Pharmacists Play a Dynamic Role in End-of-Life Care
The role of the pharmacist in end-of-life care spans across multiple realms, including compounding and dispensing, administrative, educational, and clinical, according to Allison Baxley, PharmD, BCOP, who works in the cancer center at the University of Oklahoma Health Sciences Center in Oklahoma City. Her presentation at Great Debates & Updates Oncology Pharmacy addressed the various facets involved.
Typically, medication preparation and dispensing centers around the symptom management, Dr Baxley explained. End-of-life care may require controlled substances and restricted-access medications with barriers to off-label use. Pharmacists assist in securing them, as well as in compounding for alternate dosage forms such as patient-controlled analgesia pumps or vaginal, rectal, topical, or buccal routes. Amid drug shortages or discontinuations, pharmacists can help identify alternative options for patients, while at the same time serving as an important resource for community providers caring for patients at home.
Since cancer-related pain and hospice medications may require expanded formularies for certain drug classes, pharmacy professionals are involved in formulary management. Other administrative areas that call for pharmacist input include therapeutic substitution policies, medication-use policies and procedures, opioid standards and safety, safe medication disposal, and medication-use algorithms, according to the presentation.
Pharmacists will need to introduce the fields of palliative care, and its subset of hospice care, to pharmacy students and ensure they understand the difference. (Palliative care ideally begins at diagnosis concordant with treatment, Dr Baxley coached, while hospice care starts when efforts to cure disease are stopped and patients have a life expectancy of 6 months or less). The domains of education and advocacy also include engagement in professional organizations, training colleagues, and caring for oneself to avoid compassion fatigue.
On the clinical side, pharmacists should encourage early involvement of palliative care, which the National Comprehensive Cancer Network considers the “optimal management of distressing symptoms, while incorporating psychosocial and spiritual care” that aligns with patient and caregiver values and beliefs. Pharmacists may find themselves communication intermediaries between patients and providers, patients and caregivers, or among multidisciplinary care team members. Of course, treatment adjustments and management of adverse events are key clinical duties of the pharmacist.
“While a pharmacist’s role often encompasses supportive care and management of toxicities when patients are actively on cancer treatment therapy, this may shift as the patient care plan progresses and changes,” Dr Baxley advised, “in response to disease that no longer responds to treatment, patient desire to stop therapy, [or] unacceptable toxicity/worsening performance status.”
Once treatment has ended, pharmacists can assist in finding uncommon or unique medications for symptom management. Additionally, familiarity with medical aid in dying guidelines, as well as ensuring safe disposal of medications after patient death, are important pharmacist responsibilities in end-of-life settings, the session explained.
