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

by Ira Byock

A palliative care doctor on the front lines of hospital care illuminates one of the most important and controversial ethical issues of our time on his quest to transform care through the end of life. It is harder to die in this country than ever before. Statistics show that the vast majority of Americans would prefer to die at home, yet many of us spend our last days fearful and in pain in a healthcare system ruled by high-tech procedures and a philosophy to "fight disease and illness at all cost." Dr. Ira Byock, one of the foremost palliative-care physicians in the country, argues that end-of-life care is among the biggest national crises facing us today. In addressing the crisis, politics has trumped reason. Dr. Byock explains that to ensure the best possible care for those we love-and eventually ourselves- we must not only remake our healthcare system, we must also move past our cultural aversion to talking about death and acknowledge the fact of mortality once and for all. Dr. Byock describes what palliative care really is, and-with a doctor's compassion and insight-puts a human face on the issues by telling richly moving, heart-wrenching, and uplifting stories of real people during the most difficult moments in their lives. Byock takes us inside his busy, cutting-edge academic medical center to show what the best care at the end of life can look like and how doctors and nurses can profoundly shape the way families experience loss. Like books by Atul Gawande and Jerome Groopman, The Best Care Possible is a compelling meditation on medicine and ethics told through page-turning, life or death medical drama. It is passionate and timely, and it has the power to lead a new kind of national conversation.

Genres: Nonfiction, Medicine, Medical, Health, Death, Science, Health Care

336 pages, Hardcover

First published March 15, 2012

Reviews

[Meghan Poperowitz · Rating 5 out of 5]

I may be biased because I have had the opportunity to work with Dr. Byock and his team at Dartmouth- he and his team are some very special people. I may also be biased because I focus on and promote Palliative care in my practice as a staff nurse. However, this is an excellent read for both practitioners and lay people on prioritizing PEOPLE in healthcare not diagnosis a by providing the best care possible - especially leading to and during the last phase of one's life. I recommend ALL his books to everyone.oo

[Steven Chang · Rating 5 out of 5]

A MUST read for any future physicians, pre-health students, or anyone that is interested in a career that deals with patients. Byock understands exactly what this generation has become and what it needs to be regarding care for terminal patients. He shares many stories and examples of what it truly means to care for a patient. Countless times, we hear physicians say, "I'm sorry, there is nothing more we can do to help your illness." Byock argues that should NOT be the case for any physician because there is always a way to help patients. He understands that these patients are human beings with emotions, not test subjects, experiments, or organic vessels. In a generation where healthcare is continually growing, he informs current and future physicians to see patients as PEOPLE and to care for them with utmost love. I mean... wouldn't we all want to be comforted in that way? Even if there are no more treatments to "prolong life," Byock understands that 1 month of happiness, love, and care is better than 1 year of pain, testing, and continual treatment. I highly recommend this book!

[Laurie · Rating 5 out of 5]

Dr. Byock is the head of the department of palliative care at Dartmouth-Hitchcock Medical Center and a professor at the associated medical school. This means he has dealt with a lot of patients who are reaching the end of their lives; his job is to make that end as comfortable and stress free as possible for both them and their families. It is his contention that Americans today suffer more and die worse deaths- and more expensive deaths- than ever before. How is this possible in an age when there are so many medical treatments available?

Part of it is that the patients don’t make their wishes known via advance directives. If a person comes into a hospital without one, and they are unable to make their wishes known, the hospital has the right and obligation to do everything they can to prolong life. While this is absolutely the right thing to do most of the time, it isn’t always what the person really wants. When a person is near death from cancer, say, and takes a fall that creates a brain bleed, the hospital will put them on life support and prolong their life, even if there is no chance of recovery. Would that person have wanted that, or would they prefer to let go at that point? Who wants to live another 2 weeks if they are intubated, on a ventilator and semi-conscious at best? But doctors have an obligation to preserve life, and the family feels guilty if they say ‘pull the plug’.

Add to this problem the fact that doctors get almost no training in palliative care and end of life issues. Many don’t know the best ways to deal with pain and fear, or even how to broach the subject of impending death. Some even hesitate to prescribe opiates because they are addictive- as if that could possibly be an issue for a dying person. These things need to be addressed in medical school. Medicare adds to the problem by not paying for palliative care or hospice care if the patient is still being treated for their health problem; I know from experience that some of these treatments should NOT be considered as trying to cure the patient but rather offering a better quality to their remaining life.

This book achieved what I would have thought impossible: it’s both very difficult to read, because the subject matter is emotional and painful for someone who has dealt with end of life issues, but easy to read because of Dr. Byock’s talent with words. He includes medical details but at a level that is understandable to all; he includes details about death that don’t gross a sensitive person out. I hope that this book gets very widely read by both doctors and lay people; having gone through five deaths in our families it would have been much easier on us as family and on the patients if we’d known a lot of what is in this book way ahead of time- and if the doctors had been more comfortable dealing with end of life.

