Author: Pierre Mallia
Publisher Kite Group, 2025

I am extremely thankful to Professor Pierre Mallia for asking me to write an introduction to his collection of essays entitled The Elderly. The publication is a collection of various articles dealing mostly with end-of-life challenges facing whoever is caring for dying patients, or those who are approaching death.

The range of titles is very vast, and I can safely say that this 'manual' should be compulsory reading for all those who in one way or another deal with end-of-life issues. This is because the book does not deal only with the theoretical aspects of end-of-life care, but spells out in very great detail, and I would say also in a certain amount of repetition, the steps to be taken in practice by whoever is in charge of dying patients, or patients moving fast towards their death. This includes carers, nurses, and family doctors, besides hospital staff, depending on where the terminal patient is being cared for.

This situation is all wrapped up in a quote from Neveloff Dubler, used by Professor Mallia, "In a health care setting, doctrines of justice and patient's rights, translate into concrete decisions based on immediate reality". Decisions have ultimately to be taken by whoever is in charge based on one's knowledge of the subject, one's preparation, and one's clear assessment of the prevailing circumstance of each particular case.

This book provides ample material to inform, but also to whet one's appetite to read further into a subject which as is clearly evident in this book, carries profound medical, moral, religious, ethical, and legal considerations.

The first articles deal with the elderly, the societal roles of grandparents, and their relations with their grandchildren; looking after the elderly at home, cases of abuse, and the increasing vulnerability that comes with age and disease. The 'clinical' problems as well as the 'hotel' problems the elderly face in community homes for the elderly are also looked at. Chapter 6 is a detailed clinical (semiotics) plan how to examine and look after the aged. Other contributions deal with the risk/benefit an analysis of clinical interventions in the aged, posing questions like 'is it worth treating an elderly patient at that stage of life? Is it in their best interest?' This is logically followed by the consideration between 'ordinary' and 'extraordinary' treatment. The rest of the chapters go deeper into the subject of end-of-life care and the decisions that have to be taken; pose the question as to how much must one inform the patient; the importance of patient/doctor relationship in palliative terminal care; insisting that doctors need to change from a 'doer to a helper', and from an 'expert problem solver and fixer' to a 'companion'.

Here between the lines, I am seeing a new definition of what 'family medicine' should be all about. Most of the remaining chapters go into fine detail and discussion on issues such as palliative sedation, and the ethical considerations concerning stoppage of artificial nutrition and hydration when nearing end-of-life. It is repeatedly emphasised that it is not obligatory to take extraordinary measures at end-of-life, and that patients should be allowed to die with dignity.

The subjects discussed deal with issues where science, philosophy, and theology meet. There is also involved biology, technology, ethics, metaphysics and not least spirituality. Such challenging vital end-of-life decisions should be taken within a framework of advanced care planning. One contribution in this book explains on detail a 'consensus statement' to be adopted as guidelines in end-of-life care. It warns against the 'medicalization of death' and stresses the point that we need more discussion on 'end-of-life' in general than on 'euthanasia'. It also debates the fine distinction between 'active killing' as in euthanasia, and 'allowing to die' when death is imminent.

On the same lines there is a most illuminating discussion between what is 'ordinary' treatment, and what can be considered as 'extraordinary treatment', as well as reflections on when CPR should take place, and occasions when it could be in the best interests of the weak fragile patient not to be employed. The book makes it clear that end-of-life discussions in themselves could form part of palliative care. This takes the reader into the realm of spirituality and the consideration of the patient's morals in reaching end-of-life decisions. The reader will find interesting reflections on Muslim and Christian morals, and their interpretation in actual end-of-life cases.

A concise expression of what is morally and medically acceptable is found in this extract from the Magisterium of the Catholic Church: 'Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of 'overzealous' treatment. One is not causing death; one accepts the inability to stop it'.

This book is anything but bedside reading. It has to be read with utmost attention, and the inevitable repetition, as a matter of fact, help instil important notions and definitions in one's mind. It is definitely not the last word in care of the elderly, and end-of-life situations. It is however more than just a beginning. The impressive references after each article, show how vast the subject is and how vivid is the ongoing discussion on this aspect of human life. The Erasmus+ EndCare project and the follow up to this EndCare and Active Aging being coordinated by the author continue in this important direction of care. I definitely recommend this book to whoever is interested in the subject especially carers, medical doctors, psychologists, social workers, and why not, politicians.