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Book Review

A Palliative Ethic of Care: Clinical Wisdom at Life’s End

Correspondence: James Hallenbeck, M.D., Stanford University School of Medicine, VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, California 94304, USA. Telephone: 650-366-4052; Fax: 650-849-0260; e-mail: james.hallenbeck{at}med.va.gov

A PALLIATIVE ETHIC OF CARE: CLINICAL WISDOM AT LIFE'S END

By Joseph Fins, 281 pp., Jones and Bartlett Publishers, 2006. ISBN: 0763732923.

In his book, A Palliative Ethic of Care: Clinical Wisdom at Life’s End, Joseph Fins brings a clear message: "[I]nstead of letting available technology drive the goals of care, let the goals of care drive the therapy." The author is a renowned leader in medical ethics. He draws upon his real-life experience performing ethics consults to highlight the importance of good communication and goal-setting in the care of patients. Clinicians encountering difficult decisions at the end of life do need a solid understanding of commonly accepted ethical principles and precedents. However, Fins argues that this is not enough. In the Preface he writes,

The relationship of ethical theory and clinical practice has long intrigued me. Since my days as a student interested in bioethics, it seemed to me that prevailing approaches to ethical questions in medicine and the life sciences were too deductive and prescriptive. Ethical principles seemed to exist in the abstract and were seemingly engrafted onto complex clinical scenarios without due concern for context.

This book, targeting principally physicians-in-training, provides practical advice for melding theory and practice in the real-life world of the acute care hospital. The book is written in a straightforward, informal style, often addressing the reader in the second person. Imagining the common situation of an overwhelmed resident, standing at the bedside of a dying patient, Fins writes,

If the patient were not dying, you believe that you would know what to do. But he is dying and you feel incompetent. Somehow the "full court press" does not make sense. He did not want that and you know in your heart that a stay in the intensive care unit will do little to prolong his life. ...So you stand by at his side and think. No one has prepared me for this challenge. Yes, you know how to work up a pheochromocytoma, but what do you do for a dying guy with profound dyspnea?

In a refreshing change from many ethics texts, this conversational style makes the book accessible and very readable.

The book is divided into two parts. Part 1, Death and Dying in Context, is "a review of the history of palliative care and modern bioethics and considers how these two movements have influenced our thinking about the needs of patients at the end of life."

Here, Fins succinctly presents a history of medical ethics and the parallel evolution of palliative care with an emphasis on major legal cases that have shaped current thinking and law such as Cruzan, Quilan, and Schiavo. His summaries and discussions of these cases are to the point and quite excellent.

Part 2, Goal Setting: A Strategy for Effective Palliative Care, is loosely organized around an assessment tool developed and used by the author, the Goals of Care Assessment Tool. This tool provides a framework for thinking about a wide range of topics and problems that arise in the provision of end-of-life care. A particular strength of this section is its emphasis on the necessity to develop good communication skills, given how often what is perceived to be an insolvable ethical dilemma turns out to be in fact a very solvable problem of miscommunication. The value of Fins’ experience in performing ethics consults over many years shines through in his discussions of special scenarios he has encountered, such as the "symbionic family" (in which the psychic boundaries of individual family members blur, making true surrogate decision-making difficult). In reading these sections, I really felt I was learning from a master craftsman.

The great strength of the book in terms of the author’s ethics background is offset somewhat by a weaker grounding in palliative care proper. The history of palliative care in the first section is less well fleshed out than the ethics history. For example, overstated, in my opinion, is the influence of the debate on physician-assisted suicide in shaping palliative care as we now know it. In a later chapter on formulating goals of care, he discusses the roles of various hospital disciplines, including psychiatry, chaplaincy, and palliative care, among others. To my read, his discussion of the role of the palliative care consult team, lumped together with pain services, is cursory—only two pages. For comparison, more than six pages discuss the role of ethics consults and three pages address the role of chaplaincy. While the book’s title suggests a very broad scope, in fact, the book more narrowly focuses on issues in the acute care hospital. Palliative care as it might be practiced elsewhere, in home settings, hospice, nursing homes, or clinics, receives little attention.

Still, the acute care hospital is the dominant venue for physicians-in-training, who will find the situations and dilemmas described in the book all too familiar. These readers will appreciate the sage advice given on how best to deal with them. As a palliative medicine physician, what I most appreciated in the book was the author’s sincere effort to build bridges across disciplines and his call for pragmatism. Those of us working in palliative care understand that the most challenging problems we encounter day-today involve issues of communication and goals of care. Without question, greater attention in medical education should be paid to the acquisition of necessary skills in this area. Dr. Fins’ contribution in this regard is welcomed and applauded.

AUTHOR'S NOTE

Dr. Hallenbeck’s work is supported by the VA Palo Alto Care System.

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