Pharmacy Practice in Focus: Oncology
Palliative pharmacists are invaluable assets of oncologic care.
Despite the absence of a universally agreed-upon definition, the World Health Organization (WHO), the National Hospice and Palliative Care Organization, and the Center to Advance Palliative Care broadly define palliative care as specialized and holistic support for individuals coping with serious illnesses and for those individuals’ families.1-3 Often misunderstood as a precursor to hospice, palliative care is an overarching term that encompasses hospice services but is not defined by hospice care. Although both palliative and hospice share a common goal of enhancing patients’ quality of life, they are slightly different.
Hospice eligibility is contingent upon 2 main criteria: having a terminal illness and an expected prognosis of 6 months or less. Furthermore, patients who opt to enroll in hospice must be willing to forgo curative medical interventions.4 For most patients, hospice services are provided with little to no out-of-pocket costs. Patients with original Medicare (Medicare Part A and Part B) and/or Medicare Advantage (Part C) are eligible for hospice coverage if the hospice provider is enrolled in Medicare and accepts Medicare coverage. Coverage includes physician, social work, and nursing care; medical equipment and supplies; and prescription medications related to the hospice diagnosis/diagnoses.4
Patients with a life-limiting illness with a prognosis of greater than 6 months who choose not to enroll in hospice are eligible to receive palliative care. Unlike hospice, patients receiving palliative care may continue to seek life-prolonging treatments if they choose.3 For example, patients with cancer who choose to receive chemotherapy can simultaneously receive palliative care for treatment of symptoms caused by cancer and/or chemotherapy. Simply put, all hospice care is palliative, though not all palliative care is hospice.
Palliative care is a relatively new field of medicine derived from hospice. Dame Cicely Mary Strode Saunders, OM, DBE, FRCS, FRCP, FRCN, founded hospice in the United Kingdom in 1967. As a multidisciplinary scholar with degrees in social work, nursing, and medicine, Saunders recognized the benefit of multidisciplinary care and emphasized its importance, especially for patients with life-limiting illnesses. Utilizing the groundwork Saunders created, surgical oncologist Balfour M. Mount, OC, OQ, coined the term palliative care and ultimately helped to differentiate palliative care from hospice in 1974. Despite this, it was not until 1990 and 2006 that the WHO and American Board of Medical Specialties recognized palliative and hospice as separate entities, respectively.1,5 Over time, both hospice and palliative care evolved into interdisciplinary teams. This framework continues throughout many teams today. Most teams comprise physicians, midlevel providers, social workers, chaplains, nurses, and pharmacists. Because each team member brings specialized knowledge and a unique skill set to the table, patients and families can benefit from individualized, holistic care.4
The WHO recommends palliative care be initiated as early as possible in the course of a life-limiting illness, as integration with a multidisciplinary palliative care team can enhance the quality of life of both patients and their families and even influence the course of illness.1 In addition to symptom management, palliative care teams can also provide early identification and a comprehensive assessment of burdensome physical, psychological, and spiritual symptoms throughout the course of the illness.1-3,6
Integration Into Oncology
The WHO, American Society of Clinical Oncology, American Cancer Society, National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology, and National Academy of Medicine all promote the integration of palliative and standard oncology care.1,7-10 Traditionally, oncologists have been the sole providers of both oncology and supportive care; however, there is significant variation in the supportive care provided by each oncologist. Furthermore, oncologic care continues to grow exponentially as the incidence of cancer continues to increase worldwide with an aging population while research continues to discover new curative treatments. Because comprehensive care can be extremely complex in patients receiving oncologic care, oncologists are not always able to provide satisfactory supportive care. For this reason, in addition to the fact that supportive care itself is becoming increasingly specialized, palliative care teams are well positioned to work alongside oncology teams to ensure patients receive optimal oncologic and supportive care.7
Three recent meta-analyses further analyzed the impact of palliative care on health outcomes. All 3 demonstrated an association between enrollment in palliative care and quality of life.11-13 Among the 3 analyses, 2 concluded palliative care is associated with improved symptom control.11,13 However, none reported a statistically significant improvement in survival, although this may be due to small sample sizes and variable study design.11-13
The Pharmacist's Role in Palliative Care
Because patients with cancer require complex care, collaboration with the palliative care team, specifically a palliative pharmacist, is invaluable. Although all pharmacists are qualified to provide in-depth knowledge of drugs, including mechanism of action, appropriate dosing, adverse events (AEs), monitoring, and interactions, just to name a few, palliative care pharmacists bring additional training and creativity to further optimize care for patients and their families.
