Palliative Care the Pharmacist’s Role

  

From the 2020 statistics available on the World Health Organization site Globocon, seven thousand one hundred and ninety-seven new cases of persons have been diagnosed with cancer from both male and female genders and all ages in Jamaica.^[1] With the improved healthcare delivery and innovative treatments available the number of cancer survivors are increasing, resulting in some types of cancers being treated as chronic illnesses; cancer is no longer a death sentence. This new developing situation calls for a shift in treatment strategies, one of which is called Palliative Care. ^[2,3]

Palliative Care ^[2,3] refers to that type of patient care that is patient-centered, family centered with the overall goal of maximizing quality of life while at the same time minimizing suffering. When Palliative care includes the use of conventional with complementary and alternative modalities (CAM)it is referred to as Integrative Palliative Care (IPC)^{. [3]} When Palliative care is delivered at the end of a person’s life it is referred to as Hospice Care. IPC is an appropriate intervention at any stage of disease and is important when used along with other measures to prolong life.^[3]

The National Consensus Project for Quality Palliative Care of the National Quality Forum (NQF) ^[2] describes this Palliative Care as one that optimizes the quality of life throughout the continuum of the illness, it includes anticipating, preventing and treating as well as reducing the suffering. This type of care addresses the physical, emotional, intellectual, social and spiritual needs and facilitates patient autonomy, also access to information and very importantly choice; the ability to choose and refuse treatment. The continuum of care provided by Pharmacists who operate as palliative care specialists, includes both the ideas of curative and palliative. When curative care is no longer part of the patients’ plan of care then hospice care becomes part of the extended care.^[2]

Palliative care pharmacists ^[2] therefore may offer support in administrative roles (policy and procedure, formulary management), in a consultative role (order a set algorithm of treatment plan, educational training) and in the advanced clinical practice (medication therapy management services, pain and symptom management consultations and interdisciplinary team participation)

PHC ^[2] pharmacists can bring diverse essential services to the palliative and supportive teams. The most central role for PHC pharmacists is symptom management through participation in direct patient care, providing pharmacotherapy regimens that would support optimal patient outcome. Medication therapy Management ^[4] and the application of transitional continuity of care are the key services that PHC pharmacists provide.  Collaborative practice ^[4,5] opportunities will strengthen the working relationship with palliative and supportive care medical practitioners which will only further PHC pharmacist practice development. In the Collaborative model ^[5] Pharmacists can prescribe appropriate medicines or interventions (non- pharmacologic) once agreed upon by the Interdisciplinary team Physician. PHC pharmacists may also participate in advocacy, research and scholarly activities in palliative and supportive care, furthering the growth of this area of practice.^[2]

The pharmacist as a non-dispensing pharmacist^[6,2] can provide educational activities to student pharmacists, residency pharmacists (interns for the Jamaican setting and those specializing in this area), as well as members of the interdisciplinary team, their peers, caregivers and patients about the medicines needed to be used (opioids, medicinal cannabis and other botanicals) failed therapies those that need to be abandoned, dosages which need to be reduced, ones to be added to the regimen to improve treatment outcome, such as for constipation, nausea and vomiting, pain, delirium, dyspnea or others agents which may be botanicals (ginger, medicinal cannabis, mild laxatives) or otherwise.  A new way of speech has to be adopted for all players in this scenario which emphasizes compassion and understanding, using techniques such as Motivational interviewing ^[7] can be beneficial in assisting this approach.  All these implementations need training and legislation to empower the pharmacist to be fully operational within this team and to create this new specialist role.

In the Integrative paradigm shift a survey ^[8] was conducted of the complementary therapy services provided by hospices.  60% of the organizations who offered such services revealed that the most common services included, massage therapy (83%) music therapy (50%) therapeutic touch (49%) pet therapy (48%) guided image therapy (45%) reiki (36%), aromatherapy (30%), harp music (23%) reflexology (20%) art therapy (20 %) hypnotherapy (4%) yoga (3%) acupuncture (1%) humor therapy (1%). The constraints to this practice were lack of funding, inadequate amount of appropriately trained CAM specialists, lack of staff time, inadequate knowledge about the services and importantly patient and staff resistance to CAM therapies.^[3]

A therapeutic review for a PHC ^[2-4] pharmacist may include reducing the doses of medication needed for care, thereby minimizing side effects. Ensuring the compounding of medicines in suitable manner for consumption by the patient who may need alternative safe ways of taking the required medicines (slow-release preparations may not be crushed, some tablet forms of medicines have to be compounded from injectable dosage forms and not crushed to make liquid forms). Encouraging the psychological and spiritual health and including physical comfort in the end of life care, discontinuing unnecessary therapies, using less invasive modalities in keeping with the goals of the patient and the resources available and patient’s response to them. The ultimate goal is symptom reduction for the patient. A lot of listening and careful assessment and keen observation will be needed. The overall role of the Pharmacist encompasses the Curative care that occurs at initial diagnosis, the need for Palliative Care which may be needed initially or further down the cycle of the disease process, then hospice care, and the bereavement process which is also an essential element of the care process. ^[2-4]

In concluding therefore there is an important desirable clinical role for the PHC ^[2] pharmacist in actively supporting the patient as they transition from aggressive treatment to a comfort-focused care. The pharmacist can assist in evaluating the changing risk : benefit ratio of medications as the patient transitions from a beneficial treatment to one that is no longer tolerable or there is an inability to continue therapy (loss of availability of intravenous access or inability to administer oral medications).

The PHC pharmacist can  assist the patient, family, caregiver, and other healthcare providers in successfully navigating the changes in medication regimens that are necessary to provide a patient-centered, cost-effective, and (when available) evidence-based approach.^[2]

 

Dr. Winsome Christie

President of The Pharmaceutical Society Of Jamaica

Note:

Dr. Christie operates the Sunshine Pharmacy in May Pen which is located at 7 Bryans Crescent, telephone (876) 986-9085.

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References

1. World Health Organization. International Agency for Research on Cancer, Jamaica, Globocan [Image on internet]. [cited 2022 Feb. 6].https://gco.iarc.fr/today/data/factsheets/populations/388-jamaica-fact-sheets.pdf
2. American Pharmacists Association (APHA)Medication Therapy and Patient Care: Specific Practice Areas–Guidelines https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/pharmacists-roles-palliative-hospice-care.ashx
3. Rakel, D. Integrative Medicine [Internet]. 4^th ed. Philadelphia: Elsevier, Inc; 2018. Chapter 82, [cited 2022 Feb 6]. p. 806-817. Available from: https://lcnn.loc.gov/2017000204
4. Roberts S., Gainsbrush, R., Medication therapy management and collaborative drug therapy management. J Manag Care Phar,. 2010;16;67-9
5. Weeks GR, Marriott JL. Collaborative prescribing: views of SHPA pharmacist members. Journal of Pharmacy Practice and Research. 2008;38(4):271-5.
6. Gibbe T., Hall, K., Lubman D: Facilitating behaviour change in the general practice setting. Australian Family physician  2012 Sept; https://www.racgp.org.au/afp/2012/september/motivational-interviewing-techniques
7. Hazen AC, Sloeserwij VM, Zwart DL, de Bont AA, Bouvy ML, de Gier JJ, de Wit NJ, Leendertse AJ. Design of the POINT study: Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in a primary care Team (POINT). BMC Fam Pract. 2015 Jul 2;16:76. doi: 10.1186/s12875-015-
8. Demmer, C.,A Survey of complementary therapy services provided by hospices . J.Palliat. Med. 2004;7: p 510-516