Vol. 27 No. 6 June 2004 565Reviews

to analyze and evaluate the literature and re-search that informs their clinical practice.The chapter on evidence-based practice pro-vides both the insight and tools that make thispossible. Lucid and practical checklists areprovided for assessing the validity of both quan-titative and qualitative research studies. Thisbook beautifully illustrates the depth and re-wards of palliative care nursing as a continuumof practice—from a generalized approach help-ful to most patients to a specialized disciplinein caring for the terminally ill.

doi:10.1016/j.jpainsymman.2004.02.013

Delirium in the PalliativeCare PopulationPeter Lawlor, MB

Delirium: Acute Confusional States in PalliativeMedicineBy Augusto Caraceni and Luigi Grassi Publishedby Oxford University Press, New York, USA, 2003280 pages, $45 (soft cover)

In the palliative care setting, delirium occursfrequently as reversible episodes. Most patientsactually die in a state of delirium. Despite itsremarkable frequency, there are limited data onmany of the aspects of delirium in the popula-tion. To my knowledge, the only previously pub-lished general textbook on delirium was writtenby Lipowski, on which, to some extent at least,Caraceni and Grassi’s book appears to be mod-eled. However, this book differs from Lipowski’sin that the intended audience is predominantly inpalliative care. The authors, therefore, have filleda void for a textbook on this important topic withspecial emphasis on some of its unique attributesin the palliative care population. This book is anexcellent, easily readable, concise, yet compre-hensive textbook on the topic.

Peter Lawlor, MB, is Associate Professor, Divisionof Palliative Care Medicine, Department of Oncology,University of Alberta, Edmonton, Alberta, Canada.

The aspects of delirium are addressed underthe standard division of headings such as diag-nostic criteria, pathophysiology, assessment andmanagement. It includes a chapter on familyissues, which may appear strangely out of con-text in that delirium is infrequently mentionedin the chapter, yet the chapter is well writtenand addresses issues such as family coping, griefand bereavement. Each chapter is attractivelyorganized into a general description and clearreview of the up-to-date evidence, relevant anec-dotal experience, and an abundance of caseexamples to help put the salient aspects in con-text for physicians in clinical practice.

The chapter on assessment deserves specialmention. This contains a review of a selectionof validated instruments for the assessment ofdelirium. Their psychometric properties areoutlined and copies of the actual instrumentsare included in the appendix.

Are there faults? The only marginal concernI can identify is that the authors become overlyfocused on the topic as it pertains to their ownspecialist backgrounds, namely psychiatry andneurology. At times, the text tends to drift abit into the more academic realm of their ownrespective specialties at the cost of not addressingissues more precisely within the palliative carecontext. Nonetheless, this is a minor criticism.I commend their efforts and suggest that thisbook should be included in all medical libraries.

doi:10.1016/j.jpainsymman.2004.02.015

A Narrative Handbookin Palliative CareJose Pereira, MBChB, DA, CCFP

Palliative Care PerspectivesBy James L. HallenbeckPublished by Oxford University Press, NewYork, 2003256 pages, $59.50 (hard cover)

In his introduction, Dr. Hallenbeck explainsthat Palliative Care Perspectives is intended for

566 Vol. 27 No. 6 June 2004Reviews

Diverse FactorsInfluencing Pediatric PainWilliam T. Zempsky, MD

Pediatric Pain: Biological and Social Context. Volume26 of Progress in Pain Research and ManagementEdited by Patrick J. McGrath and G. Allen FinleyPublished by IASP Press, Seattle, Washington,USA, 2003225 pages, $76 (hard cover) ($57 for IASPmembers)

Pediatric Pain: Biological and Social Context,edited by Patrick J. McGrath and G. Allen Finley,

clinicians who are relatively new to palliativecare. He also states that the book is not intendedto be either a comprehensive textbook or a“how-to manual.” While the narrative style ofthis book, including the many stories, offersan informal and captivating read, it does notlend itself to being a quick reference or a“how-to” handbook, as the author himselfacknowledges.

That being said, this book will appeal to thosewho enjoy a narrative-style handbook. The authorhas used his own experiences and compellingstories to illustrate various points throughout thevolume. These are interspersed with wisdom andreferences to various key studies.

There are some noteworthy sections in thebook. I found the sections on “Dying Trajector-ies and Prognosticating” and “Special Thera-peutic Issues” enlightening. The former is atopic that is not often adequately addressed inintroductory books, yet Dr. Hallenbeck pro-vides an excellent overview of the challenges inthis area, along with some pragmatic clinicaladvice. With respect to the therapeutic issues,his message of intent rather than the procedureor therapy itself is notable. I also found thesection on “Working the System and Making aDifference” very useful and again, an importantarea that is seldom addressed in other hand-books. Some very insightful ideas are offered toeffect change at the local level. The sectionon “Palliative Care Consults” is insightful, butsomewhat surprising, considering that that thisbook is intended for a “novice” audience.

Several assertions in the book are conten-tious. In the pain section, for example, it isstated that the dose of methadone should notbe increased more rapidly than every third dayin order to avoid the risk of dose-stacking. Mostexperts in the field, at least to this reviewer’smind, would view this assertion, as well as theassertion that methadone should not be usedfor rapidly changing pain, as somewhat ex-treme. In the non-pain section, the book indi-rectly advocates the use of nebulized opioids

Jose Pereira, MBChB, DA, CCFP, is Vice Presidentof the Canadian Hospice Palliative Care Association;the Alberta Cancer Foundation Professor in PalliativeMedicine in the Division of Palliative Medicine,Department of Oncology, University of Calgary, Cal-gary, Alberta; and a Palliative Care Consultant atFoothills Medical Center, Calgary, Alberta, Canada.

for the management of dyspnea. Current evi-dence and experts in the field of dyspnea would,with some exceptions, generally challenge thisapproach. While the points that artificial hydra-tion has a limited role in the final stages oflife and may be of some benefit in managingdelirium are justified, the section seems some-what overly-biased towards non-hydration. Inthe discussion on anorexia, the point is madethat megestrol acetate “must be given at dosesof 800 mg per day.” Current evidence supports atrial of lower doses.

Delirium is addressed in the section on “Psy-chosocial and Spiritual Aspects of Care.” Theauthor suggests that the term “delirium” is toonegative and does not appropriately describethe “pleasant” and “ecstatic” nature of some epi-sodes of delirium. He prefers to address theissue as an “altered state of consciousness.” Thisrather unorthodox approach to the topic, whileeliciting discussion on the spiritual manifesta-tions of delirium, dilutes the importance ofmedical management of this common phenom-enon, especially to someone with limited expe-rience in palliative care. The assertion thatthe most useful screening question for assessingaltered states may be “What time is it?” is alsoproblematic.

doi:10.1016/j.jpainsymman.2004.02.012