Effective delivery of pharmaceutical palliative care: challenges in the community pharmacy setting

From comfort zone to front-line care: perspectives and reflections of community pharmacists entering home-based palliative care

BACKGROUND

Palliative care requires a multidisciplinary team to assist patients and their families to obtain good quality care at the end of life. Typically, community pharmacists have fewer opportunities to provide services for patients with palliative care needs than hospital pharmacists. Moreover, home-based palliative care (HBPC) by pharmacists remains low and there is a lack of research regarding HBPC provided by pharmacists. Therefore, this study sought to understand the views and reflections of community pharmacists in the clinical frontline providing palliative home services.

METHODS

Purposive sampling was used to recruit six community pharmacists for one-on-one, in-depth, semi-structured interviews and the data were analysed using thematic analysis.

RESULTS

Five major themes emerged: [1] Engagement, [2] Challenge, [3] Mission, [4] Career metamorphosis, and [5] Outlook. The pharmacists described how they engaged in HBPC and faced the challenges. They regarded opioid management as a burden. Moreover, some mentioned that reimbursement for palliative home care is low or non-profitable. They suggested building a platform to exchange advice and legislation adjustments so that they could pass on their experiences to less experienced pharmacists in HBPC.

CONCLUSIONS

The involvement of pharmacists is crucial to provide better palliative care. Although the present study was small and might not fully represent the whole situation, the findings could still inform future education, training, and policy planning to promote pharmacists' participation in palliative care to generalise community palliative care.

Identifying Core Domains to Assess the "Quality of Death": A Scoping Review

CONTEXT

There is growing recognition of the value to patients, families, society, and health systems in providing healthcare, including end-of-life care, that is consistent with both patient preferences and clinical guidelines.

OBJECTIVES

Identify the core domains and subdomains that can be used to evaluate the performance of end-of-life care within and across health systems.

METHODS

PubMed/MEDLINE (NCBI), PsycINFO (ProQuest), and CINAHL (EBSCO) databases were searched for peer-reviewed journal articles published prior to February 22, 2020. The SPIDER tool was used to determine search terms. A priori criteria were followed with independent review to identify relevant articles.

RESULTS

A total of 309 eligible articles were identified out of 2728 discrete results. The articles represent perspectives from the broader health system (11), patients (70), family and informal caregivers (65), healthcare professionals (43), multiple viewpoints (110), and others (10). The most common condition of focus was cancer (103) and the majority (245) of the studies concentrated on high-income country contexts. The review identified five domains and 11 subdomains focused on structural factors relevant to end-of-life care at the broader health system level, and two domains and 22 subdomains focused on experiential aspects of end-of-life care from the patient and family perspectives. The structural health system domains were: 1) stewardship and governance, 2) resource generation, 3) financing and financial protection, 4) service provision, and 5) access to care. The experiential domains were: 1) quality of care, and 2) quality of communication.

CONCLUSION

The review affirms the need for a people-centered approach to managing the delicate process and period of accepting and preparing for the end of life. The identified structural and experiential factors pertinent to the "quality of death" will prove invaluable for future efforts aimed to quantify health system performance in the end-of-life period.

Community access to palliative care medicines-patient and professional experience: systematic review and narrative synthesis

BACKGROUND

Providing palliative care patients living at home with timely access to medicines is critical to enable effective symptom management, minimise burden and reduce unplanned use of healthcare services. Little is known about how diverse community-based palliative care models influence medicine access.

OBJECTIVE

To produce a critical overview of research on experiences and outcomes of medicine access in community-based palliative care models of service delivery through a systematic review and narrative synthesis.

METHODS

MEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Library databases and grey literature were systematically searched for all types of studies. Study quality was assessed using the Mixed Methods Appraisal Tool; a narrative synthesis was used to integrate and summarise findings.

RESULTS

3331 articles were screened; 10 studies were included in the final sample. Studies included a focus on community pharmacy (n=4), hospice emergency medication kits (HEMKs) in the home (n=3), specialist community nurse prescribers (n=1), general practice (n=1) and one study included multiple service delivery components. Community pharmacy was characterised by access delays due to lack of availability of medicine stock and communication difficulties between the pharmacy and other healthcare professionals. HEMKs were perceived to reduce medicine access time out of hours and speed symptom control. However, the majority of studies comprised small, local samples, largely limited to self-reports of health professionals. There was a lack of data on outcomes, and no comparisons between service delivery models.

CONCLUSIONS

Further research is required to understand which models facilitate rapid and efficient access to medicines for community-based palliative care patients.

