US Pharm. 2016;41(3):HS2-HS5.
ABSTRACT: Specialty pharmacy practice has become an increasingly popular career pathway for new practitioners; established generalist pharmacists, however, may believe that developing a niche therapeutic focus is impractical or unattainable. Hospice and palliative-care practice requires health professionals who not only seek to provide care to patients with end-of-life challenges, but also are able to deliver such care with the proper degree of empathy toward the patient, family, and caregivers. Pharmacists desiring to serve this population can be assured that there are resources that can help them obtain the clinical skills necessary to function in this professionally and personally rewarding practice environment.
The number of patients in need of hospice and palliative care continues to grow, as do the general population’s knowledge and awareness of the diagnosed conditions that render patients eligible for hospice care services. Consequently, as the need for hospice care for patients who meet eligibility requirements because of a life-limiting or life-shortening condition (e.g., chronic obstructive pulmonary disease and congestive heart failure) becomes more widely known and accepted, it is anticipated that increasingly more people will seek these services for themselves or a family member.
Hospice services begin with a plan of care that the patient, along with his or her family, develops in concert with the interdisciplinary hospice team. The care plan is designed to enable the person to achieve the highest possible quality of life for himself or herself and family members. This is achieved through a combination of medical and pain-management services and emotional and spiritual support provided by members of the interdisciplinary team, either in the person’s home or in a long-term care facility, nursing home, or inpatient facility.
Pharmacists have long served as volunteer consultants to hospice care services, but increasingly they are becoming integrated into the interdisciplinary team as key members who are paid and respected for their services. Pharmacists, particularly those with special training or experience in palliative care, bring added value to the services provided by hospice by counseling the patient in care, updating and educating the team regarding medications, and working with the team—particularly nursing staff—to closely monitor therapeutic responses.
Medicare is a primary funding insurance provider, so patients can be reassured that these services are covered and encouraged. Studies show that many patients receiving hospice care live beyond their original predicted life expectancy, owing in part to hospice’s care for the whole person, which includes not only palliative pain relief, but also improved nutrition and spiritual support.1
The explosion of new drugs to market, along with the drugs’ complexity and the disease-state challenges to which each patient population is susceptible, reinforces the recognized need for pharmacists who have specialty training and expertise in palliative care. It also points to the need for clinicians who have strong clinical skills in diverse disease states, in order to provide complete and comprehensive medication therapy management (MTM). In the hospice environment, the pharmacist plays a number of key roles including, but not limited to, those described here.
Appropriate Medication Use
Pharmacists must continually assess the appropriateness of medication orders and ensure that the patient receives safe and effective care in a timely manner.2 For patients with pain and other end-of-life medical and psychiatric comorbidities, effective and properly applied MTM can prevent stressful, potentially unnecessary emergency department and urgent care visits. Pain medications—especially the opiates—are subject to numerous sound-alike/look-alike (SALA) name pairs, which can cause dangerous medication errors resulting in serious harm or death. Pharmacists practicing in palliative-care settings are generally more aware of these potential sources of error as they emerge; they can assist in developing strategies to mitigate and reduce SALA errors and can help ensure regulatory compliance with MTM standards of the Joint Commission and other accrediting agencies that require quality-assurance measurements and benchmarking.2
Hospice pharmacists are particularly skilled at recommending dosage conversions to forms that allow for more effective pain management and reduce serum concentration peaks and troughs, thus lessening breakthrough pain and alleviating patient suffering. Conversion of these dosage forms requires knowledgeable providers who can calculate the appropriate dosing and frequency when transitioning from short-acting to long-acting agents and when using morphine equivalents to switch opiate products (TABLE 1).3 In most cases, dose reductions are necessary when products are changed, since cross-tolerance cannot be assured and excessive side effects would otherwise be likely.2
The use of complementary and alternative medication has become a more common and popular treatment option for many patients. Often, cultural factors play a role in the use of these holistic treatments, as does a patient’s perception of last-resort options when facing a terminal illness. Hospice pharmacists can help predict and evaluate not only potential drug interactions with traditional medication regimens, but also the anticipated decline in organ function as the patient’s physical condition worsens over time.2
Consultation and Education
