No Place for Dying

Chapple, H.S. No Place for Dying , Walnut Creek, California : Left Coast Press Inc. , 2010 . 322 pp $89.00 (hbk) 978-1-59874-402-6, $29.95 (pbk) ISBN 978-1-59874-403-3 Helen Stanton Chapple’s anthropological study of 211 cases of deaths in two US hospitals casts a stark light on the reality of death and dying in US hospital care; events that remain, for the most part, hidden from direct public view. Building on similar work of other authors who have explored dying in US hospitals, Chapple exposes the peculiarities of hospital clinicians’ and administrators’ recorded vernacular when asked to recount deaths they were involved with. She uses their recollections to present an argument that explains how and why patients admitted to hospital with no foreseeable prospect of survival merit a compulsory process of rescue, involving tangible displays of medical technology and co-ordinated clinical protocols delivered by highly qualified clinicians. As doubts eventually surface about the success of this strategy for such patients, a ‘ritual of intensification’ plays out, involving yet more intensive therapy and negotiation with relatives, if necessary. Whilst her research participants reflect that the process often perpetuates false hope of immortality, Chapple reveals how their rationale for accepting death is ultimately framed as failure of the body’s physiology to work ‘in sync’ (p. 91) with the hi-tech life-support provided, rather than as the cold reality that people do simply die. After an exposition outlining the author’s personal motivations and interest in end-of-life care, the reader is presented with a coherent argument stated early in the text, followed by a convincing blend of fieldwork and literature analysis developed over carefully structured chapters that, step by step, validate her thesis. As befits a good ethnography on this topic, there is as much useful background sociological and philosophical elaboration on the concepts of death and dying (‘configuration’ rather than ‘construction’) as there is on the development of US healthcare and the bioethics movement over the twentieth century (the latter interpreted in the text as a ‘counter-discourse to the ritual of intensification’ which narrowed its focus on the empowering of the individual rather than addressing the effects of sociological forces on that individual, such as ‘access to palliative care and the covert influence of reimbursement policies’ (p. 98)). A personal reflection covering practical considerations on undertaking the fieldwork, included as an appendix, is also useful for anyone planning similar research in similar settings. The style of writing is deliberately relentless due to the stepwise analysis of individual cases; each chapter throws a new analytic angle on cases introduced earlier. There is liberal use of colourful metaphor to vary repetition of what has already been said (for example, p. 88: ‘The speed and intensity of rescue and trauma care serve as strong societal antidotes to the caprice of accident’). Chapple’s text will challenge any high expectations about care of the dying in US hospitals, explaining the socio-cultural forces that have led to a prioritising of technologically-driven health care focused, almost exclusively, on stabilising lives deemed salvageable. This distorted priority, in her view, has resulted in the creation of a poorly developed undercurrent of patient care: those deemed ineligible for rescue, after admission to hospital, and thus labelled ‘dying’. Although Chapple briefly acknowledges the fact that the need for speed in the process of rescue is largely predicated on the frailty of the human cardiovascular system (brain death occurring after 3 minutes of lack of oxygenated blood, if the heart has stopped beating), she charts the changes in American legislation, the gradual sub-specialisation of medicine and shifting public expectation which have also inexorably led to the prioritisation of delivering speedy, hi-tech, hospital-based trauma care equally to all social classes, above all other types of care. This provides a useful backdrop with which readers from any country can become familiar with US healthcare. Writing from the perspective of a nurse who has experienced working in a developed country that does not provide universal health care for all its citizens, and where, perhaps, there are ulterior economic interests in buying more time alive for patients, Chapple is unafraid to highlight this veneer of equity which ruthlessly renders chronic disease care or care of the dying as second-class. Readers familiar with the inner workings of hospital care will instantly empathise with the ‘ritual’ described in all its guises in the text. Chapple’s skill is in deploying such a description that raises awareness of the tacit cultural agendas that influence clinicians’ practice. The stark point being made by Chapple is that dying patients often undergo rescue needlessly and that even if the ritual permits their re-labelling as ‘dying’ (considered, by the author, as a ‘successful’ outcome of the ritual), there follows a disappointing lack of co-ordinated clinical care to meet their and their loved one’s particular needs at that crucial time. Although the reader is likely to finish the book feeling wistful that standards for end-of-life care in US hospitals will some day be as prized as standards for rescue care, qualitative evidence of this sort must be welcomed. Given the equal-ninth ranking of the US and Canada on quality of death, according to the Economist Intelligence Unit [1], Chapple’s analysis provides compelling evidence as to why this might be the case. Whilst the academic reader will welcome the amount of wider referencing and research that Chapple has used to develop her thesis, it is to her credit that a non-clinical, lay reader will also pick up this book and understand her points easily, thanks to the skilful and coherent organisation and presentation of the complex material she has chosen to study.

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