The publication of The Art and Science of Palliative Medicine

Published: 2014-03-20

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The book, The Art and Science of Palliative Medicine, with Dr. Howard S. Smith and Dr. Julie G. Pilitsis as the co-editors and dozens of promising experts in palliative care, is now officially published with both hard-copy and e-copy available. The price for the hard copy is $338.00 (free shipping), able to be purchased in Ebay.

Table of Contents




In Memoriam 


I. Palliative Medicine Issues

A. Healthcare ethics and pain management 
Bruce D. White

B. Advance care planning 
Patricia A. Bomba

C. Nutrition and hydration 
Lorraine R. Cox

D. Spirituality 
Lorraine R. Cox

E. Family issues 
Lorraine R. Cox, Laura Maselli

F. Palliative medicine and bereavement 
Lorraine R. Cox

G. Prognostication 
Amy Allen Case, Michelle M. Walter

II. Palliative Issues in Medical Conditions

A. Neuro-oncology 
Andrea Pace, Veronica Villani

B. Cancer induced bone pain 
Intikhab Mohsin

Douglas G. Fish

D. End stage liver disease
Nicole Siparsky, Lorraine R. Cox, Purvi Y. Parikh

E. New treatments for symptomatic severe aortic stenosis 
Saroj Pani, Howard S. Smith, Farhan Sheikh, Mark P. Tallman

F. End stage pulmonary disease 
Boris Medarov

III. Symptom Management in Palliative Medicine

A. Pain

  1. Pathophysiology of pain 
    Sheng-Xi Wu, Ya-Yun Wang, Juan Shi, Yu-Lin Dong, Guo-Hong Cai
  2. Overview of pain in palliative medicine 
    Angelique Wong, Suresh Reddy, Salahadin Abdi
  3. Breakthrough pain 
    Howard S. Smith
  4. Opioids 
    Mellar P. Davis, Pamela Gamier
  5. Opioid-related adverse effects 
    Sebastiano Mercadante
  6. Nonopioid analgesics 
    Jeff Gudin, Abel Gonzalez, Joon Lee
  7. Adjuvant analgesics 
    Neha Gupta, Amy Allen Case
  8. Topical analgesics 
    Jana Sawynok
  9. Interventional pain techniques 
    Nishi Patel, James de Courcy, Salahadin Abdi
  10. Interventional procedures and minimally invasive techniques for persistent pain 
    Kyung-Hoon Kim
  11. Neuromodulation of pain 
    AmiLyn M. Taplin, Joannalee C. Campbell, Howard S. Smith, Vikas K. Parmar, Julie G. Pilitsis
  12. Neurosurgical options 
    Shiveindra Jeyamohan, Paul MacMahon, Howard S. Smith, Julie G. Pilitsis
  13. Tai Chi
    Hung Ling Tan, Philip WH Peng
  14. The role of rehabilitation
    Gerald V. Klim

B. Dyspnea 
Boris Medarov

C. Nausea and vomiting 
Howard S. Smith

D. Dysphagia 
Monisha Sudarshan, Waël C. Hanna, Lorenzo E. Ferri

E. Hiccups 
Charles Bakhos, Thomas Fabian

F. Constipation/diarrhea 
Patrick D. Meek, Michael R. Brodeur

G. Anorexia and cachexia: definitions, clinical presentations, mechanisms and treatments 
Mellar P. Davis, Pamela Gamier

H. Fatigue and sleep difficulties 
Adolfo Ramirez-Zamora, Julie G. Pilitsis, Vikas K. Parmar, Joannalee C. Campbell

I. Etiology, pathogenesis and management of pruritis 
David Shapiro, Karina Gritsenko, Naum Shaparin, Boleslav Kosharskyy