Throughout the spectrum of treatment, hospice and palliative-care pharmacists can evaluate medication treatment options based on cost, side effects, and emerging safety information.2,4 Medication shortages have become a daily complication for everyone involved in the provision or use of medications, including patients; however, when a shortage requires a search for alternatives, the pharmacist can alleviate stress by seeking appropriate substitutions. As part of the treatment team, the pharmacist may also engage in constant surveillance for insurance coverage, formulary restrictions, and prior authorizations required to initiate or continue a specific regimen that otherwise would not be covered by an insurance company. The cost may refer to the overall medication price, but it may also be based on tiered formulary placement, which leads to lower costs if less expensive alternatives—including, but not limited to, generic medications—are selected. Hospice care is generally covered by Medicare; however, when a patient is not covered by Medicare or another insurance plan and does not have sufficient funds to cover the cost of care, the pharmacist can often secure medication supplies allotted to indigent patients.2,4
Medication adherence is a challenge across the spectrum of care; however, the presence of pain fosters a greater incentive for the patient to be adherent to his or her medication regimen in order to control the pain.2,4 Adherence issues may arise if there are misunderstandings about instructions, if the patient fears the stigma of addiction and/or dependence, or if cost is a factor (which drives the patient to improperly divide or change the regimen to make the supply last longer). When a patient’s care is transitioned to caregivers, issues of nonadherence can be even greater, so constant education and information reinforcement are key to overall palliative-care management. Gaps in health literacy, language barriers, and complex medication directions, including unclear labeling, not only result in an increased risk of medication errors, but can also lead to inappropriate symptom management.2,4
Patients with chronic pain are four times more likely to experience depression. Pharmacists can remind prescribers, patients, and family members to be vigilant in detecting emerging behavioral or mood symptoms. Hospice pharmacists are well positioned to make recommendations about medication options that can effectively address symptoms concurrent with pain (e.g., depression, sleep disorders, and anxiety), such as tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors.
It is important to keep in mind that some patients have concurrent diseases that require the avoidance of certain medications, such as bupropion in patients with seizure disorders or certain selective serotonin reuptake inhibitors in patients with prolonged QTc intervals.2,4 Pharmacists on hospice teams can make recommendations for amelioration of primary pain disorders while also managing side effects.
Another area in which hospice pharmacists can play a significant role is helping the team navigate MTM scenarios of true allergy versus pseudoallergy. In many cases, opiate therapy can result in pruritus and allergy-like dermatologic symptoms. Often, these symptoms are related to the histamine-release phenomenon to which any patient is susceptible, whether allergic or not. If the prescriber, patient, and family believe that this is an allergic reaction, the patient may not receive optimal pain intervention. Pseudoallergic symptoms can be mitigated with the use of antihistamine products or by lowering the dosage. Pharmacists who are skilled in the differences between pure, natural opiates and semisynthetic or synthetic opiates may offer a truly allergic patient suggestions for careful rechallenge or reintroduction.2,4
Medication Preparation and Dispensing
Patients diagnosed with a terminal illness often require nonstandard doses that are not available commercially, so pharmacists caring for hospice patients may need to compound products to meet individual patients’ unique needs.2 This may include formulating preparations that are flavored to overcome undesirable characteristics or producing dosage forms with alternative ingredients and/or excipients to avoid allergic reactions or progressive intolerances. Pharmacists can often recommend dosing devices that help patients and caregivers deliver the proper dose of highly potent medications. Such devices might not otherwise be readily available to patients in the community. Most palliative pain medications are controlled substances and are registered among the most highly controlled Schedule II drugs. The increased surveillance and monitoring now in place for tracking the prescribing and use of controlled substances (prescription monitoring programs) can disrupt the continuity of care and increase stress and frustration for patients, families, and caregivers. Hospice pharmacists are well positioned to help patients navigate the challenges of controlled-substance logistics and may ultimately reduce potential negative events and experiences.2
Logistics and Legal Aspects of Practice
For hospice and palliative care, the logistics and legalities of practice differ significantly from state to state. The following interviews with two hospice pharmacists in different regions of the United States illustrate some of these differences. Robert G. Wahler, PharmD, is former Pharmacist Section Leader of the National Council of Hospice and Palliative Professionals of the National Hospice and Palliative Care Organization; Clinical Assistant Professor at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences in Buffalo, New York; and Director of Clinical Pharmacy Services at Niagara Hospice in Lockport, New York. Wayne H. Grant, PharmD, is Clinical Pharmacist at Hospice of the Western Reserve in Cleveland, Ohio.
