End-of-Life Content in Four General Medical Textbooks

The study of general medical textbooks (Carron et al., 1999) focused on four widely used books: Harrison’s Principles of Internal Medicine (Isselbacher et al., 1994), the Merck Manual (Berkow, 1992), Scientific American Medicine on CD-ROM (SAM-CD, 1994), and Manual of Medical Therapeutics (Ewald and McKenzie, 1995; also known as the Washington Manual). In addition, the authors reviewed (although not in the same quantitative format as the target texts) William Osler’s (1899) Principles and Practice of Medicine, and the Mayo Clinic Family Health Book (Larson, 1996) a medical reference for nonprofessionals.

Information was sought from each book on 12 of the leading causes of death in the United States, and for each disease, nine “content domains” were assessed (Table 9-4). In addition to displaying the content score for each domain by disease, a rough overall score was calculated for each book by assigning a value of 1 for each “+” rating and 2 for each “++” rating and dividing the total by the total possible score (i.e., a rating of ++ in each category).

The following are some general findings (Carron et al., 1999):

  • Harrison’s Principles of Internal Medicine, the Merck Manual, and Scientific American Medicine characterized medical interventions and prognostic factors but often did not mention decisionmaking or the effect of death and dying on the patient’s family.

  • The Washington Manual “offered almost no helpful information.”

  • Dementia, AIDS, lung cancer, and breast cancer received the most comprehensive coverage of issues related to dying. However, “the best

TABLE 9-4 End-of-Life Care in General Medical Textbooks

Diseases Studied

Content Domains



Chronic obstructive pulmonary disease

Congestive heart failure, chronic renal failure

Cancer: breast, lung, pancreas, and colon





Prognostic factors

Disease progression

Medical interventions that change disease course

Advance care planning

Mode of death


Effect of death and dying on patient’s family

Symptom management


SOURCE: Carron et al., 1999.

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