Supporting patient access to medicines in community palliative care: on-line survey of health professionals' practice, perceived effectiveness and influencing factors

Background

Patient access to medicines at home during the last year of life is critical for symptom control, but is thought to be problematic. Little is known about healthcare professionals’ practices in supporting timely medicines access and what influences their effectiveness. The purpose of the study was to evaluate health professionals’ medicines access practices, perceived effectiveness and influencing factors.

Methods

On-line questionnaire survey of health care professionals (General Practitioners, Community Pharmacists, community-based Clinical Nurse Specialists and Community Nurses) delivering end-of-life care in primary and community care settings in England. Quantitative data were analysed using descriptive statistics.

Results

One thousand three hundred twenty-seven responses were received. All health professional groups are engaged in supporting access to prescriptions, using a number of different methods. GPs remain a predominant route for patients to access new prescriptions in working hours. However, nurses and, increasingly, primary care-based pharmacists are also actively contributing. However, only 42% (160) of Clinical Nurse Specialists and 27% (27) of Community Nurses were trained as prescribers. The majority (58% 142) of prescribing nurses and pharmacists did not have access to an electronic prescribing system. Satisfaction with access to shared patient records to facilitate medicines access was low: 39% (507) were either Not At All or only Slightly satisfied. Out-of-hours specialist cover was reported by less than half (49%; 656) and many General Practitioners and pharmacists lacked confidence advising about out-of-hours services. Respondents perceived there would be a significant improvement in pain control if access to medicines was greater. Those with shared records access reported significantly lower pain estimates for their caseload patients.

Conclusions

Action is required to support a greater number of nurses and pharmacists to prescribe end-of-life medicines. Solutions are also required to enable shared access to patient records across health professional groups. Coverage and awareness of out-of-hours services to access medicines needs to be improved.

Pharmacists' knowledge, attitude and involvement in palliative care in selected tertiary hospitals in southwestern Nigeria

BACKGROUND

The growing number of people living with life-limiting illness is a global health concern. This study therefore aimed to explore the involvement of pharmacists in selected tertiary hospitals in Nigeria in palliative care (PC). It also sought to evaluate their knowledge and attitude to PC as well as factors that hinder pharmacists' participation in PC.

METHOD

Questionnaire-guided survey among pharmacists working in three-tertiary hospitals in southwestern Nigeria. The self-administered questionnaire comprised 18-item general knowledge questions related to PC, attitude statements with 5-point Likert-scale options and question-items that clarify extent of involvement in PC and barriers to participation. Overall score by pharmacists in the knowledge and attitude domains developed for the purpose of this study was assigned into binary categories of "adequate" and "inadequate" knowledge (score > 75% versus≤75%), as well as "positive" and "negative" attitude (ranked score > 75% versus≤75%), respectively. Descriptive statistics, Mann-Whitney-U and Kruskal-Wallis tests were used for analysis at p < 0.05.

RESULTS

All the 110 pharmacists enrolled responded to the questionnaire, given a response rate of 100%. Overall, our study showed that 23(21.1%) had adequate general knowledge in PC, while 14(12.8%) demonstrated positive attitude, with 45(41.3%) who enjoyed working in PC. Counselling on therapy adherence (100;90.9%) was the most frequently engaged activity by pharmacists; attending clinical meetings to advise health team members (45;40.9%) and giving educational sessions (47;42.7%) were largely cited as occasionally performed duties, while patient home visit was mostly cited (60;54.5%) as a duty not done at all. Pharmacists' unawareness of their need in PC (86;79.6%) was a major factor hindering participation, while pharmacists with PC training significantly felt more relaxed around people receiving PC compared to those without training (p = 0.003).

CONCLUSION

Hospital pharmacists in selected tertiary care institutions demonstrate inadequate knowledge, as well as negative attitude towards PC. Also, extent of involvement in core PC service is generally low, with pharmacists' unawareness of their need in PC constituting a major barrier. Thus, a need for inclusion of PC concept into pharmacy education curriculum, while mandatory professional development programme for pharmacists should also incorporate aspects detailing fundamental principles of PC, in order to bridge the knowledge and practice gaps.

How timely is access to palliative care medicines in the community? A mixed methods study in a UK city

OBJECTIVE

To investigate timely access to palliative medicines/drugs (PMs) from community pharmacies to inform palliative care service delivery.

DESIGN

Mixed methods in two sequential phases: (1) prospective audit of prescriptions and concurrent survey of patients/representatives collecting PMs from pharmacy and (2) interviews with community pharmacists (CPs) and other healthcare professionals (HCPs).

SETTING

Five community pharmacies in Sheffield, UK and HCPs that deliver palliative care in that community.