[Lisa Shultz · Rating 5 out of 5]

Ira Byock, MD has written another gem of a book. If you don't understand the power of palliative care to foster quality life, comfort at the end of life, and the prospect of gentle death, this book will illuminate you. Filled with patient stories that show how addressing death and working together to achieve a peaceful end of life is possible and can create healing and closure.
The end of the book is a strong call to transform the way we die in America. The author feels that "How we die is already a public health crisis, and care of people through the end of life is poised to become a generation-long social catastrophe." He further states that "the way many Americans die remains a national disgrace."
Dr. Byock writes with compassion and purpose. If you are willing to face the inevitable fact that you will one day die and that others might depend on you to make choices and decisions for them, this book is worth your time. It might even spark your desire to influence social change. Dr. Byock states that "For the magnitude of change that is needed to occur, social activism is necessary." Death unites us all.
How do you want to die and do you deserve "The Best Care Possible"?

[Lola · Rating 3 out of 5]

I didn't read the entire book--just skipped here & there; what I did read was interesting.
Our country is messed up when it comes to medical care.
Don't ever think that your advance directive will be followed--or even looked at.
Always have a family member present when your care is not acceptable; have them stay with you
until the care is acceptable--whether in the hospital or a nursing home.

If your doctor leaves the exam room before answering all your questions, stay put.
They will need the room so someone will be along to get it ready for the next patient.
Be courteous, be persistent until all your questions are answered.

Look up doctors & health care facilities on "HealthGrades.com"

[Kathryn · Rating 4 out of 5]

Written by one of the leaders in the Palliative Care field, this writer is a good story-teller, and tells the reader interesting and illustrative stories about some of his dying patients. Probably the most salient and astonishing point he makes in the book, is that patients, facing a life-threatening illness, who tell their doctors to do "whatever it takes, at all costs", in order to prolong their life, statistically, don't live as long as patients who tell their doctors to make them as comfortable as possible, preferring quality over quantity. In other words, if you choose quality, you get quantity - a longer life - as a bonus. He makes the reader think about our end-of-life choices and preferences, and those of our loved ones, which everyone should do.

[Michelle · Rating 5 out of 5]

BEING MORTAL and THE TIBETAN BOOK OF THE DEAD have been my favorite books about death and dying. THE BEST CARE POSSIBLE
enters that list. It was published in 2012 and has somehow missed its inclusion in suggestions for books about mortality.

THE BEST CARE POSSIBLE provides very practical solutions to very common problem surrounding the care of dying folk, that means all of us, that means all of the time. Death is the one certain quality we all have in common.And we know or can know that it is coming no matter how old we are.

As suggested IN THE TIBETAN BOOK OF THE DEAD, life is lived fully by understanding the inevitability of death.. Its arrival both on this side and the unknown is determined by our successful comprehension of death. The suggestions offered in this book will help us succeed in living a fuller life.

[Kathleen Ambrose · Rating 5 out of 5]

This is an excellent book! Palliative care and hospice care are differentiated and at the same time shown to be unified in their goal to provide the means for the best care possible in the end of life.
Seven years after this book was published, there are many more discussions, more books published and more palliative-hospice programs being developed. I wonder how many were indirectly fruits of this work.
I particularly liked hearing the stories of the different patients and Dr. Byock’s compassionate work with each.

[Elgin · Rating 4 out of 5]

I have a daughter who is a pediatric oncologist and who is involved in estblishing ``end of life"
protocols for terminally ill children. I read this book to try to learn more about palliative care and about the issues and practices, but it has also made me think a lot about what kind of care I want at the end of my life and how to be a more supportive advocate if a family member or friend has to go through a long illness. Dr. Byock comes across as a very thoughtful, kind, caring, and empathetic
member of the Dartmouth Medical School.

[Daniel Brockhan · Rating 4 out of 5]

Excellent Book, My Rating went from 5 Stars to 4 out of 5 due to the last 30-50 Pages. Byock does an excellent job of writing in narrative intermixed with information through most of the book regarding the care of those who are dying and/or living with a Chronic illness. However, the end of the book seems to become bogged down with a lot of information, with less stories to keep interest peaked. Still, will definitely be re-reading this book again in the future!

[Anvesh]

I couldn't get through series of accounts of patients who are closer to death narrated in a story form. I had read through 30% and couldn't read more, it is not lack of empathy but writing style didn't give that connect you look for when you read a grim book like this.

