Effective Delivery of Pharmaceutical Palliative Care: Challenges in the Community Pharmacy Setting

Introduction

Medication, particularly analgesia, is an important component of palliative care. However, timely access to medication, particularly opioids, can become problematic for patients receiving palliative care in the community setting.^1,2,3 Medication-related problems appear to be commonplace and occur regardless of the health care system in operation.^1,4,5 For example, 49% (n=28/53) of community pharmacists surveyed in the North Dublin area of Scotland ⁴ reported “not having the medication in stock” as a major factor causing delay in supply of medication to patients. In Japan, ⁵ only 77% of community pharmacists have a “narcotics retailer license,” thereby limiting the availability of pharmacies from which prescriptions for opioid pain relief could be dispensed.

In Scotland, an audit of palliative care services ⁶ found that access to medication, particularly unlicensed drugs, was a problem for some patients. Consequently, under the Model Schemes in Pharmaceutical Care initiative, ⁷ a Community Pharmacy Palliative Care (CPPC) Network was established in most Scottish Health Board area. Pharmacies in the CPPC Network were expected to provide an enhanced pharmaceutical palliative care service. This was achieved by the pharmacies by retaining a stock of specialized palliative care medication; arranging transportation of urgently required medicines; and supporting nonNetwork pharmacies, general practitioners (GPs), and district nurses within their local areas. A subsequent review ⁸ of palliative care services found that although the majority of CPPC Network pharmacies were now carrying the additional stock of palliative care medicines, some issues remained. These included patients being denied access to urgently required medicines, particularly Controlled Drugs, out-of-hours (after 6 p.m. and during weekends) and after discharge from the hospital. In 2009, NHS Greater Glasgow & Clyde Health Board (NHS GG&C), in partnership with Macmillan Cancer Support, established a program to improve the local provision of pharmaceutical palliative care services. Four Macmillan pharmacist facilitators were appointed, part-time, to work in four localities in the West of Scotland. The localities covered a total population of approximately 430,000 and comprised 112 community pharmacies. Twenty six of these pharmacies were members of the local CPPC Network. Researchers at the University of Strathclyde were commissioned to support the development and evaluation of this new service. A key early task for the facilitators was to understand the provision of palliative care services currently provided by CPPC Network Pharmacies. We report the findings of this initial investigation and outline an evidence-based action plan to support service improvement.

Methods

Qualitative data were gathered using focus group interviews. This method was chosen because the group interview allows participants to articulate their thoughts, opinions, and attitudes in a relatively “naturalistic” setting. ⁹ The technique is also commonly used for collecting information about health service practice and delivery.^10,11 A topic guide enquiring about participants' experiences of providing palliative care services and of being in the CPPC Network was developed and used. Ethics approval was sought but deemed unnecessary, because the project was an evaluation of current service delivery. The principles of informed consent and good ethical practice were applied and observed. The focus groups were facilitated by three members of the university team who are also authors of this paper.

Participants were identified from among those attending scheduled training events for CPPC Network pharmacies during January and February 2010. Thirty-five pharmacists were recruited to one of five focus groups each lasting between 60 and 90 minutes. The interviews were recorded and transcribed verbatim. The transcripts were independently read by the three authors and subjected to a thematic analysis using the Framework Approach.^12,13 Identified emergent and recurrent themes were coded according to the appropriate thematic reference and validated by team members through consensus.

Results

Three key themes were identified: medication supply, communication, and education and training. The themes are discussed below with participants' quotes used to illustrate the findings.

Discussion of the medication supply process identified four subthemes relating to the prescribing or dispensing of medicines.

Most participants had experience of being presented with prescriptions containing medicines that were not listed in the locally agreed palliative care stock list. Such products were unlikely to be routinely stocked in the pharmacy. This often meant that the prescriber would need to be contacted for clarification, resulting in delays with supplying the medication.

Almost all the participants identified the out-of-hours period as being more vulnerable to problems. At these times it can be more difficult to contact relevant personnel for prescription clarification and to get access to medicines that may need to be specially ordered. Additionally, at these times, the pharmacy may be staffed by individuals not usually employed during the routine working day and thus they may be unfamiliar with elements of the service.

Participants also discussed the issues they face when presented with a prescription that does not comply with legislation. In particular, Controlled Drugs need to be written in accordance with regulations. If the prescription is incomplete, it needs to be referred back to the prescriber before dispensing, potentially causing delay. The interviews illustrate the serious professional and ethical quandary faced by the pharmacists about which the rest of the palliative care team and patients are likely to be unaware.

The Taxi Protocol, whereby local taxis may be used to collect and deliver urgent medicines between pharmacies and patients was considered a helpful resource, but was used infrequently. Some participants stated that the protocol was a complicated bureaucratic procedure. They preferred to deliver the medicines themselves and use the opportunity to counsel or offer support to the patient. Some also expressed reservations about handing medicines, especially controlled drugs to non-health care staff.

Communication across the palliative care team was seen as an important factor impacting service delivery. District Nurses were recognized as being an invaluable source for information about the patients' clinical condition and medicine requirements. Some participants seemed to feel that the district nurses had a better appreciation of the potential for the occurrence of prescription-related problems. They would try to minimize these where possible, for example by contacting the pharmacy in advance to preempt supply problems and/or by guiding patients/carers to Network pharmacies where appropriate. However, the discussions revealed that communication was particularly poor between care settings, especially when patients were admitted to or discharged from the hospital/hospice. Some pharmacists reported being ill informed of changes that had occurred to the patient's regular prescriptions.

Such problems may be amplified through the use of weekly monitored dosage systems (MDS). These can be labor intensive as they require individual doses to be dispensed into compartments separated by day and time. Almost all the participants had experiences of preparing or delivering MDS to patients who had been admitted to the hospital or who had died.

