has been said that disease is a confrontation, a triumph over which is merely
a reprieve from the inevitable end.1 Death, on the other hand, may
be viewed as a simple event occurring in sequence of nature's ongoing flow.
1 While accurate and eloquently stated, that simple event can be quite a
harrowing experience for patient and family alike.
In the United States, the
majority of deaths occur in the geriatric population.2 Seniors
often develop multiple chronic medical problems and endure complicated medical
courses.2 Furthermore, there is the condition of frailty associated
with symptomatic long-term disease, decline in function, and abbreviated
survival.3 The application of multidisciplinary, team-based
palliative approaches, in conjunction with up-to-date geriatrics knowledge,
can be beneficial in the treatment of the frail elderly in light of the
complexity of their coexisting medical, psychological, and social needs.3
While the aging
process varies among individuals, for most seniors the decline in organ
function does not affect the body's function during normal daily activities;
only when a very demanding task is attempted or when a disorder develops do
patients usually notice the decline.4 Many clinicians recognize
frailty in older adults as a syndrome of decline in function and health with
clinical features including loss of strength, low levels of activity, slowed
performance, poor endurance or fatigue, and weight loss.3 While
this condition may be controlled by available approaches to care, the presence
of three or more of these features has been associated with adverse outcomes,
including new or worsened function impairment, falls, hospitalization, and
death.3 Clearly, when frailty is severe, it is highly appropriate
to deliver palliative care focused on relief of discomfort and optimal quality
Many seniors, as well as family
members and caregivers, are not aware of or presented with the options and
services available to assist with end-of-life care.5 It is
important, therefore, to ensure providerñpatient/caregiver communication in
the care of the frail elderly and to discuss advance care planning, palliative
care, and hospice referral.3 Families should discuss and complete a
living will and health care proxy before a palliative plan is necessary, since
many dying patients are too ill to communicate their wishes at the time an
end-of-life care plan is proposed.6,7
Goal of Palliative Care
Palliative care physicians require
skill to address the needs of frail seniors with life-limiting illness as they
approach the end of life.2 It is important for clinicians to
embrace the concept and importance of allowing a dying patient, and his or her
family members, control and participation in end-of-life care.5
While pain and management of symptoms (TABLE 1) appear obvious in terms
of importance to the dying patient, reports indicate that other issues rank
important as well, including communication about treatment decisions,
preparation for death, achieving completion, contributing to others, and being
known as a whole person.8 Despair and hopelessness may result if
spiritual distress is not resolved, further contributing to anxiety and
depression; in some cases suicide may ensue.6 Therefore, effective
palliative care requires a broad multidisciplinary approach for the care of
individuals with a wide variety of illnesses who have reached the stage where
focus shifts from cure to comfort. Additionally, this approach involves the
family and makes use of available community resources.
According to clinical practice
guidelines published by the National Consensus Project for Quality Palliative
Care, the goal of palliative care is "to prevent and relieve suffering and to
support the best possible quality of life for patients and their families,
regardless of the stage of the disease or the need for other therapies"; this
includes effective pain and symptom management, as well as psychosocial and
spiritual care of the patient and the family.9,10
The World Health Organization
(WHO) provides further elaboration by indicating that palliative care affirms
life and regards dying as a normal process; it intends neither to hasten nor
postpone death.11 The WHO offers support systems to help patients
live as actively as possible until death and to help the family cope during
the patient's illness and in their own bereavement.11 Through these
services, the WHO notes an enhanced quality of life and the potential for a
positive influence on the course of an illness. Palliative care is applicable
early in the course of illness, in conjunction with other therapies
that are intended to prolong life (e.g., chemotherapy or radiation therapy),
and includes investigations needed to better understand and manage distressing
clinical complications.11 Usually led by the physician, the
interdisciplinary team also includes nurses, social workers, pharmacists,
dietitians, clergy, volunteers, friends, and patient advocates.
Geriatric Palliative Care
knowledge organizes patients by disease, one disease per patient, and most
health care provision organizes patients by program/site, one site at a time.
8 Excellence in end-of-life care, however, requires integrating for
multiple diseases (i.e., comorbidities as seen in many geriatric patients) and
for multiple programs/sites (e.g., hospital, home, assisted-living facility
[ALF], nursing home).8 While an emphasis on optimizing quality of
life and function are common to geriatrics and palliative medicine,
geriatric palliative care is distinct in its focus on the geriatric
syndromes (e.g., frailty and failure to thrive, falls, dizziness, syncope,
delirium, sleep disorders, incontinence, pressure ulcers, disorders of
temperature regulation) and on the provision of care in a variety of care
settings.2 It is essential to have expertise in the diagnosis and
management of the geriatric syndromes and in the complexities of various
long-term care settings in order to provide high-quality palliative care to
Furthermore, some frail
elderly adults do not require a nursing homeñlevel of care and choose to
reside, and ultimately to die, in ALFs, as they consider this setting to be
their home.12 Theoretically, dying in place with the assistance of
a palliative care program in the ALF can be part of the aging-in-place
continuum. Experts note, however, that given the diversity of state
regulation, settings, services, and the ability and willingness of staff,
adopting this approach in the ALF setting will require much collaboration.
