Faculty members at the University of Florida Colleges of Pharmacy and Nursing were interested in incorporating simulation into their programs. Teachers also wanted to integrate an end-of-life activity into the curriculum. The two programs ended up doing both.

“This dual focus evolved into us comparing paper-based end-of-life case studies with those same scenarios brought to life through simulation on students’ perceived end-of-life care learning needs,” says Carol Motycka, PharmD, BCACP, assistant dean in the College of Pharmacy.

Groups of nursing and pharmacy students were exposed to either a case study approach in a classroom setting or simulated versions of the same cases.1 Four end-of-life scenarios were used. The cases involved a patient with muscular dystrophy, now on a ventilator; an infant dying from various birth anomalies; a 68-year-old with diminished mental capacity dying from pneumonia; and a retired chemist in severe pain who believes in physician-assisted suicide.

The simulation scenarios were conducted at the university’s Center for Simulation Education and Safety Research in bays designed like relevant units, such as a neonatal ICU or medical/surgical unit, using realistic-appearing, computer-controlled mannequins. “Patient situations focused on ethical dilemmas in the transition from curative to comfort care,” Motycka says.

Only the simulation group’s scores improved. Interestingly, the most significant changes occurred in items related to patient care, not those related to ethics. “Given that the course in which the activity took place was one focused on ethics, we anticipated that student responses would reflect greater understanding,” says Motycka, noting that the difference in ethics learning needs was only slight. “That said, we were pleased to see the patient care domain positively impacted.”

The findings underscore the important role pharmacists play in medication management at the end of life. This often happens in the midst of ethical dilemmas. “Medication plays an important role in comfort at end of life,” Motycka observes. “The role of the pharmacists in both palliative and hospice care is gaining visibility.”

Ethicists do not always obtain input from pharmacists to help resolve ethical dilemmas. “This continues to be a growing field for pharmacists, but they continue to be underutilized in this form of care,” Motycka says. This is especially important if cases involve medication-based decisions. There is growing awareness of pharmacists’ importance in this regard.

The American Society of Health-System Pharmacists (ASHP) guidelines state that pharmacists play an important role in palliative and hospice care through symptom management, medication use and counseling, and care transitions.2 Additionally, the ASHP Council on Pharmacy Practice advocates for an active pharmacist role on ethics committees. “There is a growing recognition of the need to utilize resources more effectively and appropriately at the end of life,” Motycka adds. End-of-life care often is aggressive, expensive, and aimed at preserving life as long as possible. “All healthcare providers, including pharmacists, need to be versed in communication skills in order to bring up other end-of-life care options,” Motycka says. Hospice and palliative care services must be considered.

Education on this “should be integrated throughout the pharmacy curriculum,” Motycka says. “A dearth of expertise can lead to inappropriate patient care.”

Patients in palliative care often require symptom management rather than long-term disease state management. “Thus, unnecessary medications that may be helpful in patients to extend life, such as statins, may be unnecessary,” Motycka observes. Such medications also could harm patients since they can contribute to adverse events or drug interactions.

Pharmacists also need substantial knowledge of opioids, more than just basic pharmacology. Also important: “Assessing the risk of drug diversion if the patient has a family member or caretaker with a history of substance abuse,” Motycka adds.

REFERENCES

  1. Egelund EF, Gannon J, Motycka C, et al. A simulated approach to fostering competency in end-of-life care among pharmacy students. Am J Pharm Educ 2019;83:6904.
  2. Herndon CM, Nee D, Atayee RS, et al. ASHP guidelines on the pharmacist’s role in palliative and hospice care. Am J Health Syst Pharm 2016;73:1351-1367.