Membership of the Network was seen as supportive but could also present a challenge.

Most participants agreed with a pharmacist, who suggested that, sometimes, it is difficult to provide an optimum service to individuals who present at a Network pharmacy with minimal information.

For some participants, the limited knowledge and understanding of their role by palliative care team members was a key factor affecting their provision of services to patients and carers.

Participants also expressed a need for better training of their own staff, particularly counter assistants and locum pharmacists. Counter assistants were identified as the first point of contact in the dispensing process. If their ability to recognize urgent palliative care prescriptions could be improved, then this could avoid unnecessary delays for patients and carers.

The participants reported that locum pharmacists may be unaware that a pharmacy is part of the CPPC Network and what is expected of them. Although there was recognition of the difficulty in implementing training for locums, all agreed that this should be put in place to build on the pharmacist's core knowledge.

Availability of routine resources for pharmacists to support clinical practice was highlighted. Standard references including the British National Formulary were mentioned but were identified as limited in providing specific palliative care information. The Palliative Care Formulary (also known as the PCF3) was found to be invaluable for identifying and cross-referencing unlicensed indications and doses of medicines. ¹⁴ During out-of-hours most participants reported that they would contact local hospices or hospital pharmacists and the NHS 24 professional-to-professional service for advice or information. ¹⁵ The Internet was also discussed but the practicalities of accessing and browsing web pages while being fully engaged in the workings of a busy community pharmacy were seen as major obstacles.

Discussion

In the hospital/hospice setting, pharmacists are routinely part of the clinical team and involved in the care planning process.^16,17,18 Needham and colleagues ¹⁹ reported on the beneficial role of community pharmacists in a small, in-depth case series analysis. However, the evidence base supporting the role of the community pharmacist in palliative care service delivery is generally limited as highlighted in a recent editorial. ²⁰ This paper adds to the literature by reporting a model currently operating in Scotland. It provides an insight into challenges facing community pharmacists in their delivery of palliative care services.

Exploration of the medicines supply process identified issues that were beyond the pharmacist's control, most notably incorrectly written prescriptions. This finding concurs with the study by Lucey and coworkers ⁴ in which community pharmacists cited “incorrectly written or illegible prescriptions” as factors impinging on their delivery of service. Additionally, our study uncovered a significant ethical dilemma for pharmacists that is associated with the supply of medicines when the prescription does not meet the legal requirements. Education of both the palliative care team and patients/carers of the need for legally compliant prescriptions could help to minimize delays in medicines supply and hence avoid distress for patients and carers.

An interesting finding, particularly for service managers, was participants' reluctance to implement the Taxi Protocol. The protocol can be used in urgent situations to collect a prescription form, or to collect or deliver medication between pharmacies or to the patient's home. It had been introduced with the involvement of CPPC Network pharmacists, following reflection on incidents where there had been delays in obtaining or dispensing medicines, and hence, symptom control, with ensuing distress to families and professionals. It did appear to be viewed as bureaucratic. However, it was encouraging to find that some pharmacists said they would prefer to deliver the medicines themselves, to make direct contact with the patient and offer advice or support.

The unpredictable nature of disease trajectory and the diversity of the palliative care team necessitates good communication.^21,22 Our study highlights where poor communication can impact patient care, particularly between care settings and across the palliative care team. Robust mechanisms for the transfer of clinical information between services and health professionals are therefore required. The out-of-hours period is known to be particularly problematic, ²³ and this was confirmed in our study. One solution being explored in Scotland is to give community pharmacists access to the NHS ePCS (electronic Palliative Care Summary). The ePCS contains information about the individual's medical condition, treatment, carer details, and his or her wishes concerning treatment toward the end of life. ²⁴ Another potential source of information sharing is the Supportive Care Register. This is one of the documents used in the application of the Gold Standards Framework (Scotland), which is a program based in general practice to support planning and communication for patients receiving palliative care in the community. ²⁵ Access to it would allow community pharmacists to make appropriate and safe medication-based interventions. It would be particularly helpful when a patient is specifically referred to a pharmacy because of his or her palliative care needs.

Improved information sharing could also be addressed through attendance of pharmacists at clinical palliative care team meetings. Attendance of pharmacists at clinical review sessions are known to improve patient outcomes in palliative care and other specialties.^17,26,27 However, the practicalities and logistics involved, particularly for pharmacies with only one pharmacist on staff, make this challenging in the community setting. The peripatetic nature of the Macmillan Pharmacist Facilitators may provide an opportunity; either by attendance at team meetings and dissemination of the information to the community pharmacist or by providing cover in the pharmacy to enable the community pharmacist to attend the team meetings.

Training, particularly of pharmacy support staff, to enable more effective engagement with patients, carers, and health professionals was recognized as an area for action. Small changes such as being able to identify a palliative care prescription when it is first presented would allow early identification of potential problems. Inclusion of counter staff within CPPC Network training events should provide better understanding of patients' needs, resulting in a more effective and responsive service.

The qualitative nature of the study poses limitations regarding generalizability and reproducibility. Nevertheless, our intention was to provide insight into issues faced by community pharmacists in their delivery of palliative care services. A comparative study with non-Network pharmacists would have given a more comprehensive description. However, we believe that this study provides a baseline upon which improvements to service provision can be developed. The overlap and commonalities between this and the few other studies investigating community pharmacy service delivery^4,5 suggest that our findings are not unique to our sample or the geographical area.

Conclusions

This study describes the challenges facing community pharmacists in their delivery of palliative care services. These findings have been used to develop an evidence-based action plan for the Macmillan Pharmacist Facilitators. This plan is due for completion by December 2012 and its goals include the following:

• To raise awareness and integration of CPPC Network pharmacies within their localities and the broader community pharmacy family.