Care That Enhances Quality of Life

Latex gloved hand holding the hand of an elderly individual.

Palliative care requires an interdisciplinary approach, and pharmacists are partnering with other healthcare providers to offer team-based support and treatment for patients.

By Joseph A. Cantlupe

When they first learn about palliative care, some student pharmacists are initially somewhat hesitant and reluctant. Dr. Chris Herndon, a professor at the Southern Illinois University Edwardsville (SIUE) School of Pharmacy, recalled being instructed decades ago about palliative care. He dreaded it, feeling it was wrapped in death and dying. “I thought it was going to be God-awful,” Herndon recalled. “Now it’s my favorite thing.”

The prospect of working with families through serious or advanced illness was specifically unappealing. But then Herndon gradually learned what palliative care was all about, and now he thrives in its focus on whole-person care that provides relief from symptoms and stress of an illness to maximize quality of life and minimize suffering.

Herndon, also a clinical associate professor with the St. Louis University School of Medicine, works with chronic pain and opioid use disorder patients within a family medicine residency clinic. His scholarship interest has continually focused on pain and palliative care education. He was principal investigator for the National Institutes of Health Center of Excellence in Pain Education at SIUE and 2019 president of the Society of Pain and Palliative Care Pharmacists.

While assisting students working with palliative care patients, he noted that “they were surprised to find that once they got involved, it wasn’t going to be sad or morbid or depressing. They were just blown away by how rewarding it was to work with patients and families of those seriously ill.” It also forced students to “think about the dynamics of the family situation and the caregiver situation.”

The term “palliative care” tends to cause confusion. The World Health Organization and the U.S. Department of Health and Human Services both stipulate that the tenets of palliative care include a patient-centered and family-centered approach to care with the goal of maximizing quality of life while minimizing suffering. That can be achieved through physical, psychosocial and spiritual means and can involve specialists such as chaplains or even music therapists. As members of interprofessional teams—along with physicians, nurses, social workers and others—pharmacists are becoming increasingly involved in palliative care. Pharmacists also are playing key roles in medication use management, as practitioners evaluate patients’ pain control as well as their emotional and spiritual needs.

A Collaborative Effort

As pharmacists expand their roles in care teams providing palliative care and hospice treatment, their work has been magnified due to the COVID-19 pandemic, which has now claimed 1 million American lives. Academic pharmacists like Herndon are promoting palliative care instruction, which has been slowly emerging at some pharmacy schools. It is being taught in the curriculum as well as through didactive and experiential education rotations so students can explore career options in the palliative care field. Advocates would like to see more pharmacy schools enhance their programs and encourage students to consider careers that include palliative care.

Dr. Maria Felton Lowry, an assistant professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy and a palliative care specialist at the University of Pittsburgh Medical Center Palliative Supportive Institute, said too often palliative care instruction has been ancillary to other courses “squeezed into an hour.” When Lowry graduated from pharmacy school in 2015, “there was no integration of palliative care into our curriculum,” she said. Pharmacists play a crucial role in palliative care, which helps alleviate patients’ pain, anxiety and nausea. “Pharmacists need to be part of that team early on.”

Talking to patients underscored the importance of palliative care, not only among team members but also among the patients themselves, Lowry said. “Finding what this magic we were doing, coming together as a team and asking questions in a different way, treating the whole person.”

ASHP guidelines on the Pharmacist’s Role in Palliative and Hospice Care indicate that palliative care rose from the modern hospice movement and evolved significantly over the past 50 years. While palliative care is meant to enhance a person’s care by “focusing on quality of life for them and their family,” according to the National Institute on Aging, “hospice care focuses on the care, comfort and quality of life of a person with a serious illness who is approaching the end of life. Like palliative care, hospice provides comprehensive comfort care as well as support for the family, but in hospice, attempts to cure the person’s illness are stopped.”

Dr. Rabia Atayee, professor of clinical pharmacy and associate dean for admissions and outreach at the Skaggs School of Pharmacy and Pharmaceuticals Sciences at the University of California, San Diego, said there is a misconception about palliative care that it is strictly for end of life. “It is much more than that,” she said. “In fact, studies have shown that palliative care, if offered early, can help people live longer with fewer symptoms.” Her major research focus is in the area of pain and palliative care, as well as a focus on pharmacy education. She is developing and expanding pain and palliative care clerkships for student pharmacists. For students, “the biggest surprise is the emotional aspect; they get very emotional when there is devastating and serious illness and they are confronted with taking care of another human being,” she said.

“Access to palliative care education is limited and variable across pharmacy schools,” said Dr. Kashelle Lockman, a clinical assistant professor at the University of Iowa College of Pharmacy. “It is an important and overlooked and underappreciated topic. That’s surprising given that the first vow in the Oath of a Pharmacist is ‘I will consider the welfare of humanity and relief of suffering my primary concerns.’”

