Book Review

Managing Death

N Engl J Med 1998; 338:336January 29, 1998

Article

Managing Death
By James M. Hoefler. 206 pp. Boulder, Colo., Westview Press, 1997. $25. ISBN: 0-8133-2816-0

Advances in medical technology, such as mechanical ventilation and renal dialysis, have increased the ability of physicians to prolong the life of patients who formerly would have died. Many patients greatly benefit from these developments, but as disease processes increasingly can be halted or reversed, the question whether life-prolonging medical intervention is always in the patient's best interest arises with increasing frequency.

Curing diseases and preventing death have traditionally been the main goals of modern health care, and doctors have only recently become aware that their responsibilities change beyond the stage at which death appears to be inevitable. In those situations, providing relief from pointless suffering while accepting the imminence of death can be another important goal of medicine. It seems, however, that clinical practice with respect to the end of life does not always reflect this awareness; doing everything to preserve life is still the “default” action in many cases.

In his book Managing Death, James M. Hoefler discusses “the medical, legal, ethical, and clinical issues associated with end-of-life decision making on behalf of those who have become irreversibly incompetent before an inevitable (if not imminent) death.” After comprehensively reviewing the opinions of authoritative medical and ethical groups, Hoefler concludes that there is a broad-based consensus about which principles should guide decision making when death approaches. One of these principles, which are a thread running through the book, is the patient's right to refuse treatment. When patients are irreversibly incompetent, surrogates should make decisions based on what they think the patients would have wanted, or else on what they feel would be in the patients' best interest.

Managing Death deals in detail with the question of continuing or forgoing life-sustaining treatment for irreversibly incompetent adult patients, but several other important issues concerning decision making near the end of life are less extensively discussed. The illustrative case of a patient who has been in a persistent vegetative state for 17 years represents only a small group of patients who become incompetent unexpectedly and live for a long time in a hopeless condition. By focusing on such patients and on those with end-stage dementia, Hoefler sidesteps the problem of assessing the competence of patients in less obvious conditions. The option of openly discussing end-of-life matters with patients and their families at an early stage in anticipation of a possible period of incompetency is a tactic that might contribute to the quality of the decision making, but it is only briefly touched on in the final chapter. Moreover, issues in medical decision making concerning the end of life, like palliative care with opioids that may hasten death or the intentional administration of life-shortening drugs, are hardly discussed.

Nevertheless, Managing Death makes a valuable contribution to the debate on medical practices and responsibilities at the end of life. Hoefler's plea for physicians and others involved to be more aware of the option of “providing comfort care only” as an alternative to “doing everything to preserve life” has wide appeal, and readers from many different countries with varying judicial and cultural traditions may link up with this book. In the Netherlands, many doctors also feel that the estimated benefits and burdens for the patient should guide decisions either to continue or to forgo treatment. Dutch nursing home physicians recently issued guidelines in which they distinguished among treatment aimed at cure, palliative treatment intended to relieve suffering but not explicitly aimed at extending life, and comfort care, which is aimed at relieving suffering with the extension of life considered an undesirable effect.

The publishers of Managing Death claim it is “the first guide for patients, family members, and care providers on forgoing treatment at the end of life.” The consensus principles described, however, mainly concern the range of medical options available when death approaches. Guidelines on how to act in specific circumstances are not given. In the final chapter, Hoefler gives a number of useful suggestions on how to improve the conditions under which decision making might take place.

Managing Death is very well written and easy to read for medical professionals as well as nonprofessionals. It is a timely book, since the issues discussed by Hoefler will probably become even more important in the next decades.

Johanna H. Groenewoud, M.D.
Agnes van der Heide, Ph.D., M.D.
Erasmus University Rotterdam, Rotterdam 3000 DR, the Netherlands