Pharmacists can be key members of hospice teams

Role is more than just pallatative care

Hospice-based clinical pharmacists can influence patient outcomes positively by identifying drug-related problems and recommending appropriate drug therapy, according to research conducted by two University of Maryland School of Pharmacy pharmacists who worked with three Maryland hospices.

Researchers Mary Lynn McPherson, Pharm.D., and Jerome Lee, Pharm.D., shared responsibility for providing drug therapy recommendations to the three hospice programs in the study. They collected and evaluated 98 interventions and found 87 in which specific therapeutic goals were established. Of the 87 interventions, 73 (84%) were accepted by the prescriber and 56 (77%) of the 73 helped achieve the therapeutic goals. An additional six interventions (8%) partially achieved the therapeutic goals.

More than 75% of all the pharmacists' recommendations achieved their intended therapeutic effect, resulting in better management of patients' physical symptoms. None of the accepted recommendations resulted in patient harm or the patient experiencing an adverse effect.

McPherson and Lee say that hospice programs meet the total active needs of their patients by assembling an interdisciplinary team of medical professionals, social workers, volunteer coordinators, and spiritual advisors who each lend expertise in the total care of the patient. Because medications play a large role in managing pain and other physical complaints during the terminal phase of life, pharmacists can be an important part of the interdisciplinary hospice team. The researchers say the role of pharmacists in improving patients' quality of life is very consistent with the hospice philosophy—pharmacists ensure effective medication management in several areas, including administrative, distributive, clinical, and educational.

While all hospice programs have a provider pharmacist to dispense medications to patients receiving hospice services, not all hospice programs have a clinical pharmacist as a team member. The researchers say that a growing body of evidence demonstrates the economic and clinical benefits of pharmacy in healthcare and thus it would be reasonable to take advantage of the services that pharmacists can provide to hospice and palliative care programs. But there have been very few structured, prospective studies documenting benefits of pharmaceutical care intervention in hospice.

Focus on palliative care

Those studies that have been done, the authors say, focused on palliative care through clinical pharmacy interventions in inpatient and clinical settings, and none of them focused on documenting interventions made by clinical consultant pharmacists working with a home-based hospice program. Thus, the purpose of the study conducted by McPherson and Lee was to (1) capture and describe drug-related problems encountered in practice, the recommended intervention to resolve those problems, and the outcome of the recommendations; (2) develop a tool to evaluate drug-related problem severity and the value of the intervention; and (3) assess the interrater reliability of the tool by evaluating the data captured in the first part of the study. "This descriptive study is the first step in demonstrating whether pharmaceutical care recommendations made by clinical pharmacists on the hospice team are of value and enhance patient outcomes," the authors say.

They report that more than 75% of all the pharmacists' recommendations achieved their intended therapeutic effect, resulting in better management of patients' physical symptoms. "These findings clearly suggest that clinically trained hospice pharmacists can effectively identify and appropriately manage drug-related problems," they conclude. "The high level of acceptance of the pharmacists' recommendations demonstrates that the interdisciplinary team members and primary care providers recognize the ability of pharmacists to provide responsible, accurate, and appropriate pharmaceutical care to the hospice patient. None of the accepted recommendations resulted in the patient coming to harm or having an adverse event."

McPherson tells Drug Formulary Review she went into the research knowing that she and Lee would do well. "One thing pharmacists bring to the table is that we can back up what we recommend," she says. "A lot of prescribers are uncomfortable with dosing."

She says that while every hospice must have a pharmacist, they often are simply dispensing medications. For that role to change and become more involved with clinical interventions, she says, schools of pharmacy need to increase their content on end-of-life issues. In addition, pharmacist continuing education needs to address hospice quality assurance measures.

It's a difficult situation, she says, to provide medications for the primary diagnosis and tell a family that their loved one has passed the point that drug therapy is needed and instead has reached the point where comfort is the goal. Families need to know, she says, when administering drugs is no longer worth it and may in fact increase risk.

"Pharmacists are great at revisiting drug therapy goals," she says. "We tell the nursing staff that each drug should have a therapeutic goal and that the goal is likely to change over time."

[Editor's note: Contact Ms. McPherson at (410) 706-3682 or e-mail mmcphers@rx.umaryland.edu.]

Reference

  1. Lee J, McPherson ML. Outcomes of recommendations by hospice pharmacists. American Journal of Health-System Pharmacy. 2006 Vol. 63, Issue 22, 2235-2239.