There is a growing need for palliative care pharmacists in the United States. There is also a gap in the education of palliative care for pharmacy students. To address both, pharmacy schools must develop and disseminate palliative care-focused experiences, including traditional didactic lectures, problem-based learning, interactive skills, laboratory- and web-based experiences. This commentary presents the need for palliative care-focused experiences in the Doctor of Pharmacy (PharmD) degree program, and how schools can take smaller steps to tackle this issue.
"I don't understand. Isn't there something you can do to help? He can't even interact with us and he looks like he's suffering. There has to be a medication for this, right?"
Caring for an 83-year-old African American male suffering from terminal delirium second to Alzheimer's dementia and his family may be a rare experience for a pharmacist but the themes this vignette presents are not. Every day pharmacists are faced with difficult cases where today's binary world of evidence-based literature, organizational guidelines and multiple-choice examinations fall short of the knowledge, skills and attitudes needed to navigate the gray areas of pharmacy. To add, every day pharmacists prioritize a patient's quality over quantity of life. Every day, maybe even without recognizing it, pharmacists are palliative care providers.
According to the World Health Organization, palliative care is an approach that improves the quality of life of patients and their families facing problems associated with serious illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. A serious illness requires continuing treatment by health care providers and includes conditions such as cancer, dementia, congestive heart failure and chronic obstructive pulmonary disease. Palliative care is often given in conjunction with curative therapies. The ratio of palliative versus curative therapies depends on the patient's functional status, prognosis and care goals. The palliative care approach has been referred to as "the three C's": comfort, communication and coordination. Palliative care providers are experts in the management of pain and other symptoms. As patients with serious illness often face challenging decisions, palliative care providers are trained to conduct high-quality discussions about a patient's goals. Understanding these goals allows all providers to align and improve care coordination. Coordination is particularly important if a patient decides to elect the Medicare Part A hospice benefit.
Hospice care, a subset of palliative care, is for people who are terminally ill and have opted for a comfort treatment plan. Terminally ill is defined as a prognosis of six months or less. Hospice services are provided to patients by nongovernmental agencies and are regulated by Medicare Part A. Through the hospice benefit, patients receive access to a hospice physician, nurse, social worker, and chaplain; medical equipment and supplies; short-term respite care; access to an inpatient facility for aggressive pain and symptom management; and prescription medications related to the hospice diagnosis. These services are provided at a low or no out-of-pocket cost to the patient. To supplement costs, Medicare provides the hospice agency a per patient, per diem rate.
Pharmacists play a crucial role in the specialty of palliative care. In clinical practice, palliative care providers will work within hospice care agencies, or upstream within palliative care service lines in health care systems (hospitals, clinics, nursing homes, or home-care groups). Guidelines regarding the role of palliative care pharmacists have been published through the American Society of Health-System Pharmacy (ASHP). Essential, clinical and administrative roles are listed in Table 1. Palliative care clinical pharmacists can improve patient outcomes through the rational use of medications within each of "the three C's." First, comfort can be improved as medications remain the cornerstone of symptom management. Second, as patient-specific goals are established, a palliative care clinical pharmacist can extrapolate and make changes to the patient's medication regimen to reflect. Specifically, a palliative care clinical pharmacist can deprescribe potentially inappropriate or unnecessary medications. Deprescribing can also help ease a patient's transition to hospice care. Hospice agencies usually operate under specific formularies to optimize drug spending. A palliative care clinical pharmacist can improve coordination by considering the clinical utility of a medication and whether it would be covered by the hospice formulary. Palliative care clinical pharmacists also can lead formulary decisions or participate in medication preparation and dispensing.
There is a growing need for palliative care clinical pharmacists in the United States (US). A 2014 Center to Advance Palliative Care (CAPC) report found only 56 of 389 (14%) inpatient palliative care programs included a pharmacist. As the population continues to grow, this gap will only widen. The US Administration on Aging predicts that by 2030 there will be more than 72.1 million Americans over 65 years of age, and CAPC predicts at least 6 million of those could benefit from palliative care.[10,11] Palliative care has been shown to improve patient outcomes and increase value to health care systems. In a landmark 2010 clinical trial, patients with newly diagnosed metastatic non-small-cell lung cancer randomized to receive early palliative care integrated with standard oncologic care, over standard oncologic care alone, had a better quality of life, less depressive symptoms, and most importantly, longer survival despite less aggressive care. Less aggressive care included the reduction of potentially inappropriate or unnecessary medications.
