The Palliative Care Interdisciplinary Team: Where Is the Community Pharmacist?

Context

In Australia, palliative care services are provided in designated palliative care units such as hospices, in dedicated and nondedicated palliative care beds in acute hospitals, and in the community^14,15 where palliative care patients receive care in their own home or other community living facilities such as aged care facilities. ¹⁶ This reflects the shift in health care provision from hospital-based care to “hospital in the home,” ¹⁷ which has been supported by family and community primary health care professionals for some time in Australia ¹⁸ and underpins the impetus for the Guild's initiative to increase the role of the community pharmacist in palliative care. Patients in the community may move in and out of other settings at different times during the course of their illness but the majority of care is in the community. Ninety percent of patient care in the final year of life occurs at home, ¹⁹ with many people moving to an inpatient setting only in the final days of their life. Ill children, in particular, prefer to remain at home whenever possible, and parents need ongoing interdisciplinary support throughout their child's illness trajectory.^20,21

Dying at home has been identified as the preferred care option for approximately 58% of people ²¹ but less than a third of adults actually die at home.^23,24 Predictors for home death in palliative care patients is associated with the availability of one or more carers, the patient's and carer's desire for death at home and, importantly for the argument presented in this paper, the availability of skilled primary care support in the community.^25–27

Certainly, providing in-home care for people at the end of life offers a number of benefits, most importantly maintaining quality of life and a sense of control over one's illness. ²⁸ Community care can also offer significant economic benefits, with economic modelling suggesting that end-of-life care provided in a home setting is a cost-effective method of service delivery. ²⁹ However, community care delivery has become increasingly complex, with more patients receiving comprehensive care in the home setting. As a result, much of the burden of caring is managed in the community, with the greatest burden falling to primary caregivers to provide care that may be complex and time consuming.^30,31

An additional contextual factor is the strong impetus for palliative care to be instigated at the time of diagnosis of a life-threatening illness ³² and to continue over the course of the illness. ³³ Thus, researchers and practitioners are considering approaches other than the medical model of care, which is focused on the terminal stage of illness. For instance, Salau, Rumbold, and Young ³⁴ draw upon public health approaches and recommend a palliative care approach that builds the capacity of local communities in supporting people living with chronic illness nearing end of life. Given that community pharmacies are recognized as stable delivery points for health care services in their local communities, such an approach would provide an ideal context for community pharmacists to contribute to community-based palliative care.

In Australia the provision of care in the community is complicated by two key factors. First, the capacity of GPs to provide care is already stretched; there is an insufficient number of GPs, particularly in rural and remote areas, and GPs are working fewer hours. GPs are also caring for an increasing number of patients with chronic diseases (often multiple morbidities) with complex care needs. ³⁵ Second, a declining death rate and increasing life expectancy for both sexes ³⁶ contribute to an aging population, which is increasingly characterized by multimorbidity.^14,37 Twelve-and-a-half percent of people were aged over sixty-five years in 2001 and it is estimated that this will rise to 25% by 2052. ³⁸ Inevitably, the number of people with chronic and/or life-threatening diseases will increase and, as a result, so will the number of patients requiring palliative care. The resulting demand on primary care will be marked, giving further support to enhancing the role of the community pharmacist in palliative care.

The Pharmacist in Primary Care

Visiting a pharmacist is convenient for most people, even those who have limited access to private or public transport ³⁹ and around 90% of the population sees a pharmacist at least once every year.^40,41 Community pharmacists are also easier to access than other primary care providers, especially after many GPs' surgeries close ⁴² and it is not usually necessary to make an appointment to obtain medication or advice. As such, the community pharmacist is likely to encounter palliative care patients and their carers and to be providing medication to patients receiving home-based palliative care. ⁴² Hence, community pharmacists are well-positioned to provide locally based primary care services.

A number of potential roles for the pharmacist in the general primary care arena have been developed and evaluated (including involvement in managing chronic conditions).^43,44 This expansion of the community pharmacist's role has been a focus of interest internationally since the 1990s when an editorial in the British Medical Journal outlined the advantages of greater integration of community pharmacists into the primary health care team. Research findings strongly suggest that pharmacists' health knowledge is underused. ⁴¹ In response, the Department of Health (DoH) ⁴⁵ in the United Kingdom introduced a program for pharmaceutical public health. This DoH report highlights the pharmacist's role in supporting people with long-term chronic and acute health conditions. The pharmacist's potential contribution includes providing information regarding the effective use of medicines and medication management, support for self-managed care, and disease specific care management information and strategies. The report emphasizes working in partnership with other health care professionals and community leaders and the necessity for community pharmacists to be part of interdisciplinary care teams.

The Australian Government Department of Health and Ageing (DoHA) and the Guild recognize that with training and support community pharmacists can have an expanded role in helping patients self-manage chronic conditions and/or improve their medication use. Since 2000, the Guild and the DoHA have initiated pilot programs to determine the feasibility of rolling out targeted pharmacy disease management services in community pharmacies across Australia.^46,47 These services are intended to complement management by the patient's GP and other health care professionals. However, we must be mindful that, despite the successful involvement of the community pharmacist in the primary care team, palliative care is a specialized field and there are additional barriers to be overcome to enable community pharmacists to become actively involved in the palliative care area.

