to look after them. As such, I think it has important implications for what happens in palliative care and I would recommend it to anyone who has not seen it, to read and reflect.

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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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