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Clinical Wisdom in End-of-Life Care
Vol. 31 No. 5 May 2006
Journal of Pain and Symptom Management
477
Reviews
Clinical Wisdom in Endof-Life Care Craig D. Blinderman, MD, MA
A Palliative Ethic of Care: Clinical Wisdom at Life’s End By Joseph J. Fins, MD Published by Jones and Bartlett Publishers, Sudbury, MA, USA 2005, 281 pages, US $39.95 (paperback) According to the philosopher John Dewey, Joseph J. Fins’ pragmatist hero, knowledge and morality are two sides of the same reality; ethical inquiry belongs to the same class empirical inquiry. In other words, we can test our ethical judgments by putting them into practice and assess if we are satisfied with the results. This pragmatic approach frames the justification for our value judgments with human outcomes, not with some a priori or fixed ethical principle. As such, clinical pragmatism may offer a novel approach to many ethical dilemmas in end-of-life care. It is with this philosophical background that Dr. Fins’ book, A Palliative Ethic of Care: Clinical Wisdom at Life’s End, reframes the challenge of caring for dying patients with a pragmatic approach grounded in the philosophy of palliative care. The intention of this book is simpledto improve the care of dying patients and their families. The author carefully weaves theoretical considerations with a clinical pragmatism to help the novice physician refocus the goals of care for terminally ill patients. The book is organized into two parts. Part I provides the historical and ethical considerations in endCraig D. Blinderman, MD, MA, is a Fellow in Palliative Care, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, USA. Ó 2006 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.
of-life care. Part II introduces the reader to a practical clinical tool, the Goals of Care Assessment Tool (GCAT), which is skillfully illuminated in each chapter. This synthesis of knowledge and pragmatism can be called phronesis, or practical wisdom, and in the end is delivered by this text. Part I begins with a recognition of the gaps in medical education surrounding end-of-life care and a need for additional guidance for students and medical residents. Fins then embarks on a historical account of the rise of bioethics and palliative care in the United States. Beginning with Benjamin Cardozo’s famous articulation of self-determination in the 1914 Schloendorff vs. the Society of New York Hospital decision, and the subsequent rise of patient rights against a paternalistic culture of medicine in the 1960s, Fins describes the historical background for the landmark cases in bioethics, which gave rise to the ‘‘right to die’’ movement and laid the foundations for end-of-life care discussions. The legal and ethical considerations are logically summarized, referencing many important academic papers in law and bioethics. The author’s intention here is not scholarly discourse, but pragmatic education, such that the reader will have a basic understanding before moving onto the clinically relevant structure of Part II. Part II provides the framework to systematically explore complex and often disparate issues in end of life care through the GCAT. The process begins with triggers, events, or perceptions that herald a change in our clinical assessment of care. Here, Fins guides the young physician in waters that are known only through experience. The triggers need only be recognized to be appreciated: clinician or patient perceptions of terminal status, consideration of end-of-life decisions (e.g., advance care planning, withholding life-sustaining therapy), and medical developments (new diagnostic or prognostic information, change in clinical course, admission to the intensive care unit, etc.). The chapters on goal setting highlight clinical assessment by the GCAT, which considers the information needed to formulate 0885-3924/06/$--see front matter
478
Reviews
the goals of care. We learn that the process of gathering information may bring us into conflict with the patient and family. Thus, Fins pedagogically uses these potential areas of conflict as an opportunity to offer advice on breaking bad news, dealing with difficult family dynamics, appreciating the elusive advance directive, and even negotiating within the broader cultural context of the patient. The final chapters describe, briefly, the role of palliative care for dying patients and the use of a multidisciplinary model of care. Fins teaches us that the GCAT is a tool to illuminate the complex mesh of issuesdboth clinical and ethicaldin a systematic and comprehensive way, allowing the student or resident to formulate the appropriate assessment and plan. The strength of the book lies in its easy-toread, logical structure. Dr. Fins deserves much credit for his extensive