[Ann · Rating 5 out of 5]

Y'all. Please read this. Talk to your loved ones about their frickin wishes for end of life. Use the resources available to have the best care possible and enable your loved ones to die well.

[Christine Cazeneuve · Rating 4 out of 5]

Important reading. A detailed and rational look at the end of life care. Very interesting and much food for thought. A very good read.

[Sahar Ashraf · Rating 4 out of 5]

صور من العالم الذي أحب أن أتذكر أنه موجود وممكن، وأحزن أو أغضب أني وأحبائي لن نطاله على الأرجح.

[Rahul Pokhriyal]

GOOD

[Carl Kruse · Rating 5 out of 5]

Looking forward to diving into this book after being highly recommended by a respected friend.

(Rating is one based on pre-interest).

[David · Rating 2 out of 5]

There might be lots of very useful information in this book. The only problem is you need to read the friggin' thing to get to it and I couldn't even get to page 50 before I threw in the towel. Dr. Byock walks a very fine line between explaining how he goes about his business and being a shameless humblebrag.

I wanted to give him the benefit of the doubt because I genuinely respect his line of work and am interested in the subject matter but the I, I, I, me, me, me started causing me to daydream and lose interest. (I imagined 12 people playing a drinking game where one person had to do a shot every time the phrase "the best care possible" appeared and calculated they'd all be dead from alcohol poisoning by page 8.)

Even when he's describing the illnesses and care of particular patients he meanders about telling the reader how he does this, that and the other thing and how he's such an astute listener. Well he's a dreadful storyteller. Holy shit, what's easier than telling a succinct and interesting story about a medical patient? You can even pick any patient you'd like. It seemed ironic to me that a book about palliative care could be so painful.

1 star for Byock's writing style and an overall 2 star rating because it may actually be a good book.

[Sallie · Rating 5 out of 5]

This is a perfect companion piece to "Being Mortal," which I recently reviewed. Byork has ideas that should spark reform in this book with a positive and loving message. Everyone should be able to expect humane care and comfort as they reach the end of their lives--and not be subjected to treatment without a substantial possibility of improving the quality of days--not just their quantity.

In Byork's opinion, we'll need almost a revolution to bring Americans to the place where they can accept death as part of life, and only then will we be able to engage aging people in planning for their own meaningful final months of life. Byork's medical specialty is palliative care, which does not equate simply to 'hospice,' regardless of what most of us believe. To him, palliative care means helping people be comfortable and to experience unconditional love. I have been notoriously hard on old people (yes, I am one)--impatient and annoyed oftentimes, by the slippage that occurs as we dwindle into our frail years. I am rethinking my bias against old age as a result of reading this compassionate work.

[Sevenponds · Rating 3 out of 5]

The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life is author and doctor Ira Byock, M.D.’s latest opus on end-of-life care. The palliative care physician’s reflections on being a “doctor to the dying” are an expression of hope, filled with real-life stories of love and strength in the face of impending loss – but they’re also an urgent call to action for medical reform.

Reform for Ira Byock means better doctor-patient/family relationships; it means changing the way we educate our medical students on “topics related to dying, caregiving, and grief.” And perhaps most importantly – and this is perhaps the book’s most sensitive topic – it means learning to help patients die at the right time for them.

[Continued]

Full SevenPonds review:
http://blog.sevenponds.com/lending-in...

[Tiger Gray]

I loved this book. Written by a doctor involved in palliative care, it offers many fresh and invaluable perspectives for the care worker. I found the sections on narrative note taking incredibly useful. How to take notes that are realistic and yet empowering towards the patient has long been a topic of debate in the medical world, and having this perspective before I too enter that system is a wonderful thing (I can well remember unfair and stigmatizing notes in my own charts, too).

Secondly, what stood out to me the most were the author's opinions on Death With Dignity. I support it, Ira does not. Yet, he presented his case so well that, even if I wasn't swayed to his side, I could respect and understand his views. Overall, this book made me think, and also engaged my emotions. I recommend it for anyone about to enter the medical field, and perhaps even for patients or the family of those in palliative/hospice care.

[Dorothy Mahoney · Rating 5 out of 5]

Byock uses many patient examples from years of experience with palliative care. His strong point,
given in his lectures is "alleviating suffering and eliminating the sufferer are very different acts."
He reverts back to before the 1960's when childbirth was considered a medical event and that dying
needs a similar over haul. He advocates music, poetry and stories, and includes Marge Piercy's poem, "To be of Use" and a Franz Kafka poem about the world offering itself at your feet. Communication is key and the adage, "it's too early until it's too late" holds true.

