Most community pharmacies likely have several palliative care patients, and might not know it. As a Pharmacist Manager, I was recently fortunate to have a placement with a palliative care service through the Program of Experience in the Palliative Approach (PEPA) program, and wanted to share a few take-home messages that might be beneficial for other community pharmacists wanting to contribute to better patient care in palliative cases. Please note that the summary below is my own interpretation of the information and experience I received, and should not replace recommendations or advice from palliative specialists or general practitioner (GP).
What did I learn?
Palliative care can be a long process, and patients may have very different levels of functioning in different stages; many patients in early palliative care may not seem different from non-palliative patients, and may have similar needs (eg. medicines information, medicine adherence, brand confusion, etc.).
The pharmacist should consider both the needs of the patient AND the needs of the carers/family. The journey is often difficult, and the mental health and support systems for all are important. A MedsCheck or similar may be ideal for the purpose of opening communication and building relationships with the patient and carer(s): ensuring they are aware of services offered (eg. Dose Administration Aid packing) as well as ensuring the pharmacy has relevant background to the patient’s medicines and conditions. A new diagnosis or exacerbation of chronic condition will qualify a patient for a MedsCheck; no minimum number of medicines is required. A Home Medication Review (HMR) might be suitable if the patient is unable to attend the pharmacy, or there is a complex medication regimen or issues.
For the purpose of medicine reviews, deprescribing should be considered, with possible psychological effects of rapid deprescribing in mind.
When the patient begins to deteriorate (eg. pain worsens, frailty increases, carers report increasing difficulty to manage), check to ensure the patient has been in touch with a palliative care service or GP– these services will coordinate support services and other requirements beyond the scope of a pharmacist’s practice.
It is reasonable to assume that all patients in late-stage palliative care will lose the ability to swallow, and may do so suddenly – medication reviewers should plan for the possible sudden discontinuation of all oral medicines, and focus deprescribing on medicines that might cause withdrawal effects if they could not be stepped-down.
Late-stage palliative care
In terminal phases, when prescribing and patient needs become more specialised, the key roles of the community pharmacist are support to carers and supply of medicines.
Crucially, patients may unexpectedly and suddenly require subcutaneous medicines for their symptom control when they lose the ability to swallow; 24 hours is a long time in late-stage palliative care, and often too long for a highly-stressed carer to wait. A South Australian Project has recommended the pharmacy must have minimum stock of the five core palliative care medicines1 to provide adequate care the moment it is needed:
- Clonazepam 1mg/mL inj
- Haloperidol 5mg/mL inj
- Hyoscine butylbromide 20mg/mL inj
- Metoclopramide 10mg/2mL inj
- Morphine 10mg/mL inj1
Inability to provide these items if they are suddenly needed, subjects the carer and patient to unnecessary stress at a very difficult time, and may force the carer to go elsewhere when they most urgently needed our help. It may also be worth considering offering home-delivery, even where this may be outside usual pharmacy policy.
Carers will often be completely focused on the patient’s needs at this time, and not give much thought to their own. The high stresses involved may produce unusual emotional responses, and they may not have much outlet for their stress (travelling to the pharmacy might be their only outing). Asking how the carer(s) are coping is a polite and often appropriate intervention; carers not coping should be immediately recommended to contact palliative care support services or their GP. The pharmacist is also well-placed to provide encouragement to the carer(s): gentle encouragement could make a world of difference to their state-of-mind.
After the patient has passed
Pharmacists are often made aware a patient has passed away only when a carer or loved-one is returning unused medicines to the pharmacy. We often have little or no formal training in conversations with grieving people, but will develop these skills with time and life experience; it was interesting to hear advice from health professionals with more formal training and experience.
It is appropriate for the pharmacist to switch mindset to applying their duty-of-care to the loved-ones. “Sorry for your loss” or similar phrase, said in a heartfelt way, is an appropriate early comment to show compassion. Bereavement counsellors are available for people who need longer sessions with a health professional, and could be recommended for someone who appeared to require a longer conversation. Generally, try to avoid showing too much emotion yourself (ie. remain professional), and avoid going into too much detail on your own experiences with the patient (but a statement such as “they’ll definitely be missed by many in the team here” or similar may often be suitable, provided the patient was well-known to the team).
I encourage anyone wanting to learn more to consider a PEPA placement, or to contact their local palliative services to see how we might better cooperate in palliative care.
References:
1Tait, P. Morris, B. To, T. (2014) Core palliative medicines: meeting the needs of non-complex community patients, Australian Family Physician, Vol.43, No1-2 Adam Forrest, Pharmacist Manager at Christies Guild Terry White Chemmart
Adam Forrest, Pharmacist Manager at Christies Guild Terry White Chemmart
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