Vol. 24 No. 6 December 2002 Book Reviews 621

with some excellent additional information onmanaging a pain practice. Although there are afew things that I would have liked to have seendone better, I believe that, overall, Tollison etal. have succeeded to a remarkable degree.

Symptom Management in the Terminally Ill

Linda King, MD and Robert Arnold, MD

The Medical Care of Terminally Ill Patients, 2ndEdition

By Robert Enck, MDPublished by The Johns Hopkins UniversityPress, Baltimore, 2002168 pages, $68.00

Sometimes a textbook is like a box of choco-lates. Some of the chocolates are wonderful,tasty, and make you want to eat the entire box.Others you want to put back after the first bite.The second edition of The Medical Care ofTerminally Ill Patients is like a mixed box ofchocolates. Unfortunately, because it lacks aguide to enable the reader to distinguish thedelicious gems from the not-so-tasty aspects,students will find the book of limited value.

There is much to commend the text. It rep-resents an easy-to-read, clinically useful guideto the management of symptoms in terminallyill patients. The newly updated text combinespractical clinical recommendations with sum-maries of recent studies on symptom manage-ment. Clinicians new to the field will find therecommendations regarding evaluation andmanagement of symptoms valuable, and more

seasoned readers will appreciate the succinctand well-written summaries of the studies sup-porting current clinical practice. The book’semphasis on the evidence base supporting clin-ical practice is unique, and makes it a useful re-source for teaching symptom management.

The focus of the book is the management ofbothersome physical symptoms. After a briefintroductory chapter on prognostication in se-riously ill patients with a variety of illnesses, thethree main sections of the book address gen-eral symptoms of dying patients, pain, andsymptoms during the last few days of life. A fi-nal chapter addressing advance directives, eu-thanasia, and physician-assisted suicide hasbeen expanded in this edition but still repre-sents only the briefest of introductions to thesecomplex issues. Communication with termi-nally ill patients and the management of spiri-tual, psychosocial, and existential issues at theend of life are not addressed in this text. Read-ers looking for an introduction to palliativecare beyond symptom management will needto supplement this text with other readings.

Over one-third of the book is devoted to thediscussion of pain management, includinggeneral principles of pharmacologic manage-ment, the use of specific opioids by variousroutes, the role of adjuvant analgesics, andcomplications of pharmacologic therapy. Al-though non-pharmacologic interventions, in-cluding acupuncture, relaxation techniques,and complementary/alternative medicine, re-ceive some mention, pharmacologic manage-ment is emphasized. The discussion of the roleof palliative surgery and interventional painmodalities is particularly thorough and will bequite useful for non-anesthesia trained readers.

Despite pain as a primary focus of the book,experienced palliative care clinicians will ob-serve some notable omissions. The use of meth-adone in pain management receives only briefmention. The discussion of adjuvant analgesicsis quite limited and the discussion of gabapen-tin is limited to two sentences. Although thislargely reflects the lack of specific evidencesupporting the role of adjuvant analgesics inpatients with life-threatening illness, the textprovides little clinical guidance regarding theuse of these agents safely and effectively.

Symptoms typically addressed in PalliativeCare texts—nausea, dyspnea, constipation, an-

Linda King, MD and Robert M. Arnold, MD are at-tending physicians in the Section of Palliative Care,Division of General Internal Medicine, University ofPittsburgh Medical Center, Pittsburgh, Pennsylva-nia, USA.

622 Book Reviews Vol. 24 No. 6 December 2002

orexia—are well covered here. In addition,symptoms often overlooked in other texts, in-cluding urinary incontinence, dysphagia, andpressure sores, receive detailed attention inEnck’s book. Additional chapters highlightsymptoms and management issues specific toindividual life-threatening illnesses includingcancer, dementia, motor neuron disease, AIDS,chronic vegetative state, and advanced heartand lung disease. Inclusion of common screen-ing tools used in palliative care—such as theBrief Pain Inventory and the Edmonton Symp-tom Assessment Scale—would have made thetext more useful.

Some dated information from the first edi-tion remains in this book, and some of the newmaterial is not well integrated. The discussionof HIV infection is particularly in need of up-dating. The “newer combination antiviral regi-mens” are mentioned only briefly while a longparagraph describing the initial data about a“new antiviral” AZT remains. None of the ma-terial on HIV infection adequately reflects thechange in the natural history, morbidity, andtherapy of HIV infection that has occurredsince the development of highly active antiret-roviral therapy. There is no discussion of themorbidity associated with hepatitis C, the lead-ing cause of death in HIV patients. Althoughmore effort was taken in updating the discus-sion of depression, it remains weighted towardthe tricyclic antidepressants and benzodiaz-epines, with only limited material on the roleof SSRIs and psychostimulants, and no men-tion of some of the newer atypical antidepres-sants.

It is difficult to say how this text fits into thegrowing selection of palliative care educationalresources. It is clearly intended to be an intro-ductory text and certainly will not take theplace of the

Oxford Textbook of Palliative Medi-cine

. It will prove useful for teaching symptommanagement to students and residents; thoughit is not as good as McDonald’s case-based text-book either in these areas or in discussingbroader topics in palliative care. Despite theselimitations, this new edition of Enck’s

The Med-ical Care of Terminally Ill Patients

represents auseful addition to the rapidly growing selectionof Palliative Care texts. A clinician involved inmanaging the symptoms of seriously ill patientswill find many practical guidelines that en-hance their care of patients.

Meeting the Needs of Children Living with Life-Threatening Conditions

Marcia Levetown, MD

Hospice Care for Children, 2nd Edition

Edited by Ann Armstrong-Daileyand Sarah ZarbockPublished by Oxford University Press, Inc.,New York, 2001432 pages, $45.00

There are very few resources for pediatricpalliative and hospice care currently available.Generally, the pediatric sections of palliativecare texts are small, reflecting the much smallernumbers of children who die compared toadults. Nevertheless, for those of us who carefor children living with and dying from life-threatening conditions, a comprehensive, clin-ically useful resource would be of great value.The second edition of

Hospice Care for Children

comes much closer to this ideal than the first,with expanded chapter topics and more valu-able tables, but unfortunately still falls short ofthe mark.

Still present are the important chapters onchildren’s understanding of death, thoughwith only one updated reference. Pain andsymptom management provides excellent ta-bles of assessment tools, their recommendeduses and pitfalls, but would be improved bygreater discussion of their use for infants. Inaddition, a description, based on published re-search (such as that by Hunt, McCallum, andWolfe), of the epidemiology of symptoms inchildren living with life-threatening condi-tions would be well placed here. Increased dis-cussion of pediatric-specific information, suchas physiologic differences in drug-binding andmetabolism in different phases of childhood

Marcia Levetown, MD is a pain and palliative care ed-ucation consultant in Houston, Texas, USA. Dr. Le-vetown is also a Faculty Scholar of the Project onDeath in America of the Open Society Institute.