In ancient times, a hospice was a place for sick travelers to go rest. In 1842, France was the first to associate hospice as a place for ill or dying [1]. In 1967, London created a facility to care for the dying [1]. It was known that if one did not have much time to live, they could go to this place.  At this time, hospice was the only option for the ill/dying; however, it was not until 1975 when Balfour Mount founded the concept of “Palliative Care” in Canada [1]. The concept established in North America in 1996. Palliative care is giving patients symptomatic and supportive care while trying to use all sources possible to help treat diseases and/or medical issues. The main focus of palliative care is to actively treat instead of curing the disease [1]. In order to understand palliative care; one must understand the 3 basics, which are palliative medicine; palliative care and palliative care nursing [1]. Palliative care is a team of physicians, pharmacists, nurses, social workers, clergy and other healthcare professionals who provide care at the end of life [1]. The focus of this article is to understand the role pharmacists play in providing care to patients who are in end stage of life.

In Europe, Australia and Canada palliative care is much more advanced than in the United States. One huge distinguishing factor is that our community pharmacists are not part of the palliative team [1].  In actuality, they are not even considered as probable candidates. Community pharmacists are the most underutilized health care professionals. Community pharmacists can offer service and assistance 24 hours a day/ 7 days a week. They know more about any potential drug–drug interaction that can occur and details about the patients’ pain tolerance and symptom controls [2].

Pain and symptom control is the most important factor in palliative care and therefore, we need to make sure someone is regulating it at all times [2].

In other countries, the pharmacist is in charge of identifying specific products for palliative care such as medical devices. Pharmacists advise on formulations and preparation of medicines for people with many difficulties. These community pharmacies stock small amounts of rare palliative medicines for their patients [2]. We need to aim for the highest possible level to comfort these patients. Pharmacists should also strive to have a trusting relationship with their patients [2]. It is necessary for pharmacists to offer a strong basis for psychological and social support [3].  Community pharmacy is the easiest place accessible to the patient and therefore, it gives patients a place to go for advice and help with anything else that may be hindering their quality of life.

In Australia, it is common to see patients choose to stay home as their palliative care setting [4]. A study was performed to see how effective community pharmacies are in providing services to palliative care patients [3].  The study was a multiple qualitative case study design [3]. It consisted of 16 focus groups and 19 interviews with pharmacists, nurses, and general practitioners all over metropolitan and regional Western Australia [3]. Data was collected and analyzed by similarities and differences in addition to locations being examined and compared [3]. The data was split into three categories for better analysis. They are effective communication, challenges to effective communication and best practice [3]. Best practice actually consisted in two themes: community pharmacists’ skills and community pharmacists’ needs. The main component in this study was palliative care consisting of effective communication [3].

As a result, it was shown that the pharmacists wanted an opportunity to provide interpersonal support; however, they would need to develop a more perfective and proficient communication skill to fulfill this task. In order for pharmacists to appropriately communicate effectively and manage strong emotions from patients, they would require continuing professional development in this area. Most community pharmacists have little or no training and report lack of confidence in this area. If we involved pharmacists to become part of the interdisciplinary team they could undertake patient assessments such as systematic medication reviews, patient counseling, follow-up and home visits. In addition to this study, two other studies demonstrated that community pharmacists can be active and successful members of the community palliative care interdisciplinary team and respond to the palliative care needs of patients that often have a primary and ongoing relationship [3].

The 2nd study was conducted in United Kingdom and an expert found that pharmaceutical care plans devised by community pharmacists for palliative care patients using local pharmacies were likely to be beneficial [5]. The goal of this study was to assess the effectiveness of community pharmacists’ clinical innervations in supporting palliative care in patients in primary care using an independent multidisciplinary panel review [5]. Patients with less than 12 months to live were registered to a single pharmacy [5]. The community pharmacist was able to access the general practitioners case records. Before devising the community pharmacy for palliative care, the pharmacists had to receive training in palliative pharmaceutical care and documenting interventions. After the 10-month period, an independent multidisciplinary expert panel reviews the clinical interventions made by the pharmacists [5]. The panel consisted of palliative care consultant, community palliative care nurse, and a hospital pharmacist. There were fourteen community palliative care teams involved in the study and 25 patients recruited over the 10-month period [5].  There were a total of 130 clinical interventions made by pharmacists; however, 30 interventions were excluded due to insufficient information to present to the panel. 4 The expert panel judged 81% of the clinical interventions made by pharmacists as beneficial and 3% as detrimental to the patients’ wellbeing. This study proved that community pharmacists are beneficial for palliative care [5].