Palliative care is considered
"upstream" if it is introduced when a chronic condition is initially diagnosed
and thus provided in a noninstitutional setting throughout an individual's
life and disease course, including appropriate curative interventions.12
Indicators of quality palliative care are: advance care planning, pain and
symptom management, interdisciplinary involvement, care planning, staff
education, and quality of life.12 Those working in the arena of
palliative care strive to make it available across all treatment settings to
benefit persons with life-limiting illness.8
A hospice program provides support
services to patients and their families, in addition to noncurative medical
treatment for patients with terminal illnesses and a life expectancy of six
months or less.5 Most hospice patients receive care in their homes
where they feel most comfortable. However, many hospice patients continue to
reside in the nursing home setting or assisted living residences; a smaller
number receive services while still in the hospital.
Pharmacists can assist
appropriate individuals in availing themselves of a hospice program,
especially by enrolling in a timely fashion, to benefit by the comprehensive
services provided. Data illustrate that recommendations by hospice
pharmacists, as well as clinical interventions, significantly help patients
achieve positive outcomes that affect quality of life.13
A recent study released in the
New England Journal of Medicine reports a method to improve communication
(i.e., set of communication guidelines for family conferences) between
clinicians in the intensive care unit and family members of a dying patient.
14,15 The researchers reported this method significantly reduces
feelings of stress, anxiety, and depression in family members and allows them
to express their emotions and arrive at a more realistic expectation of the
Untreated pain may manifest in a
variety of ways, including refusal of care (i.e., physical assistance or
handling of the patient may exacerbate pain), agitated behaviors, depression,
anxiety, and insomnia.16 Quality care requires regular assessment
of pain intensity. This is done over time to grasp and understand the
individual variables that exacerbate pain and promote pain relief in an
individual patient. This concept has driven the phrase "fifth vital sign,"
referring to pain and the need for its ongoing assessment.
To control persistent pain,
analgesic medication should be dosed on a regular, round-the-clock basis; this
additionally helps to avoid anxiety associated with the anticipation of pain.
To relieve breakthrough pain, escalating pain, or an exacerbation of a
preexisting morbidity that may contribute to the underlying pain, a rescue
as-needed (prn) order is recommended as part of the palliative analgesic
regimen. Monitoring the use of rescue prn medications is an integral component
of the ongoing pain assessment process, enabling the clinician to recalculate
an appropriate and adequate round-the-clock palliative dosage regimen for
comfort. Patients who are cognitively intact may effectively participate in
their own treatment by using prescribed patient-controlled analgesia.8
A critical part of quality pain management is managing adverse effects,
including anticipating and preventing them (e.g., constipation, excessive
sedation, which may lead to respiratory depression).10 Relieving
and preventing the patient's physical and emotional symptoms is a priority
because this enables the team to focus on addressing the patient's religious
and spiritual needs.6,17
Classic clinical practice
guidelines for selecting analgesic therapy include:
1. select the
appropriate analgesic medication;
2. prescribe the
3. administer via the
4. schedule the
appropriate dosing interval;
5. prevent persistent
pain and relieve breakthrough pain;
6. aggressively titrate
the dose of the medication;
7. prevent, anticipate,
and manage the side effects of the drug;
8. consider a
sequential trial of analgesics; and
9. use appropriate
The Role of the Pharmacist
According to the highlights of the
2006 American Society of Health-System Pharmacists (ASHP) Midyear Clinical
Meeting, programs supported the continuum of care in pain management and
palliative care as presenters described opportunities for pharmacists to work
not only within their current practice setting, but collaboratively with
colleagues in other environments.10
A position paper published by
the ASHP on "The Pharmacist's Role in Hospice and Palliative Care" may be
employed as a reference for those pharmacists interested, or currently
practicing, in not only palliative care and hospice but pain management as
well.10,19 The outlined roles include:
1. assessing the
appropriateness of medication orders and ensuring the timely provision of
effective medications for symptom control;
2. counseling and
educating the hospice team about medication therapy;
3. ensuring that
patients and caregivers understand and follow the directions provided with
4. providing efficient
mechanisms for extemporaneous compounding of nonstandard dosage forms;
5. addressing financial
6. ensuring safe and
legal disposal of all medications after death, and;
7. establishing and
maintaining effective communication with regulatory and licensing agencies.
Summary and Conclusion
individuals view palliative care as an absence of care approach, it is
actually compassionate, integrated care that offers a multidisciplinary team
approach to address the medical, psychological, and social needs of patients
and their families. Pharmacists may assist in this effort by raising awareness
and participating in the services and options available to assist with
end-of-life care when the focus shifts from cure to comfort. Data illustrate
that pharmacists involved in end-of-life palliative care, through their
recommendations and clinical interventions, significantly help patients
achieve positive outcomes that affect their quality of life.
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3. Boockvar KS, Meier DE. Palliative
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www.nationalconsensusproject.org. Accessed December 28, 2006.
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Palliative care is an essential part of cancer control and can be provided
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