PARTICIPANTS

Phase 1: five CPs: two providing access to PMs within a locally commissioned service (LCS) and three not in the LCS; 55 patients/representatives who completed the survey when accessing PMs and phase 2: 16 HCPs, including five phase 1 CPs, were interviewed.

RESULTS

The prescription audit collected information on 75 prescriptions (75 patients) with 271 individual PMs; 55 patients/representatives (73%) completed the survey. Patients/representatives reported 73% of PMs were needed urgently. In 80% of cases, patients/representatives received all PMs on the first pharmacy visit. One in five had to travel to more than one pharmacy to access PMs. The range of PMs stocked by pharmacies was the key facilitating factor. CPs reported practical issues causing difficulty keeping PMs in stock and playing a reactive role with palliative prescriptions. Confidentiality concerns were cited by other HCPs who were reluctant to share key patient information proactively with pharmacy teams. Inadequate information transfer, lack of CP integration into the care of palliative patients and poor HCP knowledge of which pharmacies stock PMs meant patients and their families were not always able to access PMs promptly.

CONCLUSIONS

Consistent routine information transfer and integration of pharmacy teams in the care of palliative patients are needed to achieve timely access to PMs. Commissioners of PM access schemes should review and monitor access. HCPs need to be routinely made aware and reminded about the service and its locations.

Solidarity or dissonance? A systematic review of pharmacist and GP views on community pharmacy services in the UK

There has been a strong policy emphasis over the past decade on optimising patient-centred care and reducing general practitioners' (GPs') workload by extending community pharmacy services and collaboration between pharmacists and GPs. Our aim was to review current evidence of pharmacists' and GPs' views of extended community pharmacy services and pharmacists' roles in the United Kingdom (UK). A systematic review was undertaken looking at UK studies investigating pharmacists' and/or GPs' views of community pharmacy services or roles from 2005 to 2017. A range of databases were searched including EMBASE, PubMed, Scopus, Web of Science, International Pharmaceutical Abstracts (IPA), PsycINFO, Science Direct and The Cumulative Index to Nursing and Allied Health Literature (CINAHL). In addition, reference lists of included studies were screened and grey literature was searched. Following the application of inclusion/exclusion criteria, the quality of papers was critically analysed, findings were extracted into a grid and subjected to narrative synthesis following thematic analysis. The search strategy yielded a total of 4,066 unique papers from which 60 were included. Forty-seven papers covered pharmacists' views, nine combined both pharmacists' and GPs' views and four covered GPs' views. Study designs included interviews (n = 31, 52%), questionnaire surveys (n = 17, 28%) and focus groups (n = 7, 12%). Three main themes emerged from the data: "attitudes towards services/roles", "community pharmacy organisations" and "external influences". Pharmacists and GPs perceived a number of barriers to successful implementation and integration of pharmacy services. Moreover, collaboration between pharmacists and GPs remains poor despite the introduction of extended services. Overall, extending community pharmacy services require quality-driven incentives and joint working between community pharmacists and GPs to achieve better integration within the patient's primary care pathway.

Community pharmacy integration within the primary care pathway for people with long-term conditions: a focus group study of patients', pharmacists' and GPs' experiences and expectations

BACKGROUND

This study aimed to use marketing theory to examine the views of patients, pharmacists and general practitioners (GPs) on how community pharmacies are currently used and to identify how community pharmacy services may be better integrated within the primary care pathway for people with long-term conditions (LTCs).

METHODS

A qualitative research design was used. Two focus groups were conducted with respiratory patients (n = 6, 5) and two with type 2 diabetes patients (both n = 5). Two focus groups were held with pharmacists (n = 7, 5) and two with GPs (both n = 5). The "7Ps marketing mix" ("product", "price", "place", "promotion", "people", "process", "physical evidence") was used to frame data collection and analysis. Data was analysed using thematic analysis.

RESULTS

Due to the access and convenience of community pharmacies ("place"), all stakeholder groups recommended using community pharmacies over GP practices for services such as management of minor ailments, medication reviews and routine check-ups for well managed LTCs ("product"). All stakeholder groups preferred pharmacy services with clear specifications which focused on specific interventions to reduce variability in service delivery and quality ("process"). However, all stressed the importance of having an appropriate system to share relevant information, allowing pharmacists and GPs two-way flow ("process"). Pharmacists and GPs mentioned difficulties in collaborating with each other due to inter-professional tensions arising from funding conflicts, which leads to duplication of services and inefficient workflow within the primary care pathway ("people"). Patients and GPs were sometimes doubtful of community pharmacies' potential to expand services due to limited space, size and poor quality consultation rooms ("physical evidence"). However, all stakeholder groups recommended promoting community pharmacy services locally and nationally ("promotion"). Patients felt the most effective form of promotion was first-hand experience of high quality pharmacy services and peer word-of-mouth. The added value of using pharmacy services was faster access and convenience for patients, and freeing up GPs' time to focus on more complex patients ("value").

