Hospice and Palliative Care Pharmacists Association
Challenging issues in palliative care
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On 12 September, the Hospice and Palliative Care
Pharmacists Association held a study day in conjunction with the
education centre of St Christopher’s Hospice in south-east
London. Margaret Gibbs, senior pharmacist at St Christopher’s
Hospice, who chaired the meeting, reports
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Palliative care pharmacists work in one of the most multidisciplinary
of specialties but, within that environment, they are professionally isolated.
Their work typically involves dealing with both clinical and procedural
issues. Although clinical information in palliative care has become much
more available and accessible in recent years, particularly since the
publication of the Palliative Care Formulary and its availability on-line,
the procedural and legal conundrums that arise can often be more challenging.
Non-medical prescribing
One of the issues that has implications for palliative pharmacists’
practice is non-medical prescribing. Palliative care has been selected
as one of the particular areas potentially suited for nurse prescribing,
but there are a number of anomalies that still need to be clarified.
Beth Taylor, regional principal pharmacist, community care, has been involved
in the development of non-medical prescribing from the early stages and
she explained why the situation is still somewhat confused. First, the
speed of the implementation process recently seems to be taking practitioners
by surprise and, secondly, there is confusion between patient group directions,
independent prescribing and supplementary prescribing. Mrs Taylor explained
how these three areas need to be looked at together as part of an option
appraisal in order to choose which, if any, would improve practice. She
suggested how such an appraisal might be carried out in a given clinical
area.
She suggested that independent prescribing would probably be best suited
to an area where nurses aim to complete an episode of care, such as a
minor injuries clinic. PGDs would be best for situations where prescribing
follows a predictable pattern, such as immunisation clinics, and supplementary
prescribing would be suited to chronic disease management.
Mrs Taylor acknowledged that although supplementary prescribing may be
appropriate for palliative care in some respects, the exclusion of Controlled
Drugs and off-licence indications make it limited in scope at present.
An extra burden to hospices with their restricted income is the financial
implications of training. For extended formulary nurse prescribing, this
is currently 25 taught days and although there may be funding for the
further education costs, there is none for replacing the staff who are
being trained. Another financial question — Who pays for nurse prescribing?
— has been resolved, since future prescribing budgets in primary
care are now managed by primary care trusts.
Topical opioids
Dr John Zeppetella, consultant and deputy medical director, St Joseph’s
Hospice, London, has a particular interest in the treatment of episodic
pain in cancer, shown by a survey at St Joseph’s to be a problem
for many patients. Dr Zeppetella highlighted the main problem with its
current management: although most episodic pain comes on rapidly and recedes
within about 30 minutes, the oral opioids currently used for “rescue”
analgesia have an onset of action of about 15 to 30 minutes but a duration
of around four hours. This can sometimes mean that the pain has passed
before the analgesic starts to act and then the patient is left feeling
drowsy for the next four hours.
Dr Zeppetella acknowledged the oral transmucosal fentanyl citrate product
and then provided background research and case studies where he has used
fentanyl, both nebulised and intranasally, to treat episodic pain successfully.
He highlighted the potential problems for using these routes, including
unpredictable drug distribution and metabolism, but the non-invasive,
painless nature of these routes along with their fast onset and short
duration of action may be of great potential benefit in palliative care.
Dr Zeppetella also spoke about the topical use of opioids on painful wounds.
They are currently being used widely, although the evidence of their efficacy
in this indication is anecdotal. Opioid receptors have now been identified
peripherally both in inflamed tissue and sensory nerves, but so far trials
have only shown so far that they are effective for post-operative pain
after intra-articular administration. Dr Zeppetella has been involved
in a pilot study to look at the three main issues for the use of morphine
and diamorphine for painful wounds in the palliative care setting —
efficacy, stability and establishing whether this is a truly peripheral
or a central effect. Once the results of the pilot have been published,
it is hoped that a bigger trial might be started.
Off licence drugs
Colin Hardman, a pharmacist with extensive palliative care experience,
was awarded a Wilkes fellowship in 1999, which enabled him to carry out
a project looking at this issue of the use of drugs outside their licence.
His survey found that specialists in palliative care were prescribing
many drugs outside their licence on a regular basis. Mr Hardman posed
the question: “Who needs to know?”
Although there is guidance on the subject in a Royal Pharmaceutical Society
factsheet and a published statement from the Association of Palliative
Medicine, the practice and its implications are not widely
disseminated to general practitioners, community pharmacists and patients,
mainly because of the extra burden this would incur.
Prescribing decisions are influenced by a number of factors, including
safety, evidence, severity of illness and licensing, and patients are
owed a duty of care to ensure that the drugs they receive have been appropriately
prescribed. Although there is plenty of clinical experience with the drugs
used beyond their licence in palliative care, Mr Hardman believes that
awareness in this area needs to be greater for everyone concerned. He
is planning to produce patient information leaflets for palliative care
patients in the future. Meanwhile, some hospices have produced their own
generic leaflets to reduce confusion and misunderstanding for patients
reading the patient information leaflets that come with their medicines.
Improving out-of-hours palliative care
Dr Nigel Sykes, consultant and head of medicine, St Christopher’s
Hospice, London, said that most cancer patients spend 90 per cent of the
last year of their life at home and that 76 per cent of the week is actually
“out of hours”. Improving out-of-hours care is a national issue,
with a Department of Health Implementation Group soon to publish guidelines.
Palliative care is an area where the current differences in availability
can have enormous consequences. Dr Sykes provided examples of these differences
from a survey carried out in the South London Palliative Care Network,
which comprises 11 specialist palliative care services. His survey showed
that what is provided out of hours ranges from 24-hour visiting and telephone
advice to nothing at all. The two main barriers to effective palliative
care out of hours identified were access to the necessary drugs and availability
and responses of district nurses. Dr Sykes said that although a number
of pharmacy schemes are in existence they are often underused, possibly
because of delays involved. He suggested that GPs should have access to
the necessary drugs, with pharmacy schemes providing a follow-up. He stressed
the importance of anticipation in the management of symptom, which can
help to minimise out-of-hours dilemmas.
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