review of the medical ethics literature in end-of-life care, making it accessible to the reader without a background in the subject. While the controversies and nuances of some ethical arguments are not fully explored, the expectation is that the reader will become comfortable with the topics and appreciate their significance in the care of the patient. This book is intended, as Fins notes in the introductory chapter, for residents and medical students. Indeed, it is this group of young physicians who will most benefit from the author’s years of experience as a medical educator and ethicist. The general internist also may gain much from this book, but as an educational tool, it seems most appropriate for junior level physicians and medical students. I would expect this book to become a required read for medical students as they are introduced to the medicine wards during their clerkship years. The philosophy of palliative care, as an approach to patient care, finds its grounding in end-of-life care, and it is reasonable to start with examining the quality of care at life’s end. Indeed, this book is a response to the empirical observation that oftentimes the goals of care are not well defined, and patients tragically suffer as a result. Thus, the value of Fins’ A Palliative Ethic of Care will be measured by improved discussions, awareness, and care provided at life’s end. doi:10.1016/j.jpainsymman.2006.03.001
Vol. 31 No. 5 May 2006
MGH Pain Management Handbook Shane E. Brogan, MB BCh
The Massachusetts General Hospital Handbook of Pain Management, 3rd ed. Edited by Jane C. Ballantyne Published by Lippincott Williams & Wilkins, Philadelphia, PA, USA, 2005 656 pages, $49.95 This popular pocket-sized book from the Massachusetts General Hospital is now in its third edition. Previous editions have found favor with a wide variety of pain management practitioners, including house staff in anesthesiology, pain fellows, and practicing physicians. The latest edition has added new chapters and material, becoming broader in its scope while remaining very accessible to all levels of expertise. Like all good ‘‘handbooks,’’ its content is surprisingly replete with practical information. Needed information can be accessed and consumed efficiently, without the need to retire to the library for an afternoon of trawling through the literature. The book’s content is firmly established around the interdisciplinary philosophy of pain management. It opens with three chapters on the basic science of pain. This is followed by an excellent section on pain diagnostics, including a refreshingly concise chapter on neurophysiologic testing. The third section deals with the pharmacologic management of pain, and uses a fairly standard approach to deal with the various drug classes used in pain management. Section four encompasses a diverse range of nonpharmacologic pain management modalities, including physical therapy, neuromodulation, behavioral methods, neurosurgery, acupuncture, and radiotherapy. This is followed by a section on acute pain, which Shane E. Brogan, MB BCh, is Clinical Assistant Professor of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
Journal of Pain and Symptom Management
477
Reviews
Clinical Wisdom in Endof-Life Care Craig D. Blinderman, MD, MA
A Palliative Ethic of Care: Clinical Wisdom at Life’s End By Joseph J. Fins, MD Published by Jones and Bartlett Publishers, Sudbury, MA, USA 2005, 281 pages, US $39.95 (paperback) According to the philosopher John Dewey, Joseph J. Fins’ pragmatist hero, knowledge and morality are two sides of the same reality; ethical inquiry belongs to the same class empirical inquiry. In other words, we can test our ethical judgments by putting them into practice and assess if we are satisfied with the results. This pragmatic approach frames the justification for our value judgments with human outcomes, not with some a priori or fixed ethical principle. As such, clinical pragmatism may offer a novel approach to many ethical dilemmas in end-of-life care. It is with this philosophical background that Dr. Fins’ book, A Palliative Ethic of Care: Clinical Wisdom at Life’s End, reframes the challenge of caring for dying patients with a pragmatic approach grounded in the philosophy of palliative care. The intention of this book is simpledto improve the care of dying patients and their families. The author carefully weaves theoretical considerations with a clinical pragmatism to help the novice physician refocus the goals of care for terminally ill patients. The book is organized into two parts. Part I provides the historical and ethical considerations in endCraig D. Blinderman, MD, MA, is a Fellow in Palliative Care, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, USA. Ó 2006 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.
