The Best Care Possible: A Physician's Quest to Transform Care Through the End of Life

I loved Dr. Byock's other book, Dying Well, and wanted to read this one also. To give you some backstory, I had no interest whatsoever in these types of issues until my mother died march 11, 2013. She was 69. She was in ICU for two weeks prior and admitted into hospice on March 9, 2013. Although she had a chronic illness (COPD) she had never been hospitalized before except when she was initially diagnosed in January 2010. As an only child and constant companion to my mother (she lived next door to me), everything that occurred over this two week period was a blur. I have obsessed over every decision I made, every detail of everything that was said to me in the ICU, etc. I needed reassurance that what I did was right. My mom was one of those who felt that hospice care was "giving up." I had to convince her to even enter the hospice program. While in the ICU, the palliative care nurse came to speak to me and informed me that my mom was "very fragile and very ill." She offered the in-hospital hospice or possibly at-home hospice if my mom could make it. I stated that my goal was to get her home to see her pets and grandchildren. She despised every minute of being in ICU.Much as Dr. Byock described, the mission of the ICU physicians was to treat, treat, treat. None of those physicians indicated anything other than telling me about the various tests, the results of the tests, and the next test to be performed. I would even ask point-blank, "Does a person survive these types of issues?" to which they would respond well, yes, they can. My biggest regret is that my mom didn't seem to clearly understand the severity of her situation. The palliative care team talked only to me about the seriousness of her condition. Although I was brutally honest with my mom, and she knew what going into hospice meant, I think she would have preferred to have the doctors tell her the truth.Hospice is the best thing that could have ever happened to my mom. When we arrived home on the 9th, all of the equipment was there, the oxygen concentrator, etc. On Sunday, I helped my mom bathe and we sat on her porch. There were no words left unsaid. Sunday night she slipped basically into a coma. Prior to, she requested that I assist her in dying; she stated "I am dying". I told her I couldn't do that and live with myself but I administered the morphine that hospice provided according to their dosage. From that point forward, she no longer seemed to be in pain. The following night, she died comfortably. She had started receiving continuous care from hospice after I called them terrified becuase I didn't know what to expect.All of the issues that came up in my mind were addressed in Dr. Byock's book. I absolutely love his case histories. Of course I was deperate to find a person with my mom's exact same problems (i.e. COPD, pneumonia, pleural effusion, low oxygen saturation, AFIB, etc.) but the portrait that I gathered from all of the patient histories and their symptomology helped me to know that my mom was dying, that I didn't cause her death, that bringing her back to the ER would have only prolonged her misery in the ICU with the mask vent that she hated. I am forever grateful for these books for easing my mind. I am grateful for the services provided by the local hospice. I have now developed an interest in these issues and hope to give back in some way as a hospice volunteer.I realize this review veered off course, but if you are searching for answers about your loved one's death or stay in the ICU or trying to decide about hospice, Dr. Byock's books are wonderful. Even if you do not feel your loved one is ready for hospice, I think you would be crazy to decline hospice services (I've read that COPD patients are rarely recommended for hospice becuase the nature of their illness is very unpredictable). The services they provide are invaluable and your loved one can graduate out of hospice if they are well enough to do so.

The author delves right into his premise with a few lines on the opening pages:1. "In many ways dying has become a lot harder. We are the benefactors and victims of scientific success." P22. "At present just over one-fifth of Americans are at home when they die...over thirty percent die in nursing homes...Hospitals remain the site of over fifty percent of deaths in most parts of the country." p3 Yes, I recognize that adds up to over 100%, but I am only quoting.One of the most illuminating chapters was the one on weekly Morbidity and Mortality conferences among the staff.The author appears to be a most caring, knowledgeable, and compassionate medical caregiver. He has the admirable quality of being able to not always take himself seriously or to extremes as when he described how another person sized him up, "[He] had me tagged as a public radio listening, latte-sipping, left leaning liberal (all true)." [authors own observation]In the chapter titled "What Are Doctors For" he begins to stake out his position against assisted suicide, in which he goes into much more detail in the final chapters.Many of the chapters used one case to give examples of the points he was trying to make. He stated that some of these were about real people while others were compilations of various patients and cases joined together to make a point. IMHO, the saddest chapter in the book was titled "The Busy Day that Sharon Died". It concerned a 17yo cystic fibrosis patient, who had a tough protective exterior manner, while all along being simply a teenager who hoped for a lung transplant so that she could grow up and work with animals, hopefully as a vet. Obviously from the chapter title, one can tell there was not a positive resolution to her desires.The author throughout the book, but especially near the end makes his point about how and why doctors treat patients in the manner in which they do [p231] "Insurers, Medicare, and Medicaid more readily pay for diagnosing and treating diseases than anything else that doctors do. If complications of treatment occurs, these new problems (AKA diagnoses) generate more tests and treatments, which are also paid for." Just a few pages further [p236] he discusses how when hospice was first set up it was designed to serve patients for six months - "Yet your national median length of hospice service ranges from sixteen to twenty days, and many dying people receive hospice for fewer than three days." That last statement is why so many people fight to avoid hospice, as it signifies terminality, although originally the idea was palliation.Overall, I liked the book and can heartily recommend it, especially for someone wishing more insight into death and dying in America. My only negative criticisms are that it got a little preachy at the end and the lack of more emphasis that things are the way they are not because of laws, but because of money. ALL laws are designed for winners and losers, and the best lobbying group will get laws passed that make the most money for their clients. IT MAY NOT BE FAIR, but as Robert De Niro said in the movie THE DEER HUNTER, "It is what it is!"

In our death denying society, this book (amongst some others) is a good read to have. Of course if talking about death is your cup of tea. It’s definitely mine.

Great read for medical and non medical people who is dissatisfied with current end of life care practices. The book challenges you to be a warrior to ensure good end of life care to all fellow human beings.