There are many reasons for this growing need in clinical practice. First, hospice regulations specify the hospice team must include doctors, nurses, social workers and chaplains. The team can also include volunteers and therapists such as physical or music. Pharmacists are not required. Moreover, in many states, pharmacists cannot bill third party payers for services. Pharmacists practicing in palliative care are often not revenue generating sources for health care systems. Nevertheless, it is possible through the implementation of collaborative practice agreements that pharmacists can reduce physician and advance practice provider burden and time, and further improve outcomes.
There is also a gap in the pharmacy curricula. A 2013 survey-based study found 82% of pharmacy schools (N=61 respondents, 49% response rate) reported offering palliative care or end-of-life education. This was a small increase from a 2003 study with a similar design. Both studies noted only an average of 6 hours of curriculum time devoted to this material. When considering the total hours of didactic and experiential learning for a typical student pharmacist (approximately 400 hours), this accounts for less than 1% of the total curriculum time. Unfortunately, postgraduate opportunities are also limited. As of December 2018, there are only 25 pain and palliative care postgraduate year two (PGY2) programs, and a few traineeships and online programs available for pharmacists in the US.[6,16]
In 2012, the Pain and Palliative Care Strategic Planning Summit published recommendations to improve the education of palliative care for pharmacists and student pharmacists. Within the PharmD program, six 50-minute lecture equivalents are recommended (Table 2). Most of these lectures focus on the management of pain and other symptoms. Since the Summit, the role of the palliative care pharmacist continues to evolve. There is now special recognition for the emotional, ethical, and economic costs of inadequate or overly aggressive care of those with serious illness. Palliative care clinical pharmacists are now developing and implementing pharmacist-driven deprescribing and transitions of hospice care programs.
To address the growing need in clinical practice and gaps in the pharmacy curricula, pharmacy schools must develop and disseminate palliative care-focused experiences. Pharmacy schools can select from a variety of pathways, and Introductory Pharmacy Practice Experiences and Advanced Pharmacy Practice Experiences, and/or Areas of Concentrations or certificate programs can be valuable for those looking to specialize in palliative care after graduation.
Even if student pharmacists do not choose to specialize in palliative care, the knowledge, skills and attitudes developed through palliative care-focused experiences can be applied to many fields of pharmacy practice. Pain is one of the most common reasons a patient accesses the health care system. Pharmacists equipped to manage pain and other symptoms are necessary for today's climate. Additionally, deprescribing is necessary for all populations. It has been estimated that drug-related morbidity and mortality in the US costs over $200 billion annually. Potentially inappropriate or unnecessary medications likely contribute to this; these medications have been associated with an increased risk of adverse drug events, drug interactions, medication non-adherence and reduced functional capacity. Evidence has also suggested these experiences improve attitudes toward end of life and have been shown to decrease burnout.[23,24] This is especially important as a 2015 survey-based study of pharmacy residency program directors noted pharmacy residents could be better prepared for the emotional challenges of patient care.
Palliative care-focused experiences highlight and focus on skills of empathy, critical thinking and communication. Empathy is necessary to establish a level of trust between the patient, family and pharmacist. Health care provider empathy increases patient satisfaction and may even lead to better health outcomes. Despite this, empathy in clinical encounters is often lacking and research suggests empathy in health science students decreases as they progress through graduate training.[26,27] Critical thinking has been identified as a chief outcome of pharmacy school education. Student pharmacists upon graduation must be able to examine issues rationally, logically, and coherently as much of professional practice is problem-solving. Unfortunately, a 2009 prospective study conducted at a pharmacy school in North Carolina found no differences in critical thinking over one academic year. Interpersonal communication skills are also important for student pharmacists to master. Literature suggests regrettably that student pharmacists may not recognize their verbal communication deficiencies and therefore focused experiences are needed to teach these skills.[29,30]
The vignette presented at the beginning of this commentary will be revisited to defend the importance of these skills. Empathy is vital to strengthen the relationship between the pharmacist and family of the 83-year-old African American male suffering from terminal delirium second to Alzheimer's dementia. Critical thinking is necessary to determine the role of antipsychotics, and to identify possible deliriogenic-contributing or deprescribing-eligible medications. Critical thinking is also needed when conducting a nonverbal symptom assessment, especially when considering if inadequately treated symptoms are contributing to the delirium. Communication is essential when distinguishing care goals and aligning care coordination.
