It’s summer, and the new fellows have started. I usually post around this time about a basic concept to teach new fellows. See previous posts about:
- How to explain palliative care to patients and families?
- How to explain hospice?
- Talking with families about imminent death
Here’s my favorite reference book for palliative care fellows: A Physician's Guide to Pain and Symptom Management in Cancer Patients, by Janet Abrahm.
The evidence base for symptom management, particularly in cancer care, is growing by leaps and bounds. That said, in the larger picture, there is still little evidence for much of what we do. Why do we choose this opioid over that opioid? Why do we choose this stimulant laxative over that stimulant laxative? In such situations, we turn from evidence to “guru” medicine.
Now, there are some people who are experts in symptom management. And then there are people who are on a higher level altogether – Jedi Knights, Zen Masters, or Gurus of symptom management.
These people, through years of practice, learning from with other experts and gurus, are repositories of a remarkable store of information. The key that separates these Gurus from other experts, in addition to a larger knowledge base, is their ability to teach that knowledge effectively to others.
Janet Abrahm is one of two people I know at that rarified level (the other, Eduardo Bruera, I don’t know personally, though I’ve heard him teach). I was fortunate to train under Janet Abrahm during palliative care fellowship.
I’m not saying this book is all Guru medicine, because it’s not. She references the evidence, where available. But if she only referenced what there was high quality evidence for it would be a slim volume indeed.
This is my current favorite reference book, the one that I loan to fellows when I’m on service. This is my “go-to” book when I’m stumped, uncertain, or want to double check my thinking about symptom management. I’m delighted to hear Janet whispering in my ear as I read. I used it recently to look up:
- How to treat rectal spasm- Belladona and Opium (B&O) suppositories, with topical anesthesia pre-medication prior to suppository. Consider ganglion impar block if refractory.
- Ketamine for refractory pain
- Adjuvant treatments for bone pain due to cancer (NSAIDS, corticosteroids, bisphosponates, denosumab, vertebro/kypho-plasty, radiation)
- A chapter devoted to sexuality and cancer
The book is not without weakness. The table of contents and appendix are not great, meaning it's not as easy to "search" for specific issues or symptoms as it should be. The long paragraph format is somewhat antiquated in today's "just give me the bullet point" world. There could be more white space. The penalty for comprehensiveness is a big book.
Finally, Janet Abrham is an oncologist by training, and the book focuses on symptom management in cancer care. This leaves a big void, however, for the majority of patients who do not die of cancer. The book does include a nice section on relieving pain in older persons, and a nice figure of the PAINAD scale for assessing pain in advanced dementia.
However, at the risk of being accused of therapeutic nihilism, if the evidence for symptom management is thin but growing in cancer care, it’s a complete wasteland for other conditions. What is the best medication for chronic non-malignant pain due to osteoarthritis refractory to acetaminophen? Good luck answering that fundamental question with the evidence. We desperately need more research in symptom management for conditions other than cancer! And reliable funding mechanisms for large randomized trials in frail elders.
But I’m curious – what is your favorite reference book? What do you recommend to new fellows?
Note: I’m not tooting my own horn here. I’ve authored chapters for a number of geriatrics and palliative care text books and UptoDate. They’re all great books, and with the right question, I’ll turn to them for guidance. They’re just not my first choice as a reference for symptom management in everyday clinical practice, where the most challenging symptoms in the elderly I see are still due to cancer. If you’re going to promote your own work in the comments, please make sure you’re being honest about what you use as a reference!