This is a book about delirium and far less about ‘acute confusional states in palliative medicine’. Delirium has been and remains the Cinderella of psycho-syndromes but it is wearing finer dress as a result of studies into epidemiology and pathophysiology as well as phenomenology. These are explored and presented, which is news to clinicians, for delirium is so rarely given centre-stage for its own sake, being incidental to the main players of its aetiology.

Non-pharmacological management is given due attention, though sadly busy hospital wards can be difficult environments in which to follow calming and supportive behavioural strategies for those with delirium. There is concordance with much that is contained in the National Institute for Health and Clinical Excellence guidelines on delirium and its diagnosis, prevention and management. Drug management is considered in detail and reflects international practice, with some of the key aspects of the European Association for Palliative Care (EAPC) framework for the use of sedation in palliative care being appropriately highlighted.

Less gripping are the sections describing assessment scales – five are presented in full as appendices which range from 1 to 6 pages in length. In most situations only the very shortest can be justifiable in what is always a fraught and often rapidly changing scenario. Time spent with a paper and pencil or a computer screen is time taken away from providing skilled and humane, well-informed interventions. Yet the messages are well taken: when individuals are known to be dying from an irreversible progressive pathology, they may nevertheless become temporarily less well because of intercurrent problems which can be reversed. These must be identified and then treated effectively. However, delirium is for many the gateway to death and not to be fought as something which can be avoided, but anticipated, acknowledged and managed with calm and acceptance. Judgement on response comes from a close and comprehensive clinical understanding rather than scores on a check-list.

The final chapter returns, most appropriately, to family experiences and the loss of contact before death which is the essence of terminal delirium. Although this brings a welcome emphasis on holistic palliative approaches to end-of-life care, other texts have covered this ground in greater detail, and there is much included that is not specifically concerned with the issues encountered in caring for the delirious dying patient.

This is an unexpected book. It offers more than the title suggests. It is probably too expensive for most personal collections but should find a place in bench libraries in hospices, general hospitals and larger health centres. It should become essential reading for the psychiatrist working with the physically ill including those in palliative care.