Evidence-based Symptom Control in Palliative Care Arthur G. Lipman, Kenneth Jackson, Linda Tyler, eds Pharmaceutical Products Press 10 Alice St Binghamton, NY 13904 800-429-6784 E-mail: [email protected] Web: http://www.haworthpress.com Price: $29.95

Evidence-based Symptom Control in Palliative Care (2000) is a nicely written, easy-to-understand resource for clinicians caring for patients at the end of their lives. The editors, Lipman, Jackson, and Tyler, clarify that this book is not intended to be a definitive work, but rather one that is in progress. That continual process of gathering relevant valid evidence, determining the patient's and/or family's concerns and choices, and factoring in the clinician's expert clinical judgment when formulating decisions is the nature of evidence-based practice (EBP). The definition of EBP that the editors work with is provided at the beginning of the book. EBP is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."1 Dr Lipman briefly explains EBP and its relationship to palliative care in the beginning of the book. However, unless the reader is familiar with the EBP process and critical appraisal methods, it may be difficult to understand the process the editors employed for putting forth their recommendations. The focus of the book is to provide clinicians with the best evidence that was current at publication on which to base their care of patients who are dying. Most of the studies cited were published in the 1990s and date back to 1970s. It would be the responsibility of the clinician to search for more current valid evidence to support the recommendations provided. The book is organized around the common symptoms of patients in palliative care (eg, nausea, vomiting, anorexia, anxiety, bleeding, diarrhea, and fatigue).

The chapters open with a summary of the chapter contents and keywords to use in a search. These keywords can guide readers if they choose to search for the most current evidence relevant to the chapter. Given the qualifier that the evidence may not be the most current, chapter authors provide an evidence-based algorithm for making clinical decisions about treating the symptom, a brief but meaningful discussion of the evidence, and a table of the evidence to support the recommendations in the algorithm. The evidence tables are easily read, most often containing the authors' names and year of publication, sample size, type of study, intervention, results, and level of evidence. Although the editors consider these reviews to be systematic, there is no evidence to support the rigor of Cochrane reviews. However, the authors provide solid evidence to support their recommendations.

I particularly liked the algorithms (much like the American Heart Association's ACLS algorithms) that provided a decision pathway. If the reader is not used to reading decision trees and flowcharts, the algorithms may be confusing. Careful examination will provide clinicians guidance as they sort through these types of decisions. Once I had read through the algorithms, I perused the tables of evidence to solidify my own ideas about my practice and the validity of the algorithm. As well, I went to the reference list to find study reports from the tables and chapter for further investigation that I found particularly applicable to my patients. What is missing from the chapters is a critical appraisal of the available evidence. However, inferred from the introduction is that reporting critical appraisal was not one of the purposes of the book.

Another beneficial aspect of the book is the tables that provide the pharmacotherapeutic options for various symptoms encountered in palliative care. Primary agents are listed, as well as alternative therapies. The cost of these pharmaceutical options is provided, facilitating clinicians' inclusion of healthcare resources (a central aspect of EBP) in their decision making. The consistent format across all chapters was helpful to find information, algorithms, studies, or pharmacotherapeutic interventions.

Spiritual and psychosocial aspects of palliative care are noticeably missing in the table of contents. The editors acknowledge that there is a paucity of evidence addressing these aspects of palliative care, and, subsequently, that is why they are missing from the book. When reviewing the tables of evidence, there were few descriptive and no qualitative studies listed. The qualitative research tradition could provide some rich evidence to give insight into what may assist clinicians and patients to make the most of the spiritual and psychosocial dynamics in their relationships. In a recent study, McClain et al 2 found that spiritual well-being influenced despair at end of life. These findings are important to comprehensive care of the patient who is dying. A recommendation to the authors for their next edition is to add a state-of-the-science chapter on spiritual and psychosocial care of patients at end of life, complete with the best available evidence.

Another concern is that all but 3 of the authors are doctors of pharmacy. It would have been nice to see a multidisciplinary team address these issues for this population, because their care is certainly interdisciplinary. One chapter contributor who was not a pharmacist was Mark Chambers, who cowrote about oral mucosal problems with Dr Jackson. Other nonpharmacist authors were Brian Haynes, a medical doctor and well-known contributor to the EBP literature, who wrote an appendix about evidence-based information resources, and Jeanne Le Ber, a medical librarian, who wrote an appendix about the Cochrane Collaboration and Library (an organization that provides rigorous systematic reviews of evidence on many topics (http://www.cochrane.org and http://www.cochranelibrary.com).

Overall, this book is well done and can be a great resource to the clinician caring for patients who are dying. It provides concise evidence-based recommendations for treating common symptoms of patients at end of life. I would suggest that clinicians update the evidence in all chapters in which they are interested so that their patients can receive the best care available. I also would recommend this text for graduate students who are specializing in palliative care, for primary care clinicians, and for others who will care for these patients. It is always beneficial to have the evidence synthesized and recommendations presented that flow from that evidence. Pre-appraised evidence with clear recommendations makes practice much more likely to be based on evidence than on the traditional, "we have always done things this way."

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