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Review of ‘Supportive Care and Respiratory Disease’ by Sam Ahmedzai, David Baldwin and David Currow
  1. Sara Booth
  1. Correspondence to Dr Sara Booth MD FRCP FRCP (Edin), Honorary Consultant in Palliative Medicine, Associate Lecturer University of Cambridge, Palliative Medicine, CUHNHSFT, Box 63 Hills Road, Cambridge, Cambridge, Cambridge CB2 200, UK; sb628{at}

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Sam Ahmedzai sets out ‘to inform and inspire other doctors and nurses, allied health professionals, pharmacists, spiritual care providers and students to improve the quality of living for all patients and families who live with chronic disease.’ As he notes, it is for palliative care to ‘influence colleagues in all relevant healthcare disciplines to adopt the principles of modern supportive care, to benefit a wider range of patients to the earlier stage of illness’.

There is an interesting, detailed, lengthy chapter on palliation and supportive care by Prof Ahmedzai himself. This wide-ranging and comprehensive section compares and contrasts palliative and supportive care, setting out the idea that supportive care is ‘a generic set of skills and knowledge’ rather than a distinct specialty. This section finishes with an interesting, important exposition on the ever urgent and the increasingly relevant topic of assisted dying and euthanasia and what our response as a specialty should be to this. In an excellent section I would only argue that I do not think sedation is becoming more common, rather less commonly used than when I was training. In the early general set of chapters there are also important and useful sections on anatomy and physiology (excellent from Martin Muers), measuring quality of life and the principles of economic evaluation (Willis). The latter is an excellent chapter giving a broad overview and covering ‘payment by results’ but not the more recent health economics costing work, pioneered in Australia, which is now a leading and important part of the palliative care evaluation. The context was missing for the chapter on quality of life measurement and it would have been useful to have a discussion by the authors of what they would advise clinicians and researchers to measure quality of life and outcomes of treatment in a chronic illness that can last many years.

Later in the book there is a very comprehensive chapter on the multidimensional assessment of dyspnoea (though it must have preceded the Dyspnoea 12 which is becoming widely used, Harle and Dudgeon). This chapter could have been usefully linked to this earlier, more theoretical one. General supportive interventions are discussed with an excellent review from Currow and Abernethy, fortunately for the specialty this already now needs updating because of advances in our understanding and research interest in this area but it remains a good overview setting out the principles as well as specific drugs. The review of oxygen and air flow was good and had a very useful section on air travel and advanced disease. It's good to see a specific section on the place of occupational therapy, and the content and relevance of pulmonary rehab particularly the latter as some palliative care physicians will not be familiar with it (Singh).

The book is comprehensive and includes all the important areas except perhaps one that is missing from most palliative care books. We are making the transition from palliative and terminal care, to palliative, terminal and supportive care as a specialty—that is quite a reach. We are moving more into the care of people who have symptoms and illnesses for years rather than months and yet the differences between managing chronicity and managing short term problems is very rarely discussed comprehensively; they are different. I would have liked to have seen chronicity discussed as a topic in its own right. The other area that is also an important topic in palliative care is how we address in everyday clinical practice, the lack of evidence for many of the treatments we prescribe and those which our patients choose to use, outside our care. Where there is a lack of what is now considered grade 1 evidence, meta-analysis or RCT evidence, doctors and other clinicians have to make a choice. At the moment the phrase ‘there's no evidence’ can mean don't use it and is as unhelpful to patients as ‘there's nothing we can do’ sometimes it's another way of saying the same thing. For someone with intractable symptoms or an incurable illness sharing the decision on using interventions without evidence would be a relief. They would like guidance on ‘best guess’ interventions. This is exemplified for me in an area with which I'm greatly familiar: use of the fan in breathlessness, something I have been championing since a study on oxygen versus air I did in the early 1990s, so I have a personal interest. In the section on oxygen and air flow which is comprehensive and otherwise excellent there is a line which says ‘…recommendations for the use of the handheld fan in the breathless patient. Until recently such recommendations were not evidence based…’ this is in the same book as Richard Schwarztein's masterly chapter on the genesis of breathlessness and he, of course was the person who described the use of the fan in volunteers with induced breathlessness. Commending a fan in the absence of RCT evidence (and of course now there is a small trial available where statistical significance was demonstrated, Galbraith et al, 2010) makes sense on a number of levels. First it does no harm and may do some good based on Schwartzstein's and others’ work, second there are theoretical reasons to think it might palliate breathlessness, third it has other benefits, for example, increasing self efficacy and of course, patients find it helpful (if you ask them) and this is now borne out in a number of qualitative studies. Recommending something like a fan in breathlessness is very different from recommending say cisplatinum, for example, in the absence of evidence in that it is a dangerous, untested treatment without any theoretical reasons to think it might help and in addition is expensive and cumbersome to give, reducing quality of life.

The authors of all the chapters are leaders in their fields and of a very high standard; particularly outstanding ones are the ‘Genesis of Breathlessness’, ‘The non pharmacological strategies for dyspnoea’ (as you would expect from Carrieri-Kohlman), Nutrition and Cachexia (Argiles et al), Expectoration (Morice). In a multiauthored text like this a final chapter to review any differences in outlook or recommendations from the individual chapters such as those of ‘Schwartztein’ and ‘McDonald and Ward’ would be a valuable addition. Overall, this is an outstanding book which will be of great value to all those working with this group of patients.

Supportive Care and Respiratory Disease. Ahmedzai S, Baldwin D, Currow D. Published by OUP Oxford, Oxford, UK, 2012, ISBN 978-0-19-959176-3, hardback, 400 pages, Price £70.00.

  • Received 27 November 2012.
  • Accepted 29 November 2012.
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  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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