Book Review: Psychosocial Issues in Palliative Care

The possibilities of robotic surgery, stem cell research, and cytokine-boosting immunotherapy lurk in the minds of the dying patient. Often first diagnosed in massive hospitals, the patient may have come to equate medical sophistication with blinking hardware. Alongside this battleship of technological possibility sits a sailboat of psychosocial uncertainty. Is the patient depressed? How do we talk to the terminally ill? How do we minister to spiritual needs? How should caregivers care for themselves? How should hope be defined for the dying patient? Can medical sophistication be redefined to include psychosocial and spiritual complexity? Psychosocial Issues in Palliative Care consists of a dozen chapters written by 18 clinicians and researchers, each of whom is accomplished and dedicated to the cause of palliative care. The book is intended to be a useful guide to the care of the dying, and it succeeds. The huge number of listed citations underlines the reality that sophisticated healthcare must include not only blinking machines but also the latest within the realm of the psychosocial. I very much liked the book’s attention to the human being who is sick. For example, one chapter described that, while it is important to recognize cultural differences, the clinician should still explore the person’s individual issues rather than assume that the patient fits neatly into one’s cultural expectation. I was also struck by another chapter’s description of the many ways in which clinicians dodge intimacy. Through the use of, for example, medical jargon or selective attention to dry topics, we avoid the people who are sitting in front of us. I also enjoyed the emphasis on narrative as it applies to the terminally ill. It can be very healing for the patient to integrate his illness into a personal biography. The most pressing reason for the reading of this book is the fact that much psychiatric and psychological morbidity goes untreated in the terminally ill and that much of the treatment comes too late. Some of the delay relates to the complexity of diagnosis. Acute onset of irritability is, for example, common, and the clinician may find it difficult to differentiate adjustment disorders, major depression, delirium, pulmonary embolus, and the effects of a cytokine cascade. The book expertly delineates the efforts that have been made to account for the fact that many symptoms of affective illness overlap with illness behaviors. It also discusses the controversy over whether adjustment disorder is a less severe variant of depression. An alternative theory posits that depression refers to a symptom-based cluster, while adjustment disorder is more functionally based. The authors discuss the possibility that rigid premorbid thinking might reduce the patient’s ability to adapt to the reality of constricting opportunities. Compromised coping might amplify distress and lead to depression. This underlines the importance of not only diagnosing depression but also recognizing distress and maladaptive coping styles. Similarly, the authors point out that independent determinants of the desire for hastened death include depression and a persistently pessimistic cognitive style rather than an assessment of a poor prognosis.1 To uncover cognitive and coping styles does require effort, training, and curiosity on the part of the clinician. At the same time, the book does mention Chochinov et al.’s classic study demonstrating that if the patient says he is depressed, depression is highly likely.2 I was somewhat ambivalent about the number of references provided at the end of each chapter. Evidence is critical for the advancement of the field, but, when used imprecisely, it does not help in our effort towards sophistication. For example, data are sometimes taken out of context to substantiate the author’s bias. In one generally excellent chapter, it is claimed that the paternalistic approach of physicians leads to anxiety and depression. To back