Residential aged care facilities (RACF) must provide quality palliative care for residents. Effective medication management is a key component to reducing suffering and facilitating good palliative care for dying residents. Who is better equipped to help manage medications at the end of life than pharmacists?
Current funding and practice models prevent pharmacists from practising effectively in the RACF setting. The role of pharmacists in this setting has not been fully explored and as such their contributions in this setting are poorly understood.
At the Pharmaceutical Society of Australia (PSA) we have been working on two palliative care projects funded by the 2020 Palliative Care Grants programs, to help better facilitate pharmacists’ active contribution to palliative care in RACFs, through optimising medication management. This has the goal of optimising the palliative care experience for older Australians and their loved ones.
Project 1: Palliative Care Master Class
We developed three webinars, delivered by Dr Sarah Wenham and Michaela Del Campo. These focused on deprescribing and polypharmacy in palliative care, medicines in palliative care, and medicines in the last days of life. We also developed four podcasts hosted by Carlene McMaugh, topics for these included: advanced care directives and the role of the pharmacist, communication strategies, the role of a palliative care pharmacist in aged care, and a description of a novel service hosted by Dr Riera-Gilley in Texas USA. Access these resources can be on the PSA website.
Project 2: Palliative Care Pharmacists in Aged Care
This project has developed and tested a framework and practice model for pharmacists working within aged care, focusing on palliative care. My current role as an embedded aged care pharmacist has allowed me to gain valuable insight into the current state of palliative care in aged care facilities. I have identified gaps in care and suggested how these could be addressed by pharmacists.
So, how can a pharmacist contribute to palliative care in a RACF?
Resident/Family support
Commencing on a palliative care pathway can trigger many changes for residents and their families, especially with their medicines. Many medicines are stopped (deprescribed) and new medicines are started due to the changing priorities of care and to help manage troublesome terminal phase symptoms.
Pharmacists are well equipped to facilitate conversations for families and residents, about these changes to help them make informed decisions.
Nursing support
Nurses in RACFs often need to administer medicines that they are not familiar with when providing end-of-life care. For example, administering subcutaneous hydromorphone for pain or haloperidol for agitation. Pharmacists are able to support nurses to give these medications effectively by providing administration education and support. Thus, enabling nurses to provide optimal symptom management for their residents.
Medicine reviews
Currently, accredited pharmacists are renumerated to provide residential medication management reviews (RMMRS). In my experience, these are seldom used for those who are under palliative care.
Having a pharmacist medication review conducted at the commencement of a resident’s palliative care journey and during each significant change in care can help to identify and resolve medicine-related problems earlier and more effectively.
Furthermore, pharmacist reviews can also be useful if dose form alteration is required (crushing medications or administering subcutaneous) and in situations where complex medication regiments such as opioids, Parkinson’s and Epilepsy medications need to be stopped or changed.
Supply of terminal phase medications
Involving the supply and RMMR pharmacists in the palliative care process early allows the pharmacy to order in and stock essential terminal phase medications. This can prevent the delayed supply of medicines needed to prevent suffering during the terminal phase. Pharmacists are usually the most efficient to manage a facility's imprest and delivery systems to ensure timely supply of medications is always achieved.
Participation in family meetings and case conferences
Pharmacists are valuable in interdisciplinary care meetings. Our unique and unrivalled knowledge of medicines can help to identify and reduce medication-related problems and work towards collaborative solutions.
Extra funding for General Practitioners (GPs) can be available so that they can have a pharmacist as a third health professional for a Medicare Benefits Scheme remunerated interdisciplinary case conference. This increased funding could make regular and longer visits more viable for GPs visiting RACFs.
Health system navigation
Pharmacists sit at the crossroads of various health professionals and health systems. We communicate with doctors about prescribing and supply, nurses about administration and storage of medicines, and with families and residents about making informed choices with their medicines.
This puts pharmacists in a great place to help others navigate specialist and community palliative care services. This is reliant on the pharmacists being well informed of these services and referral pathways.
Transitions of care
The PSA’s “Medicine safety: Take care” report found that over 90% of patients have at least one medicine-related problem post-discharge from hospital1.
Pharmacists can effectively manage and facilitate safe and efficient transitions of care by ensuring supply of new and existing medications when a resident returns to their RACF, completing medication reconciliation to identify intentional/unintentional changes to medicines, and communicating with health care facilities to ensure any medication-related changes are implemented and monitored closely.
Pharmacists are an essential resource in caring for residents at the end of life. I hope some of these insights inspire you to involve your pharmacist network in the palliative care process for your residents. Or, for the pharmacists reading this, to get more involved in the palliative care being offered at the RACFs you work with.
If you wish to discuss how pharmacists could help facilitate palliative care in your facility, please contact me at julian.soriano@psa.org.au.
References:
- Pharmaceutical Society of Australia (PSA). Medicine Safety: Take Care (1.73MB pdf). Canberra: PSA; 2019 Jan.
Julian Soriano, Aged Care and Palliative Care Pharmacist, and member of Pharmaceutical Society of Australia (PSA)