CONCLUSIONS

Using the 7Ps marketing mix highlighted factors which could influence utilisation and integration of community pharmacy services within the primary care pathway for patients with LTCs. Further research is needed to identify their relative importance.

Developing a Model for Pharmaceutical Palliative Care in Rural Areas-Experience from Scotland

Palliative care is increasingly delivered in the community but access to medicines, particularly ‘out of hours’ remains problematic. This paper describes the experience of developing a model to deliver pharmaceutical palliative care in rural Scotland via the MacMillan Rural Palliative Care Pharmacist Practitioner (MRPP) project. The focus of the service was better integration of the MRPP into different care settings and professional teams, and to develop educational resources for the wider MDT including Care Home and Social Care staff on medicine related issues in palliative care. A variety of integration activities are reported in the paper with advice on how to achieve this. Similarly, many resources were developed, including bespoke training on pharmaceutical matters for Care Home staff. The experience allowed for a three step service and sustainability model for community pharmacy palliative care services to be developed. Moving through the steps, the key roles and responsibilities of the MRPP gradually shift towards the local Community Pharmacist(s), with the MRPP starting from a locality-based hands-on role to a wider supportive facilitating role for local champions. It is acknowledged that successful delivery of the model is dependent on alignment of resources, infrastructure and local community support.

Community pharmacists' attitudes toward palliative care: an Australian nationwide survey

BACKGROUND

Pharmacists are among the most accessible health care professionals in the community, yet are often not involved in community palliative care teams.

OBJECTIVE

We investigated community pharmacists' attitudes, beliefs, feelings, and knowledge about palliative care as a first step towards determining how best to facilitate the inclusion of community pharmacists on the palliative care team.

METHOD

A cross-sectional descriptive survey design was used.

SUBJECTS

Community pharmacists around Australia were invited to participate; 250 completed surveys were returned.

MEASUREMENTS

A survey was constructed to measure pharmacists' knowledge and experience, emotions and beliefs about palliative care.

RESULTS

Pharmacists were generally positive about providing services and supports for palliative care patients, yet they also reported negative beliefs and emotions about palliative care. In addition, pharmacists had good knowledge of some aspects of palliative care, but misconceptions about other aspects. Pharmacists' beliefs and knowledge about palliative care predicted--and therefore underpinned--a positive attitude towards palliative care and the provision of services and supports for palliative care patients.

CONCLUSION

The results provide evidence that pharmacists need training and support to facilitate their involvement in providing services and supports for palliative care patients, and highlight areas that training and support initiatives should focus on.

Cancer Pain Management and Bone Metastases: An Update for the Clinician

Breast cancer patients with bone metastases often suffer from cancer pain. In general, cancer pain treatment is far from being optimal for many patients. To date, morphine remains the gold standard as first-line therapy, but other pure μ agonists such as hydromorphone, fentanyl, or oxycodone can be considered. Transdermal opioids are an important option if the oral route is impossible. Due to its complex pharmacology, methadone should be restricted to patients with difficult pain syndromes. The availability of a fixed combination of oxycodone and naloxone is a promising development for the reduction of opioid induced constipation. Especially bone metastases often result in breakthrough pain episodes. Thus, the provision of an on-demand opioid (e.g., immediate-release morphine or rapid-onset fentanyl) in addition to the baseline (regular) opioid therapy (e.g., sustained-release morphine tablets) is mandatory. Recently, rapid onset fentanyls (buccal or nasal) have been strongly recommended for breakthrough cancer pain due to their fast onset and their shorter duration of action. If available, metamizole is an alternative non-steroid-anti-inflammatory-drug. The indication for bisphosphonates should always be checked early in the disease. In advanced cancer stages, glucocorticoids are an important treatment option. If bone metastases lead to neuropathic pain, coanalgetics (e.g., pregabalin) should be initiated. In localized bone pain, radiotherapy is the gold standard for pain reduction in addition to pharmacologic pain management. In diffuse bone pain radionuclids (such as samarium) can be beneficial. Invasive measures (e.g., neuroaxial blockage) are rarely necessary but are an important option if patients with cancer pain syndromes are refractory to pharmacologic management and radiotherapy as described above. Clinical guidelines agree that cancer pain management in incurable cancer is best provided as part of a multiprofessional palliative care approach and all other domains of suffering (psychosocial, spiritual, and existential) need to be carefully addressed («total pain»).