Life and Death in Intensive Care, Joan Cassell, Philadelphia, Pa: Temple University Press. 2005. 248 pages, softcover, $59.50.

In the late 1990s, anthropologist Joan Cassell was invited to study end-of-life issues in a surgical intensive care unit (SICU). Cassell, a research associate in the Department of Surgery of Washington University, had already conducted extensive ethnographic research in surgical settings. In the studies reported in this book, the author focuses on 3 major groups involved in the care of SICU patients: surgeons; critical care specialists or "intensivists," some of whom are surgeons; and SICU nurses.

Employing classic ethnographic research techniques, and guided by the anthropological concept of moral economies,1 Cassell analyzes the attitudes and behavior of the SICU population-the surgeons, intensivists, nurses, graduate fellows, patients, and patients' families. She does this in 3 different settings-SICUs in a large Midwest medical center, a Texas community hospital, and a hospital in Aukland, New Zealand. The organizational structures of the 3 units are classified as open, semiclosed, or closed. In an open SICU, the operating surgeon continues to direct the patient's treatment in the SICU. The Texas SICU fell into this classification. In the New Zealand closed unit, intensivists had complete responsibility for the care of the patient. The unit in the Midwest medical center was semiclosed, with the operating surgeons sharing patient management responsibilities with the intensivists assigned to the unit.

Having defined and described her professional hierarchies in their respective settings, Cassell moves on to explore the end-of-life issues that arise in the SICU. The titles of these 6 chapters say it all: "Death or Suffering," "Confronting Death," "Intensive Caring in New Zealand," "Going Gentle Into That Good Night: Death in Aukland," "Focus on the Bottom Line," and "Dominion of Death."

In "Death or Suffering," Cassell explores the 2 ways in which the physicians look at death. Her surgeons are intent on fulfilling what they perceive to be their obligation under their covenant with the patient-to preserve life and to cure. Her intensivists are likely to accept the notion that certain patients are never going to be cured, and to prescribe comfort care as distinguished from aggressive curative attempts. As she points out, the 2 groups are guided by basically different philosophies of their obligations to the patient.

The chapter entitled "Confronting Death" deals with the impact of SICU organizational structure on patient care. The author describes the differences in treatment philosophy that distinguish closed units from open units, and the patient management styles that reflect them. A major issue reflecting these differences is the handling of the end-of-life decisions. In the New Zealand closed SICU, it is the physicians who make the decision to remove life support. Cassell seems to find that the nurses in her single New Zealand site (a closed SICU) are more interested in their patients than those, for example, in the major Midwest medical center. In the chapter entitled "Going Gentle Into That Good Night: Death in Aukland," Cassell deals very effectively and movingly with the handling of death and bereavement in the New Zealand SICU. She describes their "Bereavement Follow-Up Service" and the Bereavement Team, whose members contact bereaved family members 4 to 6 weeks after a patient's death to inquire about the care received by the deceased relative, and the bereaved person's current emotional condition. Assignment to the team is rotated among the SICU nurses, who perform a valuable and compassionate follow-up service, for which they are paid a stipend in addition to their regular salaries.

Chapter 9, "Focusing on the Bottom Line," presents an insightful look into the economic realities that help to shape the choices made in the SICU, including the withdrawal or continuance of life support. She cites economic discrimination against African Americans in the allocation of certain transplants on the basis of inability to fund lifelong immunosuppressive therapy. The author discusses the economic "fragility" of academic health centers, voicing concern lest they become more and more similar to for-profit hospitals in allowing financial considerations to weigh increasingly on patient care decisions, especially on the type of decision often called for in the SICU.

The opening paragraph of the final chapter (heavy symbolism here), "The Dominion of Death," is a grabber. That opener is followed by an extensive, thoughtful, engrossing review and discussion of attitudes toward dying and what Cassell sees as the passionate dedication of American surgeons to sometimes futile curative efforts. She addresses this analysis to the issues involved in transplant surgery. The author comes down hard on surgeons. Some of her generalizations about them, and about American surgeons in particular, seem off-the-cuff and statistically questionable to this reviewer, but as an ethnographer reporting on 3 small populations Cassell is not obliged to observe the protocols of statistical sampling. She addresses concerns such as this in the Appendix, entitled "'Hard' Science, 'Soft' Science, Social Science."

What is this book about? It's about an enormous array of issues that most of us prefer not to think about. It's about end-of-life issues and how people of differing cultures and of various levels in a hierarchy deal with them. It is a study of power invested in the physicians and of culturally prescribed submission on the part of nurses, patients, and patients' families. It's about the impact of financial considerations on the ways in which life is preserved or ends. Most of all, it is an examination of the ways in which the "web of affect-saturated values"1 that constitutes a moral economy affects the care of patients in an SICU.

Cassell's style tends to be somewhat rambling, but it's easy to forgive her, because what she's telling us is so tremendously interesting and valuable. While the many detailed and illustrative descriptions of individual patients, their illnesses, their doctors, nurses, and families are indispensable to the story, at times they tend to interrupt the flow of the analysis and of the reader's growing insight into the fundamental issues in a chapter. This situation could have been mitigated through the use of sidebars consisting of bits of the anecdotal material, signaling shifts in perspective as they occur.

This is an extremely interesting account of an ethnographer's journey through 3 provinces of a strange and exotic country. It is strongly recommended to anyone--health care professional or not--who is interested in learning more about the values and structures that shape how we look at life and death.

Jean Gayton Carroll, PhD

Editor

REFERENCE