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by Sidney Wanzer
Da Capo, 2007
Review by Leo Uzych, J.D., M.P.H. on Oct 23rd 2007

To Die Well

To Die Well is a guiding light on the turbid road to comfort, calm, and choice in the last days of life.  Sidney H. Wanzer is the former Chief of Harvard University Health Services; and Joseph Glenmullen is a faculty member, at Harvard Medical School.  Somewhat paradoxically, the book stirs a cauldron of end of life care in America seething already with assorted vexing legal and ethical ingredients.  But it is written for patients and their families and caregivers in a determined effort to shed revealing light on what contributes to a peaceful death and what does not.  The stylistically very lay reader friendly discourse is highly opinionated, quite sobering, and anchored firmly to unabashed candor.  The resultant cascade of thoughtful musings and information flowing copiously through the text's pages may be a powerfully illumining beacon for all persons searching for direction in the hazy realm of end of life concerns.

The first chapter importantly introduces the reader to the concept of "turning points", at life's end.  As conceptualized by the book, one turning point is the time when a patient rejects aggressive treatment intended to restore health, and chooses instead palliative measures intended to make the dying process more comfortable.  The second turning point is the time when a patient wishes to hasten dying, because the patient is suffering intolerably despite proper administering of all comfort measures.  Setting a precedent which is followed through the text's remainder, anecdotal material germane to end of life care is sewed artfully, and instructively, into the fabric of Chapter One.  The infusion of anecdotal matter into the textual body greatly empowers the text with the animating strength of real life details.  Critics may caution, however, that the strength of the book, in an academic sense, is diluted by the repeated injections of anecdotal matter into the textual corpus.

Some of the end of life rights of a patient, rooted in the soil of American law and ethics, comprise the substantive core of Chapter Two.  It is noteworthy that Chapter Two brings to the fore potential criticisms reaching as well to the chapters that follow.  Knowledgeable persons may describe American law, impacting care at life's end, as being pulled and tugged, sometimes quite confusingly and at times arguably conflictingly, by dynamically evolving case law as well as an ever accumulating tome of statutes.  Variant views of medical ethics experts may contribute further to seeming dissonance.  Critics may charge that unresolved tensions at the levels of law and ethics are not fleshed out fully in the book.  To counter such criticisms, the book's formidable substantive strength may possibly have been buttressed even further if it had been structured as a collection of papers, drawn from an academically and professionally eclectic array of expert contributors.

The first turning point, away from restorative care and towards comfort care, raptly engages the attention of Chapter Three.  Various real life concerns and considerations relevant to comfort care are expounded on interestingly in the chapter.  At the heart of Chapter Four is the vital matter of pain control.  In Chapter Five, numerous questions are presented which seriously ill patients may wish to pose to their doctors.  A cogent rationale is presented for the respective questions.  This well constructed chapter helps cement the book's practical value to patients regarding end of life care.  In Chapter Six, the role of family and friends, in the context particularly of end of life care, is addressed.

Chapter Seven adroitly traverses the end of life ground leading to the second turning point, when a patient is suffering intolerably and wishes to hasten death.  Historic methods of hastening death garner the attention of Chapter Eight.  Topics broached envelop morphine and Seconal.  An absorbing examination of helium, in the context of hastening death, draws the close study of Chapter Nine.  Critics may admonish that the state of medical knowledge (in the form of academic studies) in various areas connected to end of life care, including methods used to hasten dying, is relatively sparse.

Considerable territory is traveled by this book.  In Chapter Ten, the difference between persons suffering from suicidal depression in stark contradistinction to terminally ill persons who choose rationally to hasten death because of intolerable suffering is examined.  Chapter Eleven wrestles gamely with dementia in the context especially of hastening death.  The thematic emphasis of penultimate Chapter Twelve is that advance planning, with respect to eventual end of life care, is of paramount importance.  Several variants of advance directives are discussed tersely.  The textual current, of concluding Chapter Thirteen, flows with ruminations concerning a hastened death.  The view advanced in the book is that society needs to strive for the legalization of the right of physicians to assist patients with regard to hastening death in cases of intolerable suffering.  Sympathy is evinced further for legalizing euthanasia in some instances, given the clinical reality that some persons in the unyielding grip of intolerable suffering may be unable physically to end their own lives.  But critically, it is noteworthy that particular views embraced by the book may be at variance considerably with the values, possibly including those of a faith based nature, of individual readers.

A collection of appendices, adjoining the text, add materially to its instructive value.  A sample "living will" embodies Appendix E; and Appendix F is composed of a sample healthcare proxy form.  The focus of Appendix G is on constructing an advance directive taking into specific account the possibility of eventual dementia.  Other appendices:  explicate Oregon law appertaining to physician assisted dying (Appendix B); summarize the end of life movement from a historic perspective (Appendix A); comment succinctly on the legalization of assisted dying in various foreign countries (Appendix C); and provide contact information for multifarious end of life organizations (Appendix D).

Further adjoining the text are "Notes" comprised, in substantial part, of references linked to particular chapters and appendices.

Highly nettlesome issues joined to end of life care have incited polarizing societal differences in America, at both the public and professional strata of American society.  Although likely not a magical elixir for this malaise, this informative and thought provoking book may enthrall lay readers,  and greatly assist those seeking assiduously to disentangle the sorely tied knot of issues associated with care at life's end, including: pain control experts, family medicine doctors, oncologists, gerontologists, neurologists, internists, psychologists, psychiatrists, pharmacists, pharmacologists, medical ethicists, healthcare lawyers, faith counselors, health policy experts, legislators, hospice workers, and nursing home personnel.

© 2007 Leo Uzych

Leo Uzych (based in Wallingford, PA) earned a law degree, from Temple University; and a master of public health degree, from Columbia University.  His area of special professional interest is healthcare.