Barriers to Community Pharmacists Playing a Role in the Palliative Care Interdisciplinary Team

Community pharmacists wanting to provide targeted pharmaceutical care for palliative care patients face several barriers. A remuneration-based supply service does not favor the delivery of relatively time-intensive pharmaceutical care.^48–50 Moreover, in Australia, community pharmacists are not among the allied health professionals eligible to join an interdisciplinary team in providing services to patients with chronic conditions and complex care needs on referral from their GP. Patient care is managed and reimbursed under an Enhanced Primary Care (EPC) plan, a GP Management Plan, and Team Care Arrangements.^51,52 As such, tension between the business side of community pharmacies and a public health model is likely if community pharmacists cannot derive adequate financial remuneration for providing palliative care-related services (fee-for-service that depends upon patients' willingness to pay) or reimbursement (with broader eligibility criteria and a viable payment structure).

Community pharmacists will also require continuing professional education (CPE) if they are to provide pharmaceutical care for palliative care patients confidently. ¹³ It is not uncommon to find that community pharmacists dispensing medications for patients of home-based palliative care programs are unfamiliar with nonformulary or uncommon palliative care medications. ⁵³ Additionally, pharmacists' misconceptions about opiate use in patient populations reported in the literature have implications for community-based palliative care. For example, Joranson and Gilson ⁵⁴ found that Wisconsin pharmacists' views on addiction, drug abuse, and diversion interfered with their dispensing of valid prescriptions for opioid pain medications to patients with chronic cancer and those with noncancer pain, with or without history of opioid abuse, in long-term care facilities, hospitals, and outpatient clinics. This restricted patients' access to pain relief medicines and jeopardized their pain management. Community pharmacists from urban and rural communities in a small study in Australia reported that they deliver palliative cancer care services only infrequently and consequently lacked knowledge in this area. ⁴⁰ The five palliative care topics respondents most wanted to learn about in an educational program were: management of cancer pain; management of nonpain symptoms or side effects; drug interactions with palliative cancer treatments; risk factors, presentation, treatments, and prognosis of common cancers; and the principles of palliative care. A study conducted in Japan found that community pharmacists prioritized a need for skills to communicate effectively with patients and carers. ⁸

An enhanced role in palliative care requires that community pharmacists have the capacity to provide equipment, including drug administration equipment, and that they stock (or have access to) the full range of palliative care pharmaceuticals. ⁵³ However, retail pharmacists and home care nurses surveyed in Dublin, Ireland, reported that the main problem causing delays for newly referred home care patients was obtaining palliative care drugs, particularly unlicensed drugs. ⁵⁵ This finding was mirrored in Japan. ⁸

Finally, the available research evidence on community pharmacy involvement in primary care generally is inconclusive. Pharmaceutical care interventions may be ineffective or, at the very least, of unknown benefit. In a systematic review, Roughead et al. ⁵⁶ found that studies generally omit or incompletely capture data on adverse drug events as a measure of clinical outcomes of pharmacy services in the community setting and few studies utilize medication appropriateness as an outcome measure of pharmaceutical care.

Community Pharmacists' Involvement in Palliative Care

Two studies that evaluated care provided by community pharmacists to palliative care patients following training in palliative care provide tentative support for enhancing the role of the community pharmacist in palliative care. The first of these studies was conducted in the United Kingdom over a ten-month period. ⁴² Community pharmacists developed a therapeutic relationship with patients providing cognitive pharmaceutical services including: assessment, medication reviews, identifying medication-related problems, care planning, and follow-up. An expert multidisciplinary panel found that the pharmaceutical care plans devised by community pharmacists for twenty-five palliative care patients using local pharmacies were likely to be beneficial. Successful outcomes included the implementation of plans, monitoring and updating of these plans, and more frequent discussion with GPs and/or community nurses.

The second study was a 2006-2007 pilot program in San Diego, California involving pharmacists based in a retail ambulatory care (outpatient) setting. ⁴⁸ These community pharmacists initiated or modified treatment regimens for palliative care clinic patients under a collaborative practice protocol and arranged follow-up appointments with the palliative care service. Most of the pharmacists' medication recommendations in the San Diego program were accepted by the medical professionals. Physicians in this study also reported that the service was useful for managing symptoms such as pain and nausea and that the pharmacists could spend more time providing psychosocial support and managing complex situations than could physicians.

Conclusion and the Way Forward

It is essential that we build upon these tentative findings and move forward with a coherent research agenda as robust, valid research is sorely lacking. We also need to support this initiative at the systemic level by addressing structural issues such as reimbursement and the provision of clear protocols and policies; at the organizational level by providing guidelines, such as a list of essential stocks, and local resources; and at the individual level by the provision of education and training as well as supporting attitude changes among community pharmacists where necessary. If these initiatives are prioritized, community pharmacists are poised to play a valuable – and essential – role in community-based palliative care. In summary, multilevel support for community pharmacists is needed for pharmacists to take a greater role in community-based palliative care. This can be achieved by addressing barriers such as reimbursement and the lack of education and training.