Q: What is the practice setting at your hospice organization?
Dr. Wahler: Niagara Hospice has an average daily census of roughly 140, with a 10-bed acute inpatient and 10-bed residential Hospice House. We also have dedicated hospice wings at three area nursing homes. My role is generally that of a consultant. I oversee the pharmaceutical care of the patients in Hospice House. For those patients not in Hospice House, our model is that if a nurse identifies an uncontrolled symptom, he or she consults me prior to contacting the primary medical doctor (PMD) for an order.
Dr. Grant: Our nonprofit agency cares for more than 1,100 patients located in northeastern Ohio. Staffed with physicians, nurses, social workers, spiritual care providers, nursing assistants, and a host of supportive staff, we have a strong presence within our region.
Our patients live in three different settings: home, alternative home, or inpatient unit (IPU). Within the home care environment, patients receive medications delivered from a local pharmacy, while patients in alternative home care (nursing home, assisted living, transitional care unit) receive pharmacy services from the long-term-care pharmacy provider. We have IPUs that are a mix of symptom-controlled beds and residential beds. All hospice care provides palliative care, while palliative care combines symptom control with traditional medical management. Palliative care aids with symptoms that are induced by treatment or disease. A patient or provider will request an advanced practice nurse or nurse practitioner to make a visit, consult with the provider, and make recommendations for therapy if warranted. We also provide care for hospice and palliative-care pediatric patients.
Q: What are some of the challenges you face?
Dr. Wahler: Many PMDs have little to no background in palliative care. Since we are skilled in palliative care, we can provide recommendations that are patient-specific and at an advanced palliative-care level. Not only for a drug, but also for drug product and administration, since these areas become an increasing concern as our patients decline.
Dr. Grant: End-of-life care seeks out a different approach than what most patients would be used to. It is holistic in nature; clinical, social, and spiritual relevance are integrated prior to medical recommendations.
Collaborating with discharging hospitals is imperative, as patients may be on drug therapies such as total parenteral nutrition, dobutamine infusions, and IV antibiotics. Pharmacists evaluate outcomes such as appropriateness, duration, and tolerability and aid with the transition of care from the hospital to the IPU or other home environment. This requires knowledge of complex drug regimens and how best to meet the patient’s goals of care.
Q: What are some opportunities you would like new practitioners and other pharmacists to be aware of?
Dr. Wahler: We are given the challenge of controlling very difficult symptoms that don’t have very good medication choices. Many of the end-of-life symptoms that we see are not part of distinct diseases, so applying medications to these symptoms often needs to be done without the benefit of peer-reviewed evidence or treatment guidelines. For example, as patients decline, delirium—including hallucinations, delusions, and behavioral disturbances—becomes very common. Unfortunately, the knee-jerk reaction is to give a benzodiazepine, which often worsens the syndrome. Because of their status as potentially inappropriate medications under the Beers Criteria, appropriate use of antipsychotic medications has many hurdles. And even their use is often the best that we can do, even though the medications may provide only a marginal benefit.