Pharmacists have played a key role on hospice and palliative care teams for many years, though it was not until the 1990s that their expertise was widely recognized. In 1990, Arthur Lipman, PharmD, FASHP, strongly advocated for pharmacist involvement with pain management for patients on hospice.14 This recommendation led to a formalized role for the pharmacist within hospice care 3 years later. In 2002, the American Society of Health-System Pharmacists (ASHP) stated, “Pharmacists have a pivotal role in the provision of hospice and palliative care and are integral members of all interdisciplinary hospice teams.”15 However, it was not until 2016 that ASHP provided official guidelines on the role of palliative care pharmacists.16 An additional review article published in 2022 details the role of the palliative care pharmacist.17
Written by experts within pain management and palliative care settings, the ASHP guidelines outlined both essential and recommended services. Roles deemed essential included direct patient care, order verification, medication reconciliation, education, and administrative roles associated with medication management.16 Desirable roles for the palliative pharmacist included implementation of collaborative practice agreements, education to patients and families on policy development, and contribution to academic literature.16 The benefit of palliative pharmacists was further recognized in 2018 when the fourth edition of the Clinical Practice Guidelines for Quality Palliative Care called out the importance of palliative pharmacists and recommended them as members of the interdisciplinary team for the first time.18
Studies and articles further explain and assess the impact of a pharmacist with specialized training in hospice and palliative care. A study conducted in 2011 by Wilson et al assessed the impact of a palliative care pharmacist by reviewing recommendations provided by 264 pharmacists with specialized training in hospice and palliative medicine. Results indicated that recommendations from specialized pharmacists were widely accepted and allowed patients to achieve desired outcomes at a higher rate compared with pharmacists without training within palliative and hospice care.19
Palliative and hospice pharmacists are committed to providing individualized care to patients and their loved ones through creative and safe use of medications. Beyond providing expert opinions and recommendations on medication optimization to improve symptoms, they can assist with opioid conversion calculations, off-label use of medications, administration of medications via less common routes (eg, oral tablet administered rectally), titration and tapering of medications, and deprescribing. Furthermore, hospice and palliative care pharmacists can ease the burden of other health care professionals, such as providers and nurses, by working directly with the patient and their caregiver(s) to help address medication nonadherence; create methods to improve adherence to better control symptoms; discuss medication fears and misconceptions (ie, apprehension surrounding opioid use due to concern of becoming addicted); conduct thorough medication reconciliations; and provide comprehensive medication counseling, including indication(s), doses, route(s) of administration, time to effect, and potential AEs.15-21
Case Study
To gain a deeper insight into the advantages a palliative pharmacist can provide to patients receiving oncologic care, we will provide a patient case. Meet SB, a 30-year-old woman with a medical history of neuroblastoma (2-year history), irritable bowel disease, and polycystic ovarian syndrome. Her medical record indicates she’s been seen by the emergency department (ED) 4 times within the past month, all for the same symptoms of abdominal pain, nausea, and weight loss. On previous visits she’s been admitted for further work-up to determine the etiology of her pain; however, results revealed no abnormalities, and her pain was presumed to be due to a uterine fibroid or colitis. SB’s pain has persisted despite appropriate escalation of multimodal analgesia with acetaminophen (Tylenol; Johnson & Johnson), ibuprofen (Motrin; Johnson & Johnson), gabapentin (Neurontin; Pfizer Inc), and oxycodone (Roxicodone; Xanodyne Pharmaceuticals, Inc).
Worried there is an underlying medical problem not yet identified, the ED physician orders a colonoscopy. SB is admitted to the hospital overnight and completes the colonoscopy the next day. A sigmoid mass is revealed on the colonoscopy, and pathology is consistent with adenocarcinoma. Unsure how to share the devastating news, the attending physician consults palliative care for symptom management and clarification of goals of care and oncology to determine and discuss treatment options.
