No Place for Dying: Hospitals and the Ideology of Rescue (review)

Helen Stanton Chapple's No Place for Dying is an ethnography by an anthropologist with a long background in caring for the dying as both a hospice volunteer and an ICU nurse. It is a thought provoking ethnography, which offers the argument that American hospitals are based on an imperative for heroic rescue and stabilization, leaving little room for dying in the space where rescue ends. According to Chapple,

[r]escue efforts in the United States receive open, continuous support from technology, economics, cultural ideology, and the hope for salvation. By contrast, dying is poorly defined and happens in the shadows. To be admitted into hospice and receive its benefits, patients must relinquish a measure of social legitimacy in the (nonhospice) world they know, the one that privileges rescue. For these reasons, persons in the United States should not expect to receive both full attention to every physical threat to survival along with provisions for a comfortable dying situation when the time comes.

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No Place for Dying looks at hospital death based on data from retrospective interviews and observation gathered between 2003 and 2004 in two hospitals, a Catholic community hospital and a teaching hospital, in a mid-sized city in the United States. The data collection effort appears to be extensive, including involvement with chaplains, physicians, nurses, therapists, and administrators, as well as observations on and offsite, including in-service activities, trainings, commemorations, retreats, and meetings on bereavement, ethics, policy, and planning.

Unfortunately, data are not well presented in this study. This may, in part, be due to the author's methodological choice to record interviews using note-taking instead of audio records that would have provided her with a more comprehensive set of data. Case studies presented in the book are not always complete with key information about age, time from initial diagnosis to death, and illness trajectory missing. In other places, assumptions are made that are not well substantiated. In Chapter 1, for example, Chapple presents a case study from an RN informant's perspective, then states that the patient's code status "certainly must have influenced" his care by physicians. At no point, do we have information from physicians for this particular case study, leaving the reader to question whether this information was the result of data collection or assumptions made.

Data are also not always convincingly tied to Chapple's analysis and this occurs throughout the book. In Chapters 3 and 4, Chapple's idea that death and dying are separate concepts is not well delineated using data. In Chapter 4, Chapple states that patients lack legitimacy in the prevailing system of rescue, yet nowhere is that clearly defined and then substantiated using data. In Chapter 7, Chapple states that patients drop in status as a result of end-of-life care trajectories, but nowhere is status well defined and then substantiated. The exception to this critique is in Chapter 6 in which data are clearly tied to elements of economics and industry that impact hospital practices at the end of life.

Chapple applies a number of important points from the death and dying literature throughout her analysis, including Howard Brody's (1992) idea of the rescue and stabilization imperatives of modern medicine; Zygmunt Bauman's (1992) idea that death has been broken into separate causes that can be "resisted, postponed, or avoided all together;" Sharon Kaufman's (2005) idea that time drives the pathways that shape death and dying experience in the hospital creating a system in which no one entity in control; and Tony Walter's (1994) idea that the meaning of death and dying can be transformed through revivalist discourses, such as those that form the basis of hospice and palliative care.

Building on these and other theoretical perspectives, Chapple raises some original and compelling points. For example, in Chapters 3 and 4 she talks about the distinction between death, not a focus of the hospital, and dying, which...