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APS Bulletin • Volume 8, Number 4, 1998

Resource Reviews

John D. Loeser, MD, Department Editor

Approaching Death: Improving Care at the End of Life

Reviewed by Stuart Farber, MD

M.J. Field & C.K. Cassel (Eds.), National Academy Press, Washington, DC, 1997, 375 pages, $34.95 (hardcover), ISBN 0-309-06372-8

This book is the most exhaustive review on the state of end-of-life care currently available. For anyone who wonders if the need to improve care at this inevitable period in the life cycle is needed, the positive evidence the book provides is overwhelming. The report doesn't stop at this point but outlines in depth what is known from the demographics of dying to the present level of research knowledge and everything in between. In addition, areas that need further exploration are considered and specific recommendations are made. In the end, this report is a complete review of the entire field viewed from the vantage point of medical science, couched within an ethic of respect and compassion for the patient and family. For anyone interested in the topic it is essential reading.

However, the strength of this book is also its most serious weakness. The field is viewed from a positivist, reductionist approach with the underlying assumption that through rigorous scientific investigation, the "solutions" to problems in end-of-life care can be "deduced." Many people would argue that the unexamined application of scientific medicine has created much of our problem. In the postmodern world there are many who believe that some questions ultimately are unanswerable. Surely determining what is an appropriate death--perhaps the most intimate and unpredictable event we all face--may defy the best of scientific investigation. At some point the underlying moral enterprise that underpins medical care must be addressed. Issues of relationship and commitment over time to meet patient and family needs are not easily reduced to scientific measurement. To paraphrase Ira Byock, death is not an event to be cured but a process to be midwived within the context of a committed relationship.

Stuart Farber is a Project on Death in America scholar in the department of family medicine at the University of Washington School of Medicine in Seattle.

Reviewer content represents the opinion of the reviewer, not APS.

Please direct your suggestions for future Resource Reviews to John D. Loeser, MD, Department Editor, at jdloeser@u.washington.edu

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