Pharmacists supporting patients with palliative care needs

For many, the last 12 months of life is spent with significant disability, associated with rising symptom burden and functional decline. A palliative approach aims to ease difficult symptoms, encourage the best quality of life, and offer support for families.

People with palliative needs are diverse, with diagnoses including cancer, end stage organ failure, dementia and neurological disorders. Accredited pharmacists have resources to support people with palliative needs, including knowledge of the situation (clinical needs, functional ability and social networks) as well as established partnerships with general practitioners and community pharmacists.

While identifying people with palliative needs is challenging, accredited pharmacists have the opportunity to flag, document and communicate anticipated medicines management concerns.

Accredited pharmacists can facilitate links between patients, caregivers, GPs and community pharmacists, as they anticipate medicines management issues in the last year of life. Medicines management is important at all stages of the palliative care journey.

Five things accredited pharmacists can do to support palliative care needs:

1.  Identify people with palliative care needs

The authors of the Dying Well report suggest 100,000 Australians annually would benefit from palliative care.¹ In the absence of explicit mention of palliative care needs, an accredited pharmacist can often identify clues within a Home Medication Review referral.

The question “Would you be surprised if your patient were to die in the next six to twelve months?” is used to identify the appropriateness of a palliative approach to care.² Clinical and personal knowledge assists in answering this, including awareness of: poor functional status with limited reversibility; two or more unplanned hospital admissions in the previous six months; 5 to 10% weight loss over the past three to six months; and assistance required to remain at home.³

2.  Understand the journey

While deteriorating function is inevitable, there are differences in the journey. Those with end organ failure may experience exacerbations and regain function to a degree. People with cancer may experience sudden deterioration in the last weeks of life. Awareness of these patterns informs likely needs, acute health service utilisation, and issues relating to medicines.

Polypharmacy is likely and is compounded by multiple admissions to hospital, numerous prescribers, and medicines stopped and started. Confusion often occurs with multiple changes to medicines. Support strategies may include: assessment of adherence, provision of education, reconciling medicines and disposal of medicines.

As people approach the last days of life, physical deterioration results in the inability to swallow. Appropriate formulations to manage symptoms becomes limited to oral liquids or subcutaneous injections. Certain symptoms can be anticipated, including pain, nausea, dyspnoea, delirium, anxiety and noisy breathing. For patients on oral medicines, consideration will need to be given to the maintenance of symptom control with the anticipated loss of the oral route. A planned approach is possible, despite sudden deterioration.

3.  Build capacity

With functional decline, a lay caregiver’s support in managing medicines can keep people in their home environment. A caregiver may be the spouse, neighbour or an adult child. Many caregivers are challenged by managing the person’s medicines; developing skills and knowledge will improve outcomes.⁴

Identifying the caregiver and engaging with them early is important. Support strategies may include: providing education and opportunities to ask questions, empowering to keep the medicines list up-to-date, and teaching how to monitor and record symptoms.

4.  Participate as a team

Well-structured community support can reduce the need for hospital admissions.⁵ While GPs will coordinate community care, they need support in managing care. Pharmacists have a role and should highlight this when summarising HMR outcomes to GPs. Support strategies may include: advice around deprescribing, guidance in how to convert opioids from oral to subcutaneous doses, and advocacy for the patient and their caregiver.

5.  Have a plan

In the terminal phase, swallowing is difficult, resulting in a need for subcutaneous formulations. For the 14% of Australians dying at home and the 32% dying in aged care facilities, subcutaneous medicines are likely to be sourced through community pharmacies. South Australian data showed pharmacies were unable to anticipate which medicines to stock.⁶ Pharmacies may carry a broad range of subcutaneous formulations and risk them expiring on the dispensary shelf, or carry no subcutaneous medicines and risk delaying symptom control as stock is sourced.

Accredited pharmacists, having reviewed medicines, can flag likely options, ensuring the medicines prescribed are also stocked.

Support strategies may include: informing the person’s community pharmacy of their palliative needs, promoting a standard list of medicines for GPs to prescribe and pharmacists to stock,^7,8,9 anticipating the patients’ needs once the oral route is lost, and advocating on behalf of the patient and the caregiver.

PAUL TAIT is the Lead Pharmacist of the community arm of the Southern Adelaide Palliative Service.

References

1. Swerissen H, Duckett S. 2014, Dying Well. Grattan Institute
2. Reymond L, Cooper K, Parker D, et al. End-of-life care: Proactive clinical management of older Australians in the community. Aust Fam Physician. 2016;45(1):76-8.
3. Highet G, Crawford D, Murray SA, et al. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): a mixed-methods study. BMJ Support Palliat Care. 2014;4(3):285-90.
4. Lau DT, Joyce B, Clayman ML, et al. Hospice providers’ key approaches to support informal caregivers in managing medications for patients in private residences. Journal of pain and symptom management. 2012;43(6):1060-71.
5. Kim SL, Tarn DM. Effect of Primary Care Involvement on End-of-Life Care Outcomes: A Systematic Review. J Am. Geriatr Soc. 2016;64(10):1968-74.
6. Tait PA, Gray J, Hakendorf P, et al. Community pharmacists: a forgotten resource for palliative care. BMJ Support Palliat Care 2013: doi:10.1136/ bmjspcare-2012-000440.
7. Tait PA, Morris B, To THM. Core Palliative Medicines: meeting the needs of noncomplex community patients. Aust Fam Physician, 2014; 43: 29-32.
8. Health Networks. 2011. Essential palliative care medication lists for community pharmacists and general practitioners. At: healthnetworks.health.wa.gov.au/cancer/docs/EPCMLfCPaGPs.pdf
9. 2017. End of Life (Terminal) Symptom Management Medications for Older Australians Living in the Community. At: www.palliaged.com.au/Portals/5/Documents/ANZSPM_Community_Medication-List-EoL_0517.pdf