As a student pharmacist, Lockman explored geriatrics and palliative care pathways and “had never heard of palliative care and had no idea that pharmacists could be involved in hospice” until learning about palliative care in an ethics class in her first year at University of Maryland School of Pharmacy. Lockman went on to complete the school’s Geriatrics and Palliative Care Pathway. She loved the whole person approach to care and focusing on what matters most to each patient, noting, “We learned about the human approach to medicine. With all the medicines we can offer, what does each mean to them as a person and how does that fit into their family and culture.”

There are very good studies showing that superior and good outcomes occur when palliative care is implemented earlier. In the trajectory of serious illness, it behooves the patient, the families and everybody to incorporate palliative care at the time of diagnosis of serious illness whether it’s cancer, Parkinson’s disease or dementia.

Dr. Mary Lynn McPherson

An Extra Layer of Support

Advocates for palliative care education are seeing increased enthusiasm from students who are sometimes surprised and enthralled by the scope of care offered and are interested in the potential career opportunities. One of the most extensive offerings is at the University of Maryland School of Pharmacy within the Doctor of Pharmacy program, and their new Ph.D. in Palliative Care program that launched in August 2021. The Ph.D. complements their online M.S. and graduate certificates in palliative care, and they just enrolled their second Ph.D. class of 17 interprofessional learners.

Dr. Mary Lynn McPherson, professor and director of Advanced Post-Graduate Education in Palliative Care in the Department of Pharmacy Practice and Science, launched the Graduate Certificate Program and M.S. program in Palliative Care at the University of Maryland. McPherson pointed out the many different tentacles of the work: not only understanding pain and symptoms, but recognizing the psychological, spiritual and financial care involved.

“Palliative care is like an extra layer of support. We have to tend to all of the patients’ needs because we are committed to person-centric care,” she told the campus newspaper. “Our palliative care programs were a hit right out of the gate. The Master of Science Program is amazing and many students didn’t want the journey to stop. There are only three or four Ph.D. programs in palliative care in the world, and I strongly felt it was time to have one in the United States. I believe this program meets a pressing need in the palliative care field.”

With a growing number of people suffering from chronic, progressive and ultimately fatal diseases, the need for instruction is imperative, McPherson emphasized. She noted the importance of the pharmacist as part of an interdisciplinary team and evaluating medication prescriptions and “deprescribing” them if necessary, in consultation with family and patients related to their overall condition, pain and life goals.

“There are very good studies showing that superior and good outcomes occur when palliative care is implemented earlier,” McPherson said. “In the trajectory of serious illness, it behooves the patient, the families and everybody to incorporate palliative care at the time of diagnosis of serious illness whether it’s cancer, Parkinson’s disease or dementia.” As professors discuss palliative care in their courses, they must emphasize the need for interdisciplinary teams, which is at the heart of their programs, added Atayee.

“Working as a team is very hard,” Atayee acknowledged. “Ours is a group of highly skilled individuals, all passionate about palliative care and that need to come together to provide good patient care. It takes time to develop working relationships, respect and appreciation for what each team member provides.”

In an academic paper, she mentioned the importance of working as a team, and even having a daily lunch together. Atayee discussed spending “30 minutes a day appreciating each other as human beings so that we can present together when we are taking care of each other as human beings.” Atayee, Herndon and Lockman coauthored a paper outlining the role of a pharmacist on a “transdisciplinary palliative care team” and highlighted the need for “adequate instruction on palliative care and clinical reasoning skills in schools of pharmacy.”

“Delivery of a palliative care elective in the pharmacy curriculum significantly increases both student confidence in their palliative care skills and their clinical reasoning skills in these areas,” they wrote. Lockman said it is important to properly prepare pharmacists for interprofessional palliative care practice. “That is one of the key components that makes our program valuable and successful,” she said.

Outlining the University of Iowa’s offerings, Lockman said the college integrated 18 classroom hours of non-pain palliative care and 32 classroom hours of pain management across eight required courses. Since 2016, all student pharmacists spend 50 hours of class time on the principles of palliative care/primary palliative care. The program offers four elective courses in palliative care. Since 2017, 220 students have taken at least one palliative care elective and 36 students have graduated with a 17-credit hour palliative care certificate since 2019. Board certification in palliative care is not yet available for pharmacists, Lockman noted.

“Chaplains, music therapists, advance practice providers, social workers, nurses and physicians all teach in our palliative care courses,” she said. “Not all schools have access to this kind of resource.” With the university being a grantee of the Cambia Health Foundation Sojourns Scholar Leadership Program, Lockman said she is collaborating with palliative care faculty and team members across the country to create a curricular toolkit for palliative care education. “My goal is to expand knowledge of primary palliative care and palliative care as an approach to patient care, in addition to allowing students to explore the idea of palliative care as a specialty. My vision for pharmacy practice in the United States is that pharmacists attain and practice primary palliative care skills. All families deserve access to palliative care, and not just in the final days. Until we expand the reach of palliative care education beyond a few institutions, this will not be possible.”

Joseph A. Cantlupe is a freelance writer based in Washington, D.C.