I am not really sure for whom this book was written. It is a collection of medical, policy and ethical writings on the topics of either, or both, Palliative Care and Ethics focused almost entirely on the situation in the USA. The editors note that they gave their authors “considerable latitude in choosing specific questions and in undertaking ethical and policy analyses within the palliative care domain they have chosen to explore” (p. 11) which means that there is overlap on several issues, including Palliative Sedation and Delirium. The USA focus comes predominantly from the authors: all but five of the thirty one are from the USA, though the editors state that their authors are the top ones in their fields from North America and Western Europe (p. 4).
The chapters are grouped into four sections: Introduction which covers the background of the USA models of care, Ethical Challenges in the Current Systems deals with issues of pediatric palliative care, patient centered care and interprofessional teams, the third section deals with Suffering with some chapters being very focused on clinical management options. It is only the final section titled “Difficult Decisions Near the Very End of Life” that covers the issues that someone picking up the book might expect to be more front and centre, i.e. medical futility, withholding care and physician assisted suicide.
Through the initial chapters there is an overview of the current USA system of providing palliative care through hospice (which in the UK and some other countries would be called community palliative care) and hospital based palliative care similar to that in most other countries. In some instances clinical scenarios are provided to allow the reader to see the issues in context. In this regard the chapter dealing with pediatric issues is particularly good with many relevant scenarios and management suggestions for the ethical issues described.
Those chapters in the section on Suffering which include cases are more attractive and the ethical issues and their possible solutions are more obvious than in drier chapters which concentrate on a clinical symptom or sets of diseases providing evidence for best clinical care.
The final section is the most interesting and most obviously deals with the current challenging ethical issues in palliative care. There is a good chapter on the differences between withholding and withdrawing care with pertinent cases. All clinicians in this field know that there are very great emotional differences between withholding and withdrawing care even when we know that ethically there is no difference. The authors acknowledge very clearly the problems this can cause for families and clinicians.
There is an interesting chapter on medical futility, including a discussion on whether we should even use the term. The authors suggest ‘futile intervention’ as the best use and using cases remind the readers that time often assists in making decisions. A chapter on palliative sedation includes clear attempts to define what it is and is not through an exemplifying case. The book concludes with chapters on voluntarily stopping eating and drinking and then three on physician assisted death (PAD). The first of these final chapters is a discussion on the topic by the editors who state they personally support this in appropriate circumstances and then provide a series of cases asking the reader to consider whether the patient should have been allowed PAD. The last two chapters are an overview of the USA experience in the four states which allow PAD and a European view of the situation in the Netherlands, Belgium and Switzerland (which allow PAD) contrasted with data from other countries which do not allow it, but where there is research evidence of Medical Behaviours that Potentially Shorten Life.
The book as a whole is not an easy read, though several of the chapters provide valuable insights and management suggestions which would be of use to the palliative care practitioner in any part of the world.
