A Pharmacist – A critical member of the palliative care team

A Pharmacist – A critical member of the palliative care team

– Mr Fazle Noor Biswas, Bangladesh

According to the World Health Organization (WHO), pharmacists along with physicians, nursing and other health professions, play an important role to alleviate total suffering and improve the quality of life of their patients and their caregivers. An estimated 56.8 million people low and middle income countries (LMICs) currently seek palliative care services. Available evidence also highlights the importance of including pharmacists in palliative care teams to reduce the team’s workload among other benefits.

I have been working with palliative care teams since November 2011. The successful completion of a 3-day introductory course in palliative care was the turning point in my life as it motivated me to choose a career in palliative care instead of joining a pharmaceutical company. In March 2024, I participated in the ‘IAPC’s Certificate Course in Palliative Care Pharmacy’ which helped me to revise and update my knowledge with best practices. In this article, I would love to share a few of my experiences which spotlights a pharmacist’s role within a palliative care team, which contributed in delivering quality patient care.

Usually, I visit and counsel patients on the first day of their admission in our palliative care ward. Often, several patients and their caregivers also reach out to me to further understand the details of the medication prescribed and the ways of its administration. One day a patient who was admitted to our palliative care ward was experiencing moderate to severe pain. During my ‘first meeting’ I went through his prescription and noticed that our Doctor had prescribed oral tramadol to manage his pain. As I began taking his medication history and reviewed the medications he was currently on, I realized that he was already taking oral morphine which was prescribed by his former treating doctor. I then had a discussion with our doctor to share this input on how one should be prescribed a weak opioid and a strong opioid at the same time, as per the WHO Drug Ladder. The patient was then advised to continue taking morphine instead of tramadol, as his pain score was 8. This episode reiterated to me the importance of having a Multidisciplinary team caring for a patient. My presence in the team ensured that we all complement each other’s strengths to ensure that our patient received superior level of care.  

Next, I wish to highlight how a pharmacist’s domain knowledge can help enrich the collective knowledge of the team. While reviewing the medication chart of our new admissions one day, I noticed that he was currently administered both oral metoclopramide and hyoscine butylbromide. You see, both of these drugs are contraindicatory and must never be prescribed together. Upon learning this, I immediately I flagged this issue with our doctor. He then conducted a comprehensive assessment of our patient and omitted the prescription of hyoscine butylbromide.

Being a pharmacist, I have the opportunity to work alongside most of my patient’s caregivers. With each of our interaction, a bond sometimes develops as I am able to actively listen and address their queries when it comes to medication prescription and administration. As I am writing this article, I can recollect innumerable moments of love that I have received from my patients. Once, one of my pediatric patients gave me a beautiful garland which she had made herself. Another special moment for me was when I surprised my patient by visiting her home, after learning that it was one of her wishes to meet me but was unable to come to the hospital due to her deteriorating health. The surprise in her eyes and the smile on her face is something I will always remember and hold close to my heart. The next time was when one of my patient’s ensured that his wife brought me mangoes, litchis, and milk, as it was one of his last wishes to present these gifts as a token of his love.

So, you see a pharmacist has a critical role in caring for the patients and their caregivers and should be an integral part of the treating team. A pharmacist’s key responsibilities in palliative care can therefore be categorized into 3 sections:

Clinical responsibilities

• Participate in multidisciplinary team rounds, clinical meetings and patient’s bedside visit to improve medication management
• Monitor patients closely and assess their pain and other symptoms and help in symptom management
• Review medication orders and give pharmacotherapy recommendations like rationalizing of therapy, initiating therapy, dose adjustment, opioid conversion calculations, recommend alternative route of administration, dose frequency, off-label prescribing, complementary medications, tapering medications etc.
• Monitor adverse drug reactions (ADR’s) and document the ADR form.
• Therapeutic drug monitoring (TDM) to assess clinical improvement of symptoms.
• Update and maintaining a patient’s medication summary sheet.
• Counsell and educate patients and their caregivers about symptom management protocols, prescription, medication advice like drug dosages, how to administer, importance of medicine compliance e.g. take morphine on time to ensure adequate pain relief, anticipated side effects etc.

Non-clinical responsibilities

• Educate and train members of the team and hospital about new clinical guidelines, newly approved medications, indications, strengths and new packages, withdrawals of medications from the market etc.
• Enrich one’s own knowledge to say updated and build professional networks by attending conferences, workshops and join committees such as ‘pharmacy and therapeutics’ committee, ‘antimicrobial stewardship’ committee etc.
• Extemporaneous compounding of non-commercially available medications and formulations – e.g. morphine syrups, intravenous preparations etc.
• Assist with medication choices when financial issues are a significant problem, by suggesting less expensive alternatives.
• Develop medication formulary, develop policies for symptom management protocols and medication use
• Organise prompt and efficient supply of medications at a patient’s doorstep in dosette boxes
• Participate in clinical research to develop new treatments.
• Ensure pharmacy inventory management.

Administrative

• Communicate and liaison with regulatory and licensing agencies
• Ensure that pharmacy and narcotic licenses are valid
• Forecast and manage the annual budget, tenders to purchase medication and evaluate vendors
• Communicate with pharmaceutical vendors, follow-up medicine delivery process, checking batch number, manufacturing date, drug administration approval number, physical appearance of packaging etc.
• Facilitate the lowering of costs without compromising the quality of care and products

The inclusion of a pharmacist as a core member of the palliative care team especially in LMIC’s will significantly enrich the value of the team and improve the quality of care delivered by the team.