When members of the palliative team go to meet with SB the following morning, they find her alone in bed, extremely tearful. The palliative physician briefly relays why the team was consulted. Interested in improved symptom control, SB invites all members of the interdisciplinary team into her room for further discussion.
Unsure whether the pathology results have been communicated to SB before the conversation, the physician asks, “Do you mind telling us about what’s been going on?”
Trying to hold back tears, she shares how she received the news just minutes before the visit: “He [the oncologist] didn’t show any empathy, just dropped this massive bomb on me and walked out like it was nothing.”
“I’m so sorry the news was shared with you in that way,” the physician replies. “I wish that things were different, but the goal of our team is to support you through this process.”
For more than an hour, members of the palliative team engage in conversation with SB, providing support and active listening. What initially seems like a simple consult quickly becomes more and more complex. The details SB shares with the palliative team reveal that pain and nausea are unfortunately just a glimpse of the total symptoms she’d been enduring for the past 2 months. In addition, SB is suffering from significant psychosocial and spiritual distress.
Following the conversation, team members debrief on the details they have gathered. While the chaplain and social worker work collaboratively to determine how they can best support SB, the pharmacist and physician thoroughly review SB’s previous and current medication regimen, paying close attention to pharmacotherapy for pain and nausea. Because SB’s current regimen is not effective in bringing pain to a tolerable level and in anticipation of pain becoming worse, the pharmacist and physician adjust her medication regimen. Ibuprofen and acetaminophen are continued, gabapentin is increased, and oxycodone is substituted for sublingual hydromorphone (Dilaudid; Rhodes Pharmaceuticals). Intravenous (IV) hydromorphone is also added to provide more rapid analgesia during pain flare-ups. Despite gentle titration of the medications throughout the week, SB reports minor improvements in her symptoms.
The following week, SB’s mother is present during the visit with the pharmacist and provider. She agrees that while the current medication regimen provides some pain control, it can still be optimized. Furthermore, she has noticed SB’s nausea seems to acutely worsen in instances of heightened anxiety. The pharmacist and physician debrief on this visit, discuss potential medication changes, and request the assistance of a palliative social worker to provide companionship and help decrease anxiety with nonpharmacologic interventions.
To ease both anxiety and acute episodes of nausea, SB is initiated on a low dose of scheduled lorazepam (Ativan; Bausch Health Companies Inc). SB reports the most pain relief with IV hydromorphone, although she is frustrated that the effects last less than 2 hours before she needs an additional dose to adequately control her pain. She requests a longer-acting pain medication to improve pain control and decrease pill burden.
Because SB is opioid tolerant and has mixed (neuropathic and nociceptive) pain, the provider and pharmacist deem her an ideal candidate for methadone (Dolophine; Roxane Laboratories, Inc). Prior to the medication’s initiation, the pharmacist provides an in-depth review to SB and her mother; both are amenable to trialing the medication. Based on SB’s opioid requirements over the past several days, the physician and pharmacist agree to initiate methadone 5 mg by mouth twice daily.
The following week, SB is pleased to report a vast improvement in pain management. With the help of the palliative pharmacist, SB’s methadone is carefully titrated to oral pain regimen, SB is able to be discharged home to spend time with her beloved husband and 3 dogs and follow up on an outpatient basis with her oncologist to initiate chemotherapy.
Conclusion
Alexis Beachy, PharmD, is a palliative care pharmacist at OhioHealth in Plain City, Ohio.
Jessica Geiger, PharmD, MS, BCPS, is a clinical pharmacy practitioner, pain, at VA Illiana Health Care System and a contingent pharmacist at OhioHealth in Powell, Ohio.
This case demonstrates several aspects of care palliative pharmacists can assist with, though it is certainly not all-encompassing. All things considered, pharmacists are an essential asset of the palliative team. Their experience further enriches the interdisciplinary team and grants all patients and families many benefits. Specifically, patients receiving oncologic care benefit from collaboration with a palliative care pharmacist. In addition to offering a more individualized and holistic approach to care, palliative pharmacists can also provide patients with quicker and improved symptom management, which often improves quality of life and may also increase survival rates.
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