Csikai, E. L., & Chaitin, E. (2006). Ethics in End-of-Life Decisions in Social Work Practice. Chicago: Lyceum Books.

Reviewed by David S. Dran, Ph.D.

Helping clients and their families with end-of-life decisions is one of the most complex areas of practice for social work. Social workers are called upon to incorporate culture, religion, family and individual histories, and knowledge of ethical principles into an assessment and intervention. To make matters more complicated, this is done in a context of medical technology that is constantly reshaping the moral landscape. Preparing for the end of life is daunting for the variety of factors involved. It is also an area for which social work is ideally suited by virtue of a practice approach that takes into account diverse cultural and social factors.

To their credit, the authors of this work have fashioned a thorough guide to help social workers navigate the complexity of end-of-life decisions. This book should be a valuable resource for social workers in hospitals, hospice, home health, nursing homes or any setting in which clients and their families deal with preparations for the end of life. This guide is especially welcome at this point in time, given the aging of Baby Boomers who will soon swell the ranks of retirees. As more Boomers face health issues in their maturity, the pressure for attention to and redefinition of end-of-life issues will likely increase.

The authors are eminently qualified to provide a lucid guide through end-of-life issues. Ellen Csikai is associate professor in the School of Social Work at the University of Alabama. Elizabeth Chaitin is the director of Medical Ethics and Palliative Care Services Department of University of Pittsburgh Medical Center--Shadyside Hospital. Both have extensive experience in the area of bioethics and have provided significant contributions to social work practice in this area.

The authors begin by offering a clear exposition of ethical reasoning, including ethical principles and approaches that support them. The principles discussed in the first chapter are referred to often in the remainder of the work as specific end-of-life issues are discussed. The authors do well to point out the similarity that exists between these ethical principles and the core values of the social work profession. This is especially true for the values of client autonomy and dignity.

Two strengths of the book are immediately apparent. The authors provide a description of cases that have established legal precedent, such as those regarding Karen Ann Quinlan and Elizabeth Bouvia. These and other cases of legal precedent will be referred to often in the examination of end-of-life issues throughout the work. The authors also provide practice examples that demonstrate how complex issues can unfold in a particular case. Both legal precedents and practice examples help immeasurably to illuminate the process of helping clients and families prepare for the often difficult decisions faced at the end of life.

The second chapter is one of the most interesting and provocative in the book. Here the authors tour the breadth of issues that provide the end of life with its complexity. Many of the issues could easily fill chapters, if not books, in themselves. The discussion of religious and cultural views is especially effective at demonstrating the diversity encountered in end-of-life issues. The topics of withholding or withdrawing intervention, euthanasia, and physician-assisted suicide prepare for the issues that unfold in subsequent chapters.

The authors provide a primer in advance directives in chapter three. Again, the authors bring to life the place of advance directives by practical case examples. The authors make clear that there is no substitute for dialogue among all parties involved for successful advance care planning. To participate in this dialogue, social workers should be prepared to exercise considerable communication and advocacy skills, as well as know the many options available in planning advance directives.

The life-values history offered by the authors is an interesting method of uncovering what the client’s preferences for end-of-life care may be. The social worker’s role in this process includes appreciating the social and cultural context surrounding the client and family. Here the authors outline the variety of issues that may be uncovered in such an investigation.

Noteworthy is the authors’ suggestion that social workers should become involved in proactive community education for advance care planning. Hopefully, such an effort would result in earlier preparation for deciding upon options in the later stages of care.

In the fourth chapter, the authors outline the history and importance of hospice and palliative care. The authors describe the values at the core of hospice as embracing a holistic view of care compatible with the approach in social work practice. The issues that arise for both families and social workers are well described. One of the issues is that of pain management, which remains a serious concern of care at the end of life.

The fifth chapter of this work is one of the most important. The chapter first presents the types of consent and the necessary conditions for consent to be voluntary. Decisions in end-of-life care are immeasurably complicated when the client is unable to express his or her preferences. At such a time, who will assume the role of a surrogate and how that person will make decisions on the client’s behalf becomes a paramount concern. Surrogate decision making is one of the most difficult issues that a social worker will face in helping clients and families with the end of life. The authors make good use of cases establishing legal precedent, and provide an excellent discussion of the different standards that can be used for surrogate decision making. Sound ethical reasoning and assessment are required. While there is no easy method of determining competency of the client, the authors identify the factors that must be considered so that the client’s autonomy and dignity have the best chance of preservation.

The authors point out that to date there is no universal standard of client competency. In the appendix, the authors offer the Chaitin Informed Consent Capacity Tool. Although at the time of printing, the reliability of this instrument had not been established, it should be very useful as a guide to judge the ability of clients to make informed decisions.

In the sixth chapter, the authors present issues related to organ donation and the determination of death. This topic clearly demonstrates how advances in technology force the consideration of issues that were unthought-of in the recent past. The pressure to revisit topics in this area is likely to increase as the vast numbers of the Boomer generation mature.

The seventh chapter describes two important resources in ethical decision making--ethics committees and ethics consultants. The authors provide a history of ethics committees and a description of what they can do in resolving ethical issues. Not all settings will have access to ethics committees or to the ethics consultants described here.  However, the authors provide the social worker with several models of ethical decision making. Each model has merit. All models share similarities. It will be up to the social worker to inspect the models and come away with a guide to the process of analyzing and resolving ethical issues that may arise for a particular case. The authors demonstrate that finding a way through such issues is a complicated affair requiring far more than formulaic application of ethical principles. Thorough assessment and considerable judgment are required.

The book ends with a chapter about confidentiality and disclosing the truth framed in terms of honesty between client and social worker. The authors do well to stress that these considerations are necessary ingredients for helping clients to navigate choices at the end of life.

Altogether, the authors have successfully crafted an essential collection of principles, examples, and precedents required to deal with the complex issues of end-of-life decision making. More important, they have provided a guide to the process of ethical reasoning in planning for the difficult issues that can arise. No guide can keep abreast of changes in interpretation of law or the latest possibilities opened by technological advances. However, with this guide the social worker will be well positioned to meet the changes that will come.