Also, although we’ve had very good response rates to our recommendations, there are still many clinicians whose fear of using opioids often denies our patients appropriate and timely medications. We provide extensive outreach in the way of education, yet I believe that since they still don’t have the comfort level that comes with using opioids, some prescribers are still wary of using opioids, especially in our current atmosphere of opioid misuse and abuse. Our patients suffer from the sometimes overzealous application of regulations and laws; however, with our advocacy, this provides opportunities for better treatment outcomes.
Dr. Grant: Advocacy opportunities occur in all pharmacy practice settings, including end-of-life care. Working individually or collaboratively with a state hospice association, pharmacists are engaged with state and federal congressional representatives in various ways. Interested-party committees, testimony, or congressional visits are offered to hospice pharmacists. A recent example of such work had required testimony on how hospice organizations spend considerable effort protecting the general public from illicit opioid use while aggressively managing the symptoms associated with a terminal illness.
Further, our agency worked on a house bill that requires a hospice organization to have established procedures for decreasing the diversion of opioids. Working in tandem with a state hospice organization, pharmacy services collaboratively gave support for the use of a tamper-resistant formulation for an extended-release hydrocodone.
Clinical pharmacy in end-of-life care is dedicated to providing appropriate choice, education, and research in order to minimize physical discomfort while enhancing quality of life.
The Role of the Pharmacist
Clinical pharmacy practice now offers increased specialized practice opportunities, but it must be an appropriate “personal fit” for the pharmacist who pursues such practice.5,6 Not every pharmacist is suited to end-of-life care; however, many of those who choose this area of practice find that the personal and humanitarian rewards of comforting people in their last days cannot be paralleled. According to Dr. Wahler, professional satisfaction is also high, with “acceptance rates of clinical recommendations around 90% and management support with pharmacist services in hospice paying for the cost of the pharmacist and then some.”5,6
A group of palliative care pharmacists, including Dr. Wahler, have submitted a paper that will update the ASHP’s (American Society of Health-System Pharmacists) 2002 statement on the pharmacist’s role in hospice and palliative care.4,7 This update describes the varied roles pharmacists can play in hospice and palliative care, ranging from dispensing to administrative to clinical, and the many combinations of these. The update also describes the basic foundation in palliative care all pharmacists should have in order to be considered a palliative-care specialist. According to specialists already in practice, new practitioner pharmacists should consider the postgraduate year 2 (PGY2) residency as the best route. However, pharmacists who have been practicing without a Doctor of Pharmacy degree or a residency may find that organizations of the ASHP and the American Society of Consultant Pharmacists offer pain-management certificates that may help them navigate the path to practicing in this specialty environment.
Specialty pharmacy practice is an attainable career goal for even established generalist pharmacists. For those who have an interest in helping hospice patients and are skilled in providing palliative care recommendations with the appropriate degree of empathy, this can be a very rewarding professional endeavor. Pharmacists desiring to care for this population can be assured that there are opportunities to obtain the necessary clinical skills through continued professional development.
1. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363:733-742.
2. American Society of Health-System Pharmacists. ASHP statement on the pharmacist’s role in hospice and palliative care. Am J Health Syst Pharm. 2002;59:1770-1773.
3. Von Korff M, Saunders K, Thomas Ray G, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24:521-527.
4. Lohman D, Schleifer R, Amon JJ. Access to pain treatment as a human right. BMC Med. 2010;8:8.
5. Wilson S, Wahler R, Brown J, et al. Impact of pharmacist intervention on clinical outcomes in the palliative care setting. Am J Hosp Palliat Med. 2011;28:316-320.
6. Motiwala S, Wahler RG, Paladino J. Clinical pharmacy services in hospice care: a cost benefit analysis. Poster presented at: 19th Management and Leadership Conference of the National Hospice and Palliative Care Organization; September 30-October 2, 2004; Washington, DC.
7. Herndon CM, Nee D, Atayee RS, et al. Pharmacist’s role in palliative and supportive care. Am J Health Syst Pharm. In press.
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