The pharmacist’s role in palliative care – a perspective from Bangladesh

In caring for people with palliative care needs, pharmacists have much to offer. They can work either as a clinical pharmacist, in the in-patient department of a hospital, or as a community pharmacist, serving those with palliative care needs in the community.

They provide medication reviews, education to people and families seeking out their services, and advice to physicians about a person’s pharmacotherapy.

A good relationship based on trust

A good relationship with those accessing care is very important to providing total care. A trusting relationship with the pharmacist offers a strong basis for the psychological and social support needed by the person accessing care and their family.

The pharmacist, along with other healthcare professionals, can support this person and their family members in coping with the difficult situation and taking the right decisions in these situations.

Pharmaco-therapeutic advice, education and research

Pharmacists can provide recommendations to clinicians for appropriate therapy, and education to people and the palliative care team about medications and monitoring of therapeutic responses.

Often people accessing palliative care are taking many medications. The pharmacist can advise the palliative care team about the right choice of medicine, the most appropriate dose and dosage form.

They can also advise detection of side effects, e.g.: constipation due to morphine, or medication interactions, e.g.: morphine with sedative or antihypertensive.

For people who have difficulty remembering to take their medication, the pharmacist can provide ‘compliance aids’. They can also advise on medication preparations or combinations for syringe drivers, or for people with swallowing difficulties.

The pharmacist may also assist with medication choice when financial issues are a significant problem.

Pharmacists can educate the palliative care team on pharmacology of palliative care medications, including new medications, and may actively participate in palliative care research work.

Community pharmacists

Community pharmacists are very important for the distribution of rarely used medications (such as morphine) to ensure these are available when they are needed, especially at night and at weekends.

They may organise systems to stock small amounts of these medicines for palliative care in community pharmacies.

A survey conducted in Australia and Canada on the role of pharmacist in palliative care^[1], showed that approximately 70% of respondents in each country who worked on palliative care provided specific service on pharmacotherapy, administrations, treatment, advice effects and incompatibilities.

Physicians completed a satisfaction survey^[2] and reported that top three useful activities of the pharmacist were:

1. additional time spent with patients without physicians presents (91%)
2. pain and symptom management (82%); and
3. psychosocial support (73%).

Challenges faced by the pharmacist

The most common challenges I face in my work are as follows:

• some patients come to palliative care with complex neuropathic pain, which is very difficult to manage
• in palliative care, pharmacists have many duties to perform, so time management is key
• sometimes communicating with paediatric or young patients and their families is challenging for the pharmacist
• availability and accessibility of opioids, especially morphine, is another challenge
• myths about morphine among healthcare professionals and patients make them reluctant to prescribe or use these helpful medications
• narcotic laws for production of morphine and stock of morphine is another issue. Due to these laws, pharmaceutical companies are not interested to take initiative for morphine production and retail pharmacies are not interested to stock morphine.

The value of the pharmacist in the palliative care team

A study presented at American College of Clinical Pharmacy (ACCP) 2015 Global Conference, concludes that: “the inclusion of pharmacists on palliative care team can reduce pain and save money.”^[3]

The authors reported that, after a pharmacist’s intervention, there was decrease in the average acute pain score of 2.6 points on a 10 point pain scale and a decrease in the average chronic pain score of 2.8 points.

They estimate that pharmacist’ recommendations for the discontinuation of unnecessary medication that did not support palliative care goals could save up to $100,000.

Palliative care is everyone’s business

Palliative care is everyone’s business, including the pharmacist.

The pharmacist works with physician and nurse members of the inpatient and outpatient services to capitalise on available evidence to develop and revise cost-effectiveness and consistent medication options for inpatient and outpatient symptom management protocols.

Every community palliative care service should have a pharmacist. It would be a huge loss to any palliative care team not to include a pharmacist.

The role of the palliative care pharmacist in Bangladesh

In Bangladesh, pharmacists working in hospital or in palliative care not a popular job. After completing the graduation, pharmacists will typically choose to start working in pharmaceutical companies.

Recently, graduate pharmacists have been recruited by private hospitals, but this has not yet extended to palliative care.

The Centre for Palliative Care (CPC) at BSMMU is the only large (20 bed) palliative care centre in Bangladesh.

A few more palliative care units have opened in government and private hospitals, but as yet, they have no pharmacist on their team.

Since 2011, I have been the only palliative care pharmacist working in CPC. There is one community palliative care center in Munshiganj District where a community pharmacist started working.

In Bangladesh, palliative care is a new concept in the medical sector. Therefore, working as a palliative care pharmacist is almost a new experience for me. I have duties and responsibilities to the people who access my services and their families, and I am trying to give my best effort for them.

Conclusion

I want to build up my career as a palliative care pharmacist and spread my knowledge to the other pharmacists about palliative care, pain and other symptom management, as well as highlighting the role of the pharmacist in palliative care among the health professionals.