The Best Care Possible

One of the world’s guardians and leaders in Hospice and Palliative Medicine, Dr. Ira Byock, has published another excellent and powerful book.  The Best Care Possible is written for a broad patient, family and medical audience.  It tells remarkable stories of loss, bravery and hope.  In his engaging, emotional style, Dr. Byock moves forward his argument that proper end of life care is a national crisis demanding our attention.  At the same time, this wonderful work teaches us about ourselves.

Dr. Byock is the Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center in New Hampshire.  He uses his intimate daily experience with patients, families and other doctors, to weave a series of detailed stories about medical care near the end of life.  Dr Byock covers it all from diagnosis, therapy, complications, ethics, to counseling. He uses the dying or surviving process to make the case for sweeping societal reform. There can be no doubt that he is one of the world’s preeminent experts in this area and simply reading this book will enhance anyone’s working knowledge of this field.

The book focuses on how individuals react to the news of terminal disease and how they cope. There are several unique stories, including the diagnosis, treatment and cancer death of an Oncologist. Dr Byock uses that story, of a sick doctor who knew all the possibilities, to show how it is necessary to find balance in treatment and goals.  In other chapter, he tells the story of a teenager who died of Cystic Fibrosis. Here his visits the darkest pit to show hope and light.  If the story of “Sharon” does not bring tears to your eyes, then you are of stronger stuff then me.

The Best Care Possible has several broad themes.  First, that Hospice and Palliative Medicine are not about achieving death, but about giving life.  He makes that point by introducing us to families whose lives were improved despite the progression of disease.  He also tells several tales to emphasize the research which shows that instead of last ditch chemotherapy, hospice has a better chance of helping a patient to live longer.

Dr. Byock is very concerned that our fragmented society leaves many without a care network, when we need it.  He discusses several “Care-Full Society” models to solve that problem (NORC, PACE, the Eden Alternative).   He emphasizes the need for each of us to reach out and support each other.

There is an extended discussion of the health care debate from an end of life and quality standpoint. Dr Byock believes that if our society took a more realistic view of death as a natural unpreventable event, that we could save billions of dollars.  Dr Byock notes that death is not the worse thing that can happen to us.  The worse thing is dying badly.

There are a few areas through this book, where I might have come to different conclusions.  First, perhaps one of medical style.  Dr. Byock describes removing the breathing tube from a patient whose brain had been destroyed.  She was in a deep coma.  Still, before he removed the tube he gave the patient a sedative and a narcotic.  As the patient was no longer conscious, I not certain whose suffering he was treating.

Dr. Byock tells a long and remarkable story about a young man with advanced HIV (AIDS).  Daren deteriorates over 139 days in an intensive care unit and suffers a wide range of terrible complications.  Finally, the time comes for him to die and… he does not.  In miraculous fashion, he gets better.  Dr Byock notes the paradox that had this young man died the $1,061,629.41 dollars spent on his medical care, would have seemed a waste.  However, Dr Byock concludes, because Daren survived the money spent and the events which occurred, seem “utterly sublime.”   I might suggest that this patient only had a 1/200 chance of surviving.  This means that 199 others like him suffered and died for Daren to survive.  Thus, it did not cost 1 million dollars to produce this one “miracle.” It really cost over 200 million dollars.  The very hard question, which we must ask, is can any society afford to pay that cost for one life?   Put another way, how many lives might be saved with 200 million dollars?

Finally, and as a teacher this is mission for me, I was surprised that essentially every end of life story in Best Care focuses around the Hospice and Palliative Medicine doctors at Dartmouth.  I personally believe that in most situations of terminal illness the primary doctors that already know the family can give the best care.  I do not believe that the dying process should be routinely referred to specialists.  Most patients want the support of those doctors who know them personally and well.

The Best Care Possible is an excellent book and a superb addition to the literature in Palliative Medicine.  I am awed by Dr Byock’s expertise, breadth of understanding and vision. He tells a complex story with clarity.  However, more then that, this book shows Dr Byock’s deep love for his fellow man.


The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life; Penguin Group (USA); 2012; 320p


  • Couldn’t have done it any better myself. Thumbs up for this post. Bookmarking this on StumbleUpon now.
    • James Salwitz, MD
      Thanks. So important to get the word out. jcs
  • amy galaudet
    I agree, that spending such a large amount on one person is obscene. especially since he could shorty become in that same condition. He has an incurable disease. the same can be said, separating conjoined twins. mostly left with terrible disabilities. why not help the living that can be helped, and why, when death is just not negotiable have we made it such a fearful thing, wouldn't we be better off to try and accept or at least not think about it as the most dreadful of actions. Pain, discomfort is worse.
    • James Salwitz, MD
      I believe our society needs to move to a place where we accept that just because we can do something, does not mean we should. I suspect that will mean not only less suffering, but actually longer lives. Thanks for your comment. jcs

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