Book Review  |   September 2011
Care at the Close of Life: Evidence and Experience
Author Affiliations
  • Katherine E. Galluzzi, DO, CMD
    Department of Geriatrics, Philadelphia College of Osteopathic Medicine, Pennsylvania
Article Information
Book Review   |   September 2011
Care at the Close of Life: Evidence and Experience
The Journal of the American Osteopathic Association, September 2011, Vol. 111, 552-553. doi:
The Journal of the American Osteopathic Association, September 2011, Vol. 111, 552-553. doi:
Recently, palliative care has gained acceptance as a distinct medical specialty. This acceptance has occurred in direct response to 2 main factors—increasing numbers of people living longer with chronic, potentially devastating diseases and the complexity of addressing myriad concerns attendant to serious illness. Palliative care now has formal certification and fellowship programs approved by both the Accreditation Council on Graduate Medical Education and the American Osteopathic Association. In addition, there are evidence-based guidelines and a core body of knowledge representative of the maturation of palliative care services, as well as an increased availability of physicians who possess advanced training and certification in palliative care. 
Nevertheless, it remains true that all physicians—regardless of specialty—use many precepts of palliative care as integral components of treatment plans for their patients, especially those patients facing serious illness or the end of life. Care at the Close of Life: Evidence and Experience, edited by Stephen J. McPhee, MD; Margaret A. Winker, MD; Michael W. Rabow, MD; Steven Z. Pantilat, MD; and Amy J. Markowitz, JD, is a valuable resource that can help physicians enhance these vital skills. All the editors are from the University of California, San Francisco, except for Dr Winker, who is with JAMA. 
This text is a compendium of 42 recent, well-referenced articles that were published in JAMA. In the foreword, Irene J. Higginson, BMBS, PhD, of the Department of Palliative Care, Policy, and Rehabilitation in the Cicely Saunders Institute at King's College London in England, summarizes the scope of the book as representing “an important milestone in the evolution of care for people with advanced disease—for which the editors and authors of JAMA should be rightly proud.” The articles included in the book address core concepts of that evolution. Osteopathic physicians will find the book valuable not only for its concise, evidence-based content and timeliness, but also as a source for improving skills at prognostication, communication, truth-telling, advanced care planning, and specialized management of complexes with difficult-to-treat symptoms. 
The format of Care at the Close of Life includes case presentations to preface each of the articles, which was the technique used by the editors and authors of the articles originally published in JAMA. The clinical case-based format is further enhanced by examples of actual dialog from both the patients and physicians described in the case scenarios. In one such example, which highlights the diagnostic and prognostic uncertainties in the case of a patient with cancer who eventually died, the physician is quoted as saying the following:

One of the things I learned is that presenting them [ie, patients] with information is one thing, but assisting them in the decision making is another thing. I should have made stronger recommendations.

The chapter author then notes the following:

Uncertainty characterizes all medical decision making, and physicians must help patients manage it. Surveys consistently show that most patients wish to receive as much information as possible, perhaps as a way to cope with uncertainty. However, patients who are at either extreme of preferences for decision making—those who want to be entirely in control of decisions and those who defer entirely to their physicians—are less satisfied and are more anxious than those who take an intermediate role.

Rather than merely recapitulating previously published articles, the editors of Care at the Close of Life have thoughtfully and usefully grouped the various chapters into 9 topic sections (listed here consecutively): Communication Issues; Symptom Management; Disease Management; Other Patient Management Issues; Psychological, Social, and Spiritual Issues; Ethical Issues; Cross-Cultural and Special Populations Issues; Settings of Care (Structural Issues); and Clinician Self-Care. This last section includes a fascinating chapter titled “Care of the Dying Doctor: On the Other End of the Stethoscope.” This topic—fraught with issues that transcend the practice of caring for non-physician patients—is handled in a forthright and helpful manner. In addition, each of the 42 articles has been updated to reflect the most current evidence-based information. Each chapter concludes with a brief multiple-choice quiz to test knowledge of the reader—a feature that is especially helpful for physicians preparing to take examinations for added certification in hospice and palliative care. 
In full support of the clinically relevant format of Care at the Close of Life, chapters are authored by noted leaders in the field of palliative care. Among the outstanding contributors are Susan D. Block, MD; J. Andrew Billings, MD; Kathleen M. Foley, MD; Joanne Lynn, MD; Diane E. Meier, MD; Timothy E. Quill, MD; and David E. Weissman, MD. 
It certainly requires such a highly skilled group to tackle the often confusing and sometimes controversial issues covered in this book. Questions such as “Shifting goals of care to palliation: why is it so difficult for physicians?” “Doesn't honesty take hope away?” “Whose job is it, anyway?” and “What can a physician do?” are handled with thoughtfulness and insight. Concerns related to cultural competency as well as nitty-gritty, occasional conflicts that occur between physicians, between physicians and nurses, and between physicians and patients or family members are illustrated by recognizable scenarios. Suggestions for opening lines of communication, defusing anger, and reaching consensus are discussed. For example, a “Dr C” recommends the following when working with patients from minority populations:

You know, it always says in the literature that you should select the spokesman for the group and communicate with that person. That is dead wrong when it comes to minority populations. You need to have every person who has anything to say. There may be a spokesman in that group that you may identify. But he or she will need the consensus of the group in order to make a decision. And [he or she] will almost always be unwilling or very uncomfortable about making a decision, unless there is consensus in the group. So I'll have conferences with 30 people.

The book is also replete with numerous useful tables. These tables cover such material as diagnostic tools, management strategies and resources, commonly occurring clinical situations, physician and patient responses, and suggested words for improving dialogue and enhancing trust. 
By its very nature, palliative care is holistic and, therefore, closely aligned with many tenets of osteopathic principles and practice. Palliative care seeks to treat the entire individual in terms of symptom relief. Thus, the authors address not only biomedical and physical problems, but also psychosocial, spiritual, and existential concerns. This too is congruent with the osteopathic view of the individual as encompassing mind, body, and spirit. This excellent compilation would have been further enhanced by a chapter on osteopathic manipulative medicine for treatment of patients with such symptoms as pain, dyspnea, edema, and constipation. 
Care at the Close of Life provides a comprehensive look at the role of palliative care in the office, the hospital, and at home by the patient's bedside. Concise, well-illustrated examples present a model of comprehensive, compassionate care for patients who face the trials of serious illness at the close of life. Physicians who seek to improve their communication techniques and to gain a better understanding of ways to approach complex, emotionally fraught medical situations would benefit from reading this text.