J. Supportive and palliative care in dentistry and oral medicine 
Sharon Elad, Robert Horowitz, Yehuda Zadik

K. Genitourinary issues 
Petros Sountoulides, Athanasios Bantis

L. Cough
Howard S. Smith

M. Delirium
Eric Prommer, Sara E. Wordingham

N. Dementia 
Abdul Qadir Brula

O. Encephalopathy 
Renato V. Samala, Mellar P. Davis

P. Depression
Lisa J. Norelli

Q. Death rattle 
Bee Wee

IV. Palliative Issues in Special Populations and Circumstances

A. Palliative emergencies 
Dirk Schrijvers

B. Malignant wound management 
Vincent Maida, Susan Alexander, Amy Allen Case, Pirouz Fakhraei

C. Cancer care for infants, children and adolescents 
Joanne C. Porter

D. Evaluation and management of aerodigestive conditions 
David W. Yaffee, Thomas Fabian, Michael D. Zervos, Costas S. Bizekis

E. Management of malignant bowel obstruction 
Robert A. Milch, Jaclyn Schneider

F. Evaluation and management of pleural conditions 
Thomas Fabian, Charles Bakhos

G. Controlled sedation for refractory symptoms in dying patients 
Sebastiano Mercadante

H. Palliative radiotherapy 
Kenneth Li, Florence Mok, Danielle Rodin, Kam-Hung Wong, Rebecca Yeung, Edward Chow

I. Neuromodulation for end of life symptoms 
AmiLyn M. Taplin, Joannalee C. Campbell, Howard S. Smith, Vikas K. Parmar, Julie G. Pilitsis

Page count: 569


Death. Are you ready?

Simple, but complicated. Pessimistic, but optimistic. Morbid, but cathartic. I have asked myself this question many times overthe 20 years since it was posed to me and noted that the answers become surprisingly more complex with experiences and responsibility.For me, however this question is currently hypothetical. For the palliative care patient, this is the daily questionas they live with the knowledge that death is eminent. This is the question the patient’s caregivers and physicians constantlygrapple with as the patient’s clinical situations wax and wane on the way to an end that is guaranteed. This is the question thatunderlies every decision that is jointly made and every decision to treat or not to treat. This is the question that transcendsreligion, culture, ethnicity, gender, and age.

Becoming at peace with the situation (dying) and the known outcome (death) is the ultimate goal for the palliative patient,the caregiver, and the healthcare team caring for the patient. In order to allow for this ideal mental catharsis, the patient mustbe comfortable and every aspect of this comfort must be examined. Relieving pain, treating sleep disturbances, and addressingdepression and anxiety are some of the cardinal features of effective palliative care. This book goes on to look at each organsystem and how to maximize its comfort.The goal of the book was to provide a resource that is usable in all countries, providing straightforward data as well as foodfor thought for providers worldwide. Its design by Howard Smith, MD, was brilliant in its simplicity as well as its breadth ofcoverage. It is useful both for the student and resident physician being first exposed to death and dying as well as the palliativecare specialist that may be an expert in one facet of the patient’s disease, but not in others. After reading this book, it was Dr.Smith’s goal to arm the reader with a new set of tools in their daily responsibility and to be the best provider possible for theirpatients. It is meant to spawn interest in further reading on topics of interest and to promote future directions of study.

The text starts with an introduction to palliative care as a specialty, situations unique to the palliative care patient, andthe mind-body connection. The next section focuses on palliative management related to different organ systems as each ofthese patient groups faces a novel set of concerns. Next, treatment of specific symptoms is discussed. These chapters provideexcellent detail on the differential diagnosis of various signs and symptoms, and standard as well as creative treatment optionsranging from the very traditional to the futuristic. Finally the book concludes with discussion of special conditions that mayoccur in palliative patients.

It was a great honor to be able to take over the task of editing this text from Dr. Smith and to continue working with hislong-time associate Pya Seidner, MEd. I am a better provider for having this knowledge and I am confident that using thistext will afford readers the same experience.


“ ... to cure sometimes, to relieve often, to comfort always.”

Attributed to Dr. Edward Livingston Trudeau, founder of a 19th century tuberculosis sanatorium, this could easily be adefining slogan for palliative care because nearly all care models highlight the reigning importance of the individual as thecentral point of care. From its humble beginnings, the hospice movement and practice of palliative medicine have experienceda paradigm shift in the locus of treatments. Thought leaders and practitioners have transitioned from care when death isimminent to instituting palliative measures upon initial diagnosis of a life-threatening or serious illness.

