A Review of “To Comfort Always” by Professor David Clark

Categories: Opinion.

A book on the history of palliative medicine may seem like a potentially dry topic or one geared specifically towards doctors, but Professor David Clark’s ability to bring history to life with the stories of people involved makes this an interesting and enthralling read.

Chronologically ordered, the first four chapters cover everything from 19th century doctors and their role in care of the dying: early homes for the terminally ill, the start of the welfare state, and social attitudes towards dying and the work of Cicely Saunders.

The final three chapters move into the “clinical realm” and the growing field of hospice and palliative care: the issue of pain, the concept of “total pain”, and the importance of research. “Specialty recognition and global development” is covered in chapter six before concluding in the final chapter with the challenges that face palliative medicine.

What may well be fascinating to many is that Clark’s research goes back to origins of the field of palliative medicine, way before St Christopher’s Hospice and Cicely Saunders, and shares stories of key figures who set the scene for what later became palliative medicine.

Before the modern hospice movement

It is surprising to read of the work of Dr Carl Friedrich Marx (1796-1887) and how he describes care of the dying as a science that “controls the oppressing features of illness, relieves pain, and renders the supreme and inescapable hour a most peaceful one” (Clark, 2016, p12). Marx was also critical of doctors losing interest in patients that were no longer curable. 

Another key figure the reader discovers is William Munk, a physician who worked in London in the mid-to-late 19th century, and produced a comprehensive text “Euthanasia: Or Medical Treatment in the Aid of an Easy Death”. 

The term Euthanasia as used in both Munk’s and Marx’s work did not have the same meaning then as it does today. Both Marx and Munk describe care in a way that would not be out of place with any more modern interpretation of palliative care.

Clark suggests that dying people were hidden away and excluded from the growing medical institutions where death was seen as failure. In this context Clark explores the role of pioneering women who led the development of homes to care for the dying. 

Some of these homes survive as hospices today and their histories are well known, such as Royal Trinity Hospice and St Joseph’s hospice. Others, such as Frances Davidson’s The Friedenheim, have previously received less attention.

Clark’s history of palliative care feels relevant and familiar as the narrative tackles the difficulties that the NHS faced in meeting the demands of its ‘cradle to grave’ ambitions. 

The reader is introduced to a growing number of individuals writing articles and raising concerns about care of people with terminal cancer as well as advanced age. It appears in this era the medical profession became vocal again having perhaps been less so since the work of Munk.

The modern era

No book on this subject would be complete without a focus on the contribution of Dame Cicely Saunders. Regardless of how many times her contribution is described it is impossible not to be left with an incredible sense of admiration, both from the perspective of her being a woman and as a pioneer in palliative medicine and hospice care.

As the story moves to describing the ‘Brompton Cocktail’, the concept of “total pain”, the introduction of syringe drivers and the growth in both research and service models, it feels inevitable that specialty recognition would be achieved and in fact be essential in ensuring acceptance within the wider medical profession. 

The pace of development and global spread of palliative medicine and hospice care as described by Clark is astounding.

The book ends by bringing the reader up to date and confronting them with the many questions faced today. Here Clark discusses whether care of the dying has been over medicalised, confusion around definition, the challenges of our demographics in terms of quantity and case mix of patients, and the issue of equity and of assisted dying.

Like the key personalities presented earlier in the book, Clark introduces the reader to Allan Kellehear, Atul Gawande and Dr Eduardo Bruera. These new pioneers are challenging the profession’s thinking as it once again attempts to tackle social challenges and to grow its place in mainstream medicine.

Looking forward

For me in writing this review and considering our strategy as a hospice, I’m left with a feeling of ‘Back to the Future’. There are important lessons in our history that remind us about the true holistic nature of our care so well described by Marx, Munk and Cicely Saunders that both embrace the role and influence of medicine whilst guarding against medicalisation. 

I think the book reminds us that in our history hospice leaders were pioneers, lobbying, influencing, researching and innovating – all whilst running their emerging charities. In many ways the challenges we face today are no different but are at scale and require the pioneering focus and spirit worthy of our predecessors.

I would recommend “To Comfort Always” to everyone working in hospice and palliative care. This book is not long, complicated to read or full of jargon – it provides a richness to our history that I think is essential to our future. 

This article originally appeared on ehospice UK.

Professor David Clark, of the School of Interdisciplinary Studies, University of Glasgow, was a keynote speaker at Hospice UK’s annual conference 2016.

A copy of his book is available on the Oxford University Press website.

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