The 3rd study involved pharmacists based in a Californian outpatient ambulatory setting [6]. These community pharmacists started or modified treatment regimens for palliative care clinic patients under a collaborative practice protocol and arranged follow-up appointments with the palliative care service [6].  The purpose of this report was to publish a study on pharmacists in an ambulatory care setting for palliative care patients [6].  The study established a model for incorporating outpatient clinical pharmacists as part of a multidisciplinary palliative care team [6]. Firstly, a pharmacist was chosen from a retail pharmacy and was incorporated as part of a consultative ambulatory palliative care service at University of California [6].  The pharmacist had to complete legal requirements (National Provider Identifier and US Drug Enforcement Agency registration) needed to be able to prescribe under a collaborative practice agreement in California. The study interval was from November 2006 to August 2007. The pharmacist had consulted 29 new patients and in total, there were 114 clinic visits [6].  The pharmacist was consulted mainly for pain management 93%. The primary care oncologist accepted 98% of the palliative care medication recommendations made by the pharmacist for the 114 clinic visits [6].  Also, physicians completed a satisfaction survey and reported the top three most beneficial palliative care by the pharmacist: additional time spent with patients without physicians present (90.9 %), pain and symptom management (81.8%), and psychosocial support (72.7%). This study was the actual first to report on palliative care pharmacists in a retail-based ambulatory care setting [6].

While studies have been published demonstrating the positive impact of pharmacists in various health care settings, few have looked specifically at the role of the pharmacist in the palliative care setting [7,8]. Studies that have looked at the role of pharmacists in palliative care settings have assessed the pharmacists value predominately by physician-based surveys that subjectively rate the pharmacist’s interventions [9]. This study was conducted to identify factors that impact physician acceptance of the pharmacist’s recommendation and to determine whether acceptance is a significant predictor of clinical outcome [9]. 

Two clinical pharmacists tracked each request for pharmacotherapeutic interventions over a 4-month period and a retrospective examination of clinical notes was made. Each intervention was reviewed to determine age, gender, death rate, presenting symptom, recommending pharmacist, recommendation type, recommendation status (accepted vs. declined) and clinical outcome (achieved or not achieved) [9]. 264 pharmacists recommendations were made that met the inclusion criteria of the study [9]. As a result, 89.4% of recommendations were accepted and 79.9% of patients achieved the desired clinical outcome [9]. As seen in previous palliative care studies [6,10], the pharmacist’s recommendations acceptance rate was high in this study [9]. The primary care physicians did not really have a specific expertise in palliative care; however, the pharmacists in this study each had experience and training in palliative care [9]. This could be one reason why the pharmacists had a high acceptance rate. Overall, any pharmacist with a role in palliative care must have experience and training in palliative care to help offer the best quality of care to the patients. Also, age gender, proximity to death, presenting symptom, type of pharmacist, or the type of recommendation do not significantly influence the primary care physician’s decision to accept or decline a recommendation [9]. 

The multivariate analysis showed a strong association between the acceptance of the pharmacist’s recommendations and the patient achieving the desired clinical outcome to be significant [9].

In conclusion, there are some researches out there proving the necessity of community pharmacists in palliative care settings. Unfortunately, this practice is not happening in the United States. However, it is common in Europe, Australia and Canada [1].  It is important for pharmacists to first have a strong working background on palliative care before they provide support. Pharmacists would need extra training in continuing professional development in palliative care [3].  However, at the end of the day,

The patient’s quality of life is the ultimate goal of our care [1].
 

1. Williams M, Wheeler M (2001) Palliative Care: What is it?. Lippincott Williams & Wilkins, Inc 19:551-57.

2. The role of the pharmacist in Palliative Care (2002) Euro Pharm forum.

3. O’Connor M, Fisher C, French L, Halkett G, Jiwa M, et al. (2011) pharmacist’s role in palliative care: Focusing on the person not just the prescription. J. Exploring the Community Elsevier 83:458-64.

4. Hussainy S, Box M, Scholes S (2011) Piloting the role of a pharmacist in a community palliative care multidisciplinary team: an Australian experience. BioMed Central Palliative Care 10:1-12.

5. Needham DS, Wong ICK, Campion PD (2002) Evaluation of the effectiveness of UK community pharmacists’ interventions in community palliative care. Palliative Medicine 16:219-225.

6. Atayee RS, Best BM, Daniels CE (2008) Development of an Ambulatory Palliative Care Pharmacist Practice. Journal of Palliative Medicine 11:1077-1082.

7. Schumock G, Butler M, Meek P (2003) Al Evidence of the economic benefit of clinical pharmacy services:1996-2000. Pharmacotherapy 23:113-132. 

8. Perez A, Doloresco F, Hoffman J (2008) Economic evaluation of clinical pharmacy services 2001-2005. Pharmacotherapy 28:285-323. 

9. Wilson S, Wahler R, Brown J, Doloresco F, Monte SV, et al. (2011) Impact of Pharmacists Intervention on Clinical Outcomes in the Palliative Care Setting. American Journal of Hospice and Palliative Medicine 28:316-320.

10. Lee J, McPherson M (2006) Outcomes of recommendations by hospice pharmacists Am J Health Syst Parm 63:2235-2239.