The profession is riding a rising tide of recognition of the importance of best end-of-life care for the patient and family.Serving over 1 million patients each year and receiving high praise from families touched by impending death, palliative care stillremains somewhat on the periphery of mainstream medicine until death approaches and curative therapies have been stopped.Families, however, appreciate and embrace the broad tenets of palliative care that promote and encourage communication,advance care planning, and interventions for the highest possible quality of life by providing continuous, competent, andcomprehensive care that addresses each patient’s specific complications and distress.

This book, envisioned and initiated by Dr. Howard (“Howie”) Smith and finished by his colleagues after his passing, bringsan unparalleled exploration of our field. Assembled is an impressive faculty of thought leaders who are active researchers,practitioners, and educators, bringing critical background knowledge that has helped build the field, shape its domains, andinform future direction.

This valuable resource begins with issues that influence the staffing of a palliative care team, continues with thepalliative issues associated with specific medical conditions and treatments across the scope of symptoms afflicting thosewith life-limiting illness, before concluding with unique populations and circumstances. In total, providers will raise theirunderstanding of the role of palliative medicine through practical and investigative experiences of those who have struggledwith the distinctive physical, psychosocial, and spiritual challenges that distinguish this population of patients in need ofspecial care. Be confident that the experiences learned and presented here will strengthen the ability of both the newlycredentialed physician and the mature practitioner’s ability to deliver culturally sensitive and personalized care based onsound practical and theoretical experiences. Only by increased awareness and thought will we continue to advance empatheticpractices that continue to define and improve our roles in advocacy, treatment, care, and support for the end of life patient byraising professional standards in the core palliative care competencies that are applied in the hospital, long term care facilities,and at home.

I am confident that this authoritative, comprehensive, diverse, and readable compendiums like The Art and Science ofPalliative Medicine will further elevate and influence the potential, growth, development, policy, ethics, and very future ofour field through balanced presentations about providing quality care as the dying patient comes to terms with their ownmortality, and also for the families and their loved ones as grief, bereavement, and death approaches.

I add my gratitude, alongside the rest of the authors of this book, that Dr. Smith’s vision has been realized so that patients,caregivers, and providers in the community will grasp his caring and unselfish dream in this important work that he felt would“set the standard for further development of collaborations between professionals from many disciplines and countries.”Ultimately, our successes will shift the caring professions from believing there is ‘nothing more we can do’ to realizing that ‘thereis more that we can do’ by reaffirming the person and improving their quality of life.


I would like to dedicate this book in memory of Howard Smith, a great mentor, family man, and friend. Many thanks to my husband Tim, and children Ryan and Lauren.

In Memoriam

Howard Steven Smith, MD, known to his friends as “Howie,” left the world on Wednesday, May 8, 2013. Howie was adistinguished physician, having completed training and receiving board certification in anesthesiology with a subspecialty inpain medicine, internal medicine, and nuclear medicine.

Born in San Francisco, California, Howard Smith grew up in East Meadow, New York, completing his medical school andresidencies in Chicago, Albany, Cincinnati, and New York. He held many positions in various departments as an academicianalong with multiple positions as a prolific researcher with a wide range of publications. He was editor-in-chief of two painjournals—Pain Physician and Journal of Pain Research. Howie was not only a prolific writer, but he was also a scientist. Hispublications ranged from basic science to clinical aspects of patient management. He was a great teacher and guided manywith his knowledge and wisdom.

His involvement in the American Society of Interventional Pain Physicians (ASIPP) since its inception was intense in allaspects including teaching with participation in board reviews and publication of evidence-based guidelines of interventionaltechniques and opioids.

Above all, he was a loving husband, father, son, and brother. Howie’s loss is such that no one can express in wordspersonally and professionally for all of us who have been associated with him.


I would like to acknowledge the enormous efforts of Pya Seidner which helped bring this project to fruition. Additionally, Iwould like to thank Drs. Kevin Roberts and Alan Boulos for their support in finishing this final work of Dr. Howard Smith.Finally, this work would not have been possible without the many undergraduate and medical students who have aided inproofreading these chapters: Gabriella De La Cruz, Priscilla De La Cruz BS, Jessica Haller, Steven Lange BA, Nicole Patel,Julia Prusik BS, Elaina Pullano, Stephen Roth MS and Cailey Simmons BA.