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Book Forum: The End of Life   |    
Approaching Death: Improving Care at the End of Life
THEODORE NADELSON, M.D.
Am J Psychiatry 1999;156:655-655.
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by the Committee on Care at the End of Life, Institute of Medicine; edited by Marilyn J. Field and Christine K. Cassel. Washington, D.C. National Academy Press, 1997, 418 pp., $34.95.

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In ancient Egypt, living and dying were within a continuum. The most elite group of royal physicians, those skilled in embalming, prepared dead pharaohs for their seamless journey into the dark world, protecting the noble body against corruption so that their ruler could continue to live in the elegant house of the dead for eternity.

Present-day physicians do not deal well with death; death is neglected because doctors are trained to extend life. As science has made life easier and more possible, death has become more difficult. Medical miracles are sought in the picking of Mother Nature’s locks, in discovering the secrets of health and disease, and in the clinical prolonging of life and life’s quality. The end of life, the quality of dying, has been out of focus for most of us. But not for all.

This present volume comes from a committee of the prestigious Institute of Medicine. Its authors attempt to rethink attitudes and practices relating to care at the end of life. They focus on the goal of directing society toward achieving a good death, that is, one without great distress for patients or families, in accordance with their wishes, and reasonably in keeping with the social ethos. It is a very successful excursion into a daunting and drab territory.

Approaching Death contains a vast amount of information and synthesis: the way people die; the demographics of when, why, and how; and the elements that define quality of care at the end of life. Three chapters are devoted to organizational structures and procedures influencing quality of care, assessment and improvement of quality, financial arrangements, and the education of health care providers. Other chapters address biomedical research and studies of systems to create a better database for examining the end of life and the means by which all involved—individual deliverers of care, policy makers, and administrators—can help toward a decent death. There are abundant references and an appendix with information on existing programs that will be of interest to many readers.

Each chapter contains references to the preceding and following chapters—knitting the volume’s major theme. There are boxes within the text that succinctly display important definitions and information. This is not only an academic, encyclopedic collection of information, it is a synthesis, and the many illustrative case studies make for clinical immediacy. It is time for such a report, and the Committee members wrote it passionately. They call for consensus and action because care for those who are dying should be an integral and important part of health care.

Goethe’s final wish as he died was "more light." This book is to be read as a way of illuminating the way toward civilized care at the end of life for all. It is most informative and literate and very human.

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