of-life care. Part II introduces the reader to a practical clinical tool, the Goals of Care Assessment Tool (GCAT), which is skillfully illuminated in each chapter. This synthesis of knowledge and pragmatism can be called phronesis, or practical wisdom, and in the end is delivered by this text. Part I begins with a recognition of the gaps in medical education surrounding end-of-life care and a need for additional guidance for students and medical residents. Fins then embarks on a historical account of the rise of bioethics and palliative care in the United States. Beginning with Benjamin Cardozo’s famous articulation of self-determination in the 1914 Schloendorff vs. the Society of New York Hospital decision, and the subsequent rise of patient rights against a paternalistic culture of medicine in the 1960s, Fins describes the historical background for the landmark cases in bioethics, which gave rise to the ‘‘right to die’’ movement and laid the foundations for end-of-life care discussions. The legal and ethical considerations are logically summarized, referencing many important academic papers in law and bioethics. The author’s intention here is not scholarly discourse, but pragmatic education, such that the reader will have a basic understanding before moving onto the clinically relevant structure of Part II. Part II provides the framework to systematically explore complex and often disparate issues in end of life care through the GCAT. The process begins with triggers, events, or perceptions that herald a change in our clinical assessment of care. Here, Fins guides the young physician in waters that are known only through experience. The triggers need only be recognized to be appreciated: clinician or patient perceptions of terminal status, consideration of end-of-life decisions (e.g., advance care planning, withholding life-sustaining therapy), and medical developments (new diagnostic or prognostic information, change in clinical course, admission to the intensive care unit, etc.). The chapters on goal setting highlight clinical assessment by the GCAT, which considers the information needed to formulate 0885-3924/06/$--see front matter
478
Reviews
the goals of care. We learn that the process of gathering information may bring us into conflict with the patient and family. Thus, Fins pedagogically uses these potential areas of conflict as an opportunity to offer advice on breaking bad news, dealing with difficult family dynamics, appreciating the elusive advance directive, and even negotiating within the broader cultural context of the patient. The final chapters describe, briefly, the role of palliative care for dying patients and the use of a multidisciplinary model of care. Fins teaches us that the GCAT is a tool to illuminate the complex mesh of issuesdboth clinical and ethicaldin a systematic and comprehensive way, allowing the student or resident to formulate the appropriate assessment and plan. The strength of the book lies in its easy-toread, logical structure. Dr. Fins deserves much credit for his extensive review of the medical ethics literature in end-of-life care, making it accessible to the reader without a background in the subject. While the controversies and nuances of some ethical arguments are not fully explored, the expectation is that the reader will become comfortable with the topics and appreciate their significance in the care of the patient. This book is intended, as Fins notes in the introductory chapter, for residents and medical students. Indeed, it is this group of young physicians who will most benefit from the author’s years of experience as a medical educator and ethicist. The general internist also may gain much from this book, but as an educational tool, it seems most appropriate for junior level physicians and medical students. I would expect this book to become a required read for medical students as they are introduced to the medicine wards during their clerkship years. The philosophy of palliative care, as an approach to patient care, finds its grounding in end-of-life care, and it is reasonable to start with examining the quality of care at life’s end. Indeed, this book is a response to the empirical observation that oftentimes the goals of care are not well defined, and patients tragically suffer as a result. Thus, the value of Fins’ A Palliative Ethic of Care will be measured by improved discussions, awareness, and care provided at life’s end. doi:10.1016/j.jpainsymman.2006.03.001
Vol. 31 No. 5 May 2006
MGH Pain Management Handbook Shane E. Brogan, MB BCh
The Massachusetts General Hospital Handbook of Pain Management, 3rd ed. Edited by Jane C. Ballantyne Published by Lippincott Williams & Wilkins, Philadelphia, PA, USA, 2005 656 pages, $49.95 This popular pocket-sized book from the Massachusetts General Hospital is now in its third edition. Previous editions have found favor with a wide variety of pain management practitioners, including house staff in anesthesiology, pain fellows, and practicing physicians. The latest edition has added new chapters and material, becoming broader in its scope while remaining very accessible to all levels of expertise. Like all good ‘‘handbooks,’’ its content is surprisingly replete with practical information. Needed information can be accessed and consumed efficiently, without the need to retire to the library for an afternoon of trawling through the literature. The book’s content is firmly established around the interdisciplinary philosophy of pain management. It opens with three chapters on the basic science of pain. This is followed by an excellent section on pain diagnostics, including a refreshingly concise chapter on neurophysiologic testing. The third section deals with the pharmacologic management of pain, and uses a fairly standard approach to deal with the various drug classes used in pain management. Section four encompasses a diverse range of nonpharmacologic pain management modalities, including physical therapy, neuromodulation, behavioral methods, neurosurgery, acupuncture, and radiotherapy. This is followed by a section on acute pain, which Shane E. Brogan, MB BCh, is Clinical Assistant Professor of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA.