Palliative Care: The Role of the Pharmacist
Pharmacists are essential in developing an individualized treatment regimen for each patient.
Palliative care is defined as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems—physical, psychosocial, and spiritual.”1
Pharmacists are essential in developing an individualized treatment regimen for each patient. A treatment plan requires specific patient goals with pharmacologic and nonpharmacologic management to improve quality of life while reducing costs and unnecessary medications. Effective utilization of pharmaceutical options optimizes the care of active disease states, enhances individualized dosing regimens, and assists in reducing the adverse effects (AEs) of medications.2
Excessive medication use can lead to polypharmacy and AEs. In palliative care patients, AEs can be avoided by discontinuing inappropriate medications. Examples of interventions pharmacists can use to prevent and reduce polypharmacy include medication reconciliation, patient education, geriatrics consultation, and multidisciplinary team consults.3 In addition, resources such as the Beers List Criteria4 can be used as a guide for effective and appropriate medication de-escalation in elderly patients.
Nontraditional Administration Routes
Alternative administration routes for palliative care are vital to providing effective patient care. Many commonly prescribed drugs (eg, promethazine, morphine sulfate) may be used in nontraditional routes.5 Topical gels containing lorazepam, diphenhydramine, or metoclopramide can be effective for patients with refractory nausea and vomiting.6 Various dosage forms, including transdermal patches of scopolamine and depot injections of octreotide, are used to treat specific needs of individual patients.7 Many medications not manufactured in parenteral or suppository formulations can pose administration challenges in patients with an interruption in oral access. Commonly prescribed medications can have nontraditional uses and rectal bioavailability, such as carbamazepine tablets or suspension for convulsions; rectal use may allow rapid absorption and partially avoid first-pass metabolism.8 If necessary, drugs can be compounded into parenterals, solutions, creams, ointments, and transdermal dosage formulations to improve patient adherence and ameliorate AEs, such as constipation, nausea, gastrointestinal issues, and sedation.9
Because palliative care regimens are highly individualized to meet each patient’s needs, integrating a pharmacist into the interdisciplinary team is vital to achieving a patient’s care goals. Body kinetics and volume of distribution are altered in patients in end-of-life care. Pharmacists have a unique knowledge base for optimizing patient care while reducing AEs and toxicity.10 Specific characteristics of a patient affect his or her pain. Patients in palliative care typically require higher doses of opioids. This results in greater stimulation of mu-receptors and, in turn, increases activation of delta and kappa receptors, contributing to increased AEs. In addition, fentanyl patches in patients with cachexia may provide less pain relief due to protein binding and low subcutaneous fat stores.11
Gastrointestinal issues may develop secondary to many chronic conditions (eg, advanced cancer, neurologic disorders).12 Constipation is one of the most common problems patients experience at the end of life. The cause can be as simple as dietary alterations or the inability to ambulate or exercise. Severe discomfort and pain from constipation may cascade into an unrelenting decline in a patient’s quality of life, requiring pharmacologic intervention.13 Privacy issues during toileting and the inability to complete defecation without assistance may progress as a chronic disease worsens.
Pharmacists can play an important part in preventing and managing the symptoms of constipation, such as bowel obstruction, dehydration, loss of appetite, mobility issues, and medication AEs.12 Many nonpharmacologic approaches (eg, dietary changes, avoidance of negative environmental stimuli, behavioral measures such as relaxation) may assist patients without adding to the pharmacologic burden.
Nausea and vomiting are frequently reported because medications and chronic illnesses stimulate different mechanisms and receptors in the body7 (Table 17,14).
As patients cope with their illness and chronic pain, anxiety and depression are often comorbid conditions. Distinguishing between grief and depression is essential in determining appropriate pharmacotherapy. Many pharmacologic options (eg, benzodiazepines, anxiolytics, antihistamines, antidepressants) are available to assist with symptoms of anxiety and depression. By carefully interviewing patients, pharmacists can delineate the most appropriate therapeutic class to use. Evaluation of life expectancy is critical because some medications take many weeks of use to produce the desired therapeutic effect, possibly resulting in minimal patient benefit.
The Interdisciplinary Team
In collaboration with the interdisciplinary team, the pharmacist must assess the needs of each patient, including family dynamics and spirituality, to select the best method of treatment.15 This team may include a spiritual counselor, nurses, physicians, caregivers, and volunteers.16
Tapering or Discontinuing Medications
Appropriateness of therapy should be evaluated in regard to a patient’s anticipated life expectancy.17 Research shows that discontinuing certain medications in elderly patients and those in palliative care does not worsen outcomes, but can actually reduce the risk of AEs and decrease patients’ overall costs.18 Pharmacists can de-escalate medications by eliminating long-term medications that do not show immediate benefit to elderly patients and those in palliative care. As treatments centered on comfort and quality of life become a greater priority, many common long-term medication therapies may require reevaluation for patients in palliative care 3 (Table 23,19). Antihypertensive medications, for example, can be lifesaving; however, for patients receiving palliative care, the AEs (ie, fatigue and orthostatic hypotension) should be considered on an individual basis. It may be more appropriate to taper or discontinue these medications than to continue them.19
Counseling by pharmacists can bridge the knowledge gap for patients and caregivers to prepare them for possible discontinuation of long-term medications. Pharmacists within the interdisciplinary team can help patients and their families understand the risks and potential dangers of these medications. Some drugs may not be beneficial for sustaining life or providing comfort at the end of life, but may increase AEs.
Improving patients’ quality of life during the transition into palliative care is an essential goal of the interdisciplinary team. As the pharmacist’s palliative care role continues to evolve, pharmacists need to step out of their comfort zone. Patients need to be assessed and treated appropriately, which may require using dosages and medications to which pharmacists are unaccustomed.
Each patient’s dignity and comfort are always at the center of any care plan. As pharmacists, we should do what we can to make the last days of our patients lives as good as possible. There is never a more pressing time for palliative care pharmacists to advocate for their patients.
Jerry Barbee, Jr, PharmD, BCPS, CPh, is a clinical pharmacist at HCA West Florida Hospital. Suzanne Kelley, is a hospice clinical pharmacist. Jessica Andrews is a 2017 PharmD candidate at the University of Florida. Amanda Harman is a 2017 PharmD candidate at Mercer University.
- World Health Organization. Cancer. World Health Organization website. http://who.int/cancer/palliative/definition/en. Accessed August 16, 2016.
- Demler TL. Pharmacist involvement in hospice and palliative care. US Pharmacist. 2016;41(3):HS2-HS5.
- Gokula M, Holmes HM. Tools to reduce polypharmacy. Clin Geriatr Med. 2012;28(2):323-341. doi: 10.1016/j.cger.2012.01.011.
- The American Geriatrics Society Foundation for Health in Aging (AGSFHA). 2012 American Geriatrics Society Updated Beers Criteria. AGSFHA website. americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf. Accessed August 16, 2016.
- Masman AD, van Dijk M, Tibboel D, Baar FP, Mathôt RA. Medication use during end-of-life care in a palliative care centre. Int J Clin Pharm. 2015;37(5):767-775. doi: 10.1007/s11096-015-0094-3.
- Del Fabbro E. Palliative care: assessment and management of nausea and vomiting. UpToDate website. uptodate.com/contents/palliative-care-assessment-and-management-of-nausea-and-vomiting. Accessed August 23, 2016.
- Glare P, Miller J, Nikolova T, Tikoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging. 2011;6:243-259. doi: 10.2147/CIA.S13109.
- Giving meds by alternative routes. Pharmacist’s Letter/Prescriber’s Letter. February 2015. Detail-document#: 310208.
- Walker KA, Scarpaci L, McPherson ML. Fifty reasons to love your palliative care pharmacist. Am J Hosp Palliat Med. 2010;27(8):511-513. doi: 10.1177/10049909110371096.
- National Collaborating Centre for Cancer (UK). Cardiff (UK). Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. May 2012.
- McPherson ML. Demystifying Opioid Conversion Calculations: A Guide for Effective Dosing. Bethesda, MD: American Society of Health-System Pharmacists; 2010:97-98.
- Erichsén E, Milberg A, Jaarsma T, Friedrichsen MJ. Constipation in specialized palliative care: prevalence, definition, and patient-perceived symptom distress. J Palliat Med. 2015;18(7):585-592. doi: 10.1089/jpm.2014.0414.
- Goodman M, Low J, Wilkinson S. Constipation management in palliative care: a survey of practices in the United Kingdom. J Pain Symptom Manage. 2005;29(3):238-244. http://dx.doi.org/10.1016/j.jpainsymman.2004.06.013.
- Baines MJ. ABC of palliative care. nausea, vomiting, and intestinal obstruction. BMJ. 1997;315(7116):1148-1150.
- Thompson CA. Palliative care pharmacists consider patients' psychosocial issues. Am J Health Syst Pharm. 2008;65(6):500, 502. doi: 10.2146/news080024.
- National Hospice and Palliative Care Organization (NHPCO). The hospice team. NHPCO website. caringinfo.org/i4a/pages/index.cfm?pageid=3357. Accessed August 16, 2016.
- Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166(6):605-609. doi: 10.1001/archinte.166.6.605.
- Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use processes. J Am Geriatr Soc. 2008;56(10):1946-1952. doi: 10.1111/j.1532-5415.2008.01916.x.
- Allen R. 10 drugs to reconsider when a patient enrolls in hospice. NHPCO NewsLine website. nxtbook.com/mercury/nhpco/Newsline_201405/#/14. Published May 2014. Accessed August 16, 2016.