[Lynn · Rating 4 out of 5]

Too many comments and favorite quotes to include them all here. Standouts:
"...we're just kicking the can down the road."
"Until you're convinced she is safe, don't leave your mother alone."
"dying is hard, but it does not have to be this hard."
"Dying is the most inevitable fact of life.". DUH!!!
I propose that that until we develop a culture of respect for our elderly AND believe aging is a good thing rather than a feared thing, dying and the process of dying will continue to be hard for the dying and their caregivers. I lay blame for this on the way we have distanced illness and dying by relegating both processes to institutions, thereby eliminating family exposure and familiarity to the processes. We fear what we don't know, and if we fear these, we will continue to experience harder than necessary deaths.

[David Ellis · Rating 5 out of 5]

This book helped me clarify my thinking about end-of-life care and the conversations families need to have before it is too late. Neglecting to carefully make and share specific choices risks subjecting the dying person to multiple, futile resuscitations and prolonged, hopeless lingering before the death finally, inevitably occurs.

This book does not argue for euthanasia or assisted suicide. As the author makes clear, these two controversial issues distract our attention from the values and concerns we share about living a good life that ends with a dignified, gentle death. Whatever your position on those topics (the author calls himself 'pro-life' and explains why he does not agree with physicians practising euthanasia or assisted suicide) you will find yourself sharing many of the author's concerns and values on the vital topic of end-of-life care.

[Saysha · Rating 4 out of 5]

I heard Dr. Byock on NPR and was really impressed. The book teaches its reader how to improve end-of- life care. The "best care possible" includes life-prolonging treatments, pain management, tenderness, and respect for people's right to say when enough is enough. As a palliative care specialist his suggestions are very practical ones: providing support for caregivers, using hospice sooner, supporting the dying in our communities, making corrections to our healthcare system and doctors' education, and on and on. Every once in a while the writing was clunky, too medical, and redundant, but I thought the message was compelling, and his treatment of the subject was fair and compassionate. Almost 5 stars.

[Courtney Mauzy · Rating 5 out of 5]

Realistic look at major issue in US health care - allowing patients to die well. Docs trainned to be reactive to diseases/injuries rather than proactive in trying to prevent same. For all our advances, as Dr. Byock says, we will never be able to do away with death. His conclusions:
1. "We must escape our fixation with diseases and health care rather than people's well being."
2. "We must get beyond seeing people solely as individuals/patients and begin seeing people as individuals within families and communities."
Stong endorsement of hospice and palliative care - hospitals should take lead.

[Kate · Rating 3 out of 5]

I really enjoyed the first 3/4 of this book, a lot more than I was expecting to. The personal stories of different people and their experience with hospice I found very persuasive and effective. Even if the author did seem a little full of himself about his ability to change people's lives for the better (both his patients and his students)...But then the last section turned to physician assisted suicide and society's obligations as caregivers and etc. I quickly lost interest in reading one doctor's personal opinion on the world at large. It tried to be contemplative and philosophical and instead became preachy and kind of annoying. Worth reading the first seven chapters.

[LINCCReviews · Rating 5 out of 5]

An excellent look at what care for the dying should be, what palliative and hospice care means and why no one should die in the ICU. As a person who worked in the medical field for years, not much of it was new to me but it reaffirmed and added to what I already knew.



Since all of us and all the people we love are going to die, I wish everyone would read at least the first few chapters of this excellent book. Sadly, I think the people who really need to read it the most, especially those who talk about "death panels" and "killing grandma", will NOT read it. (PaulaM)

[Kate · Rating 4 out of 5]

I appreciate the work that went into Ira Byock’s book, “The Best Care Possible.” He is, without a doubt, one of a handful of the absolute top palliative care physicians in the country. Clearly, this is a person committed to his work, and to his patients. If the term, “palliative care” is new to you, then you will have a much more nuanced understanding of what it means by the time you’ve finished this. I find myself comparing this book to Atul Gawande’s “Being Mortal.” For lyricism, Atul is the better writer. But, for understanding the relatively new field of palliative medicine, Ira’s book is a much better explanation.

[Jessica Bang · Rating 3 out of 5]

The urgency for change is what I appreciate here. The anecdotes are (inevitably) touching. That being said, the way the public is told to go about reformation is too broad. To the people who don't know to advocate and vote for politicians effectively (immigrant Americans, younger Americans)? To those whose family's cultural/religious beliefs affect death and dying in much more complicated ways? If anything, this book can spark a lot of discussion. One can only hope things will get done after talk.

[Joanne · Rating 4 out of 5]

I read this book and immediately felt I should reread it. Dr Byock does a great job of sharing his experiences with palliative care and then applying those experiences to the greater health care worls around him. I will be reading other things he has written and reading books he recommended in this book. The more I am part of the end of people's lives, the more I feel like we could do a better job during those last hours, days, or months.