Incorporating palliative care-focused experiences into the PharmD curricula for the benefit of student training also benefits pharmacy schools. These experiences will improve a school's ability to meet the Accreditation Council for Pharmacy Education (ACPE) Standards. Appendix B of the 2011 Standards acknowledges the importance of palliative care and principles of end-of-life care as clinical science curricular content suggestions. In addition to improving skills of empathy, critical thinking and communication, palliative care-focused experiences notably bridge the gap between basic science and pharmacy practice. For example, pain management requires knowledge of pathophysiology, hypothesized mechanism(s) of action, as well as the pharmacokinetic and pharmacodynamic properties of medications. Though unlike the management of high blood pressure, an unbiased symptom assessment and medical chemistry extrapolation in lieu of evidence-based guidelines is necessary to determine the most rational medication regimen.
Incorporating these experiences will also elevate the PharmD curricula to equal its health science colleagues. In fact, the 2012 Summit was held partially in response to the then efforts to improve the education of physicians, nurses and social workers. A raw and limited December 2018 Pubmed literature search found almost 900 peer-reviewed articles involving the education of physicians, over 400 articles involving the education of nurses (search criteria: ("Palliative Care"[MeSH]) AND "Education, Medical/Nursing"[MeSH]), and close to 50 articles involving the education of social workers (search criteria: ("Palliative Care"[MeSH]) AND "Social Work"[MeSH]) AND "Education"[MeSH]). Only 21 articles were found regarding the education of pharmacists (search criteria: ("Palliative Care"[MeSH]) AND "Education, Pharmacy"[MeSH]). Currently three design themes have been used for palliative care-focused experiences within health science schools (Table 3): traditional didactic courses; interactive skill laboratory or end-of-life simulations; and web-based experiences. Various assessment methods have also been considered, including knowledge assessments or grading rubrics, reflective journaling or interviews, and surveys exploring attitudes and competencies with end-of-life experiences. Most experiences have been created for specific disciplines, while some have been interprofessional.[35–47]
Schools looking for small steps to incorporate palliative care-focused experiences into the PharmD curricula may look to Table 3 for reference. Many of these learning designs and assessment methods are already used by schools (eg, patient simulations), therefore finding places within the curriculum to adapt, or combine with, may be feasible and achievable. As palliative care is often given in conjunction with curative therapies, schools may not need to remove specific lectures or concepts to make room for these experiences. Also, any pharmacy practice faculty member can lead or drive these experiences. Broad concepts of palliative care are present in all other specialties, therefore even those faculty members who do not identify as palliative care clinicians can direct or participate.
An ideal palliative care-focused experience should include a novel approach of interactive skill laboratories or end-of-life simulations, plus web-based experiences. The Summit recommendations advocate for research and innovation in teaching methods and curricular design, including case study developments and pedagogical models which encourage interprofessional learning. ACPE Standard 10 discusses the need for student pharmacists to develop problem solving and critical thinking skills and encourages the use of active learning methods with the goal to develop self-directed, lifelong learners. Laboratories or simulations are best to develop and evaluate skills of critical thinking and communication. To maximize curriculum time and the school's resources, web-based experiences may help scale and disseminate other didactic learning objectives to student pharmacists or to include other disciplines. Technology already plays a central role in pharmacy and palliative care education, as well as our culture.[48,49] Web-based experiences may help develop and evaluate a student pharmacist's empathy through the presentation of case-based studies.
Every day pharmacists are palliative care providers, even if they do not identify as one. However, the specialty of palliative care puts a spotlight on the skills necessary to place quality over quantity of life. Incorporating palliative care- focused experiences within the PharmD program will not only help pharmacy schools better meet ACPE Standards but provide skills to all student pharmacists that transcend every specialty and patient population. Novel approaches can be used and are encouraged to adapt current experiences or combine with others within the curriculum.
The authors would like to acknowledge Maria Felton, PharmD, Michelle Howerton, PharmD, Emily Bobrzynski, PharmD, Lindsay Jablonski, PharmD, and Barbara Grden, PharmD, for their assistance with the content of this manuscript.
Am J Pharm Educ. 2019;83(5) © 2019 American Association of Colleges of Pharmacy