Palliative care pharmacists study day
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Pharmacists working in palliative care need a broad outlook in order to respond to the many and varied queries they face. A study day, held on 12 September at St Christopher's Hospice in South East London, combined four different subject areas. Margaret
Gibbs, senior pharmacist, St Christopher's Hospice, reports
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Concordance in palliative care
From left to right: Margaret Gibbs, Andrew Dickman, Bel Morris,
Nick Avery and Gillian Arr-Jones |
There are three main influences on palliative care patients’ decisions
to take their medicines, said Bel Morris, principal pharmacist for cancer
and palliative care services, Sheffield Teaching Hospitals NHS Trust.
These are the provision of verbal and written information, relationships
with and support gained from professionals, family and friends, and good
communication between professionals.
Ms Morris undertook a research project to examine concordance among day
centre patients. She began her presentation with an overview of concordance,
quoting the somewhat demoralising fact that 50 per cent of patients fail
to take their medicines as directed and outlining some of the reasons
for this. Patients with chronic disease and the elderly tend to make “cost
versus benefit” decisions on whether or not to take a medicine.
Many patients make a reasoned decision not to take their medicine or
to reduce doses and many do not suffer ill effects as a consequence,
she said.
The opinions and experiences of friends and family can also have a considerable
influence on a patient’s tendency to concord, explained Ms Morris.
Semi-structured interviews with patients also confirmed that they were
more likely to take their medication as directed if they understood the
clinical need for it and the potential side effects.
Role of the National Care Standards Commission
Improving the quality of care services and protecting vulnerable people
who use these services are the two main aims of the National Care Standards
Commission (NCSC), said Gillian Arr-Jones, a pharmacist who is senior
professional adviser to the commission.
In co-ordination with other bodies, the commission’s aim is also
to ensure a consistent national approach, which is monitored for quality
of inspection and performance. The organisation has been pared down to
create nine regional and 71 area offices as opposed to 230 previous registration
and inspection units. These offices are now responsible for 40,000 establishments,
of which 160 are hospices. Ms Arr-Jones gave her view of her own professional
role, which she sees as providing channels for advice, exploration of
problems, enabling a discursive and consultative approach, operating
with open eyes and ears and “calming stormy seas”.
The national minimum standards that specifically refer to medicines were
then discussed covering the most commonly raised topics. These include
telephone prescribing, out-of-hours issues, use of products outside their
licences, use of patient group directions and keeping medicines for one
week after a patient’s death. She explained the importance of demonstrating
to inspectors that the relevant standards have been taken on board although
different hospices may have chosen to approach them with different solutions.
Ms Arr-Jones finished by reassuring participants that the future organisation — the
Commission for Healthcare Audit and Inspection (CHAI) — has a similar
agenda to the NCSC, with a main focus on assessment and quality (of care,
patients’ experiences and organisations) and a slight shift of
emphasis from inspections to the collation of intelligent information
to judge continuing performance.
New approaches to use of syringe drivers
It has been an eventful year in relation to syringe drivers with new
thoughts on site reactions, new injectable opioids and new devices
on the horizon, said Andrew Dickman, specialist principal pharmacist,
Whiston Hospital, Merseyside.
Mr Dickman suggested the possible causes of site reactions include
reactions to glass, infection, sterile abscesses, reactions to metal
needles, chemical
reactions in subcutaneous tissue, inappropriate pH and osmolality.
He went on to list the commonly implicated drugs, including cyclizine,
levomepromazine, metoclopramide and methadone.
He shared with participants the guidelines written by the Merseyside
and Cheshire palliative care network audit group. The guidelines incorporate
a step-wise approach, including changing the site, increasing the volume
of the infusion and changing the diluent to 0.9 per cent sodium chloride
(except for cyclizine).
Mr Dickman then discussed the recent introduction into practice of adding
low dose dexamethasone to the contents of a syringe. Although a recent
study has shown it to be effective in relation to site reactions, no
chemical testing or stability data has been provided and he believes
that it cannot currently be recommended.
The use of alfentanil in syringe drivers is proving a useful alternative
to diamorphine for patients with renal impairment. However, the place
for the newly launched oxycodone injection has yet to be established,
he said.
Concluding with a look at the future of the syringe driver, Mr Dickman
said that Graseby is launching a new model and eventually discontinuing
the MS26 and MS16A. The financial and practical implications of this
are enormous, he said.
Complementary therapies play part
There is good evidence and a wealth of clinical experience to show
that complementary therapies can treat many of the symptoms of terminal
illness, but they should only be used under the direction of a palliative
care specialist, said Dr Nick Avery, a GP, a homoeopath and a consultant
at the Centre for the Study of Complementary Medicine, London.
He provided evidence-based ratings for a number of complementary
therapies using a numerical rating scale similar to those used in
conventional
studies. Acupuncture scores five (good evidence with clear randomised
controlled trials (RCTs)). Mind-body therapies score four (RCTs showing
positive result but more research needed). Nutritional medicine, dietary
approaches and homoeopathy all score three (descriptive studies). |
