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Book and Media Reviews
November 3, 2010

Last Acts: Discovering Possibility and Opportunity at the End of Life

JAMA. 2010;304(17):1960. doi:10.1001/jama.2010.1601

In Last Acts: Discovering Possibility and Opportunity at the End of Life, David Casarett uses his experience as a palliative care physician to explore the choices patients make when faced with their own mortality. In doing so, he offers a book that is part memoir, part scholarly exploration, and part handbook for clinicians caring for patients at the end of life.

Casarett describes his experiences in caring for approximately 50 terminally ill patients and creates a “Taxonomy of Last Acts” (p 11), his own classification system for the variety of responses individuals have when they realize they are dying. The first patient introduced is Sylvester, who says bluntly to Casarett, “I have no time left. What do I do?” (p 6). Casarett's discomfiture with the question spurs him to try to understand the choices available to dying patients and his role as their physician in facilitating better outcomes for them. As he considers these questions he introduces readers to his patients, among them Jacob, who insists on being intubated despite certainty that he is dying; Marie, who plans to exact revenge on her family; Tom, who spends his limited time finishing paperwork for his job; and Christine, who comes to a surprisingly peaceful acceptance of her illness after years of protest. Casarett uses core elements of his patients' stories—as well as his own reactions to them—to group them by themes such as reconciliation, hopelessness, celebration, and forgiveness.

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