Managing medicines at the end of life: a position paper for health policy and practice

Utilizing Dexmedetomidine for Opioid-Resistant Pain and Anxiety in the Palliative Care Unit: A Case Report on Efficacy, Withdrawal Challenges, and Protocol Adaptations

Dexmedetomidine (Precedex™) has proved useful in palliating anxiety and intractable pain in patients at the end of life. However, abrupt cessation can precipitate withdrawal, which is highly unpleasant and potentially dangerous. Here, we present the case of a patient whose intractable pain was successfully palliated with a dexmedetomidine infusion but who then developed severe withdrawal when the infusion was stopped with a change in her plan of care. We present a review of the literature around transitioning patients off dexmedetomidine and highlight the need for more guidance on nonintensive care unit management of its side effects and alternatives.

Family Caregivers in Palliative Care Therapeutic Management: An Integrative Review

In palliative care, family caregivers are partners of multidisciplinary teams in the continuity of care at home. Effective therapeutic management provides optimal relief of distressing symptoms. It requires the acquisition of specific knowledge and care, but it also involves decision-making with ethical implications that increase the stress and burden on caregivers. The themes identified reflect the tangled dynamics of managing therapeutic regimens in the complexity of being a family caregiver. Therapeutic management relates to effective symptom management, which requires tasks and skills. This management is filled with uncertainties, fears, and emotions that arise from the complexity, responsibility, and weight represented by managing therapeutic regimens. Family caregivers are presented as coordinating elements within the healthcare system. The role of family caregivers is multidimensional, with numerous tasks and skills needed to support their relatives. Therapeutic management is more than just administering medications and needs to keep up with growing and fluctuating needs.

A Goal-Concordant Prescribing Conceptual Framework: Implications for Practice and Measurement

Optimizing medication benefit and minimizing harm through effective and appropriate medication management is emerging as an important strategy in hospice and palliative care. This approach, however, often fails to align patient and family goals for remaining life with clinician priorities. Ascertaining patient and caregiver values and goals and aligning these goals with clinicians' priorities for care is a complex and iterative process. This process requires effective communication between all participants as a patient's illness trajectory moves toward death. The purpose of this article was to present a beginning conceptual framework for clinical consideration and use, as well as an example of a potential measurement framework envisioned from the conceptual framework for future research application. Both frameworks focus on goal-concordant prescribing among seriously ill older adults in home hospice. An environmental scan of existing deprescribing frameworks and approaches to goal ascertainment that inform hospice deprescribing was conducted. Feedback from practicing hospice clinicians engaged in a pilot project implementing a novel goal-concordant prescribing approach, as well as interprofessional clinicians and family caregivers from previous projects, were also used to identify theoretical and clinically relevant gaps in care as well as future research opportunities. The environmental scan and multiproject feedback served as the foundation for the development of the conceptual framework. The suggested communication frameworks for goal-concordant prescribing seek to bridge the gap between the preferences and priorities of the patient and family caregiver, and the risk-benefit considerations brought forth by clinicians.

A qualitative exploration of the role of a palliative care pharmacist providing home-based care in the rural setting, from the perspective of health care professionals

INTRODUCTION

Pharmacists are often not recognised as a core part of palliative care teams, despite their ideal placement to assist with the burden of medication management.

OBJECTIVE

This study explored the role of pharmacists working in the rural palliative care team, in the home-based setting.

DESIGN

Health care professionals working with palliative care patients in rural South Australia participated in semi-structured interviews. Data were analysed using thematic analysis.

FINDINGS

Data from 20 participants identified 10 themes. Theme 1: This model of care gives patients a choice. Theme 2: The pharmacist is a trusted source of support and information. Theme 3: Patient, carer and family distress is reduced. Theme 4: Enables patients to stay at home by improving medication knowledge and decreasing burden; 4.1-Patient, carer and family's understanding about medication management is improved, 4.2-Patient, carer and family travel is decreased, 4.3-Burden associated with getting to the doctor is decreased. Theme 5: Communication between all parties is enhanced; 5.1-Enhanced communication between the patient and health care team, 5.2-Enhanced communication within the health care team. Theme 6: Patient, carer and family burden of coordinating prescriptions and medications is reduced. Theme 7: Benefits health care professionals by improving medication knowledge, reducing workload and stress; 7.1-Understanding about medications and their management is improved, 7.2-Workload is reduced, 7.3-Work-related stress is reduced. Theme 8: The disparity of care between rural and urban patients is reduced. Theme 9: Helps to address rural workforce shortages. Theme 10: Challenges of this model of care; 10.1-A need for greater pharmacist capacity to meet demand, 10.2-A need for increased and sustained funding for the pharmacist role, 10.3-Large amount of travel to get to patients.

CONCLUSION

Rural health care professionals are supportive of pharmacists working as part of the palliative care team in home-based settings and identified many benefits of this model of care.

Palliative Care: A Primary Care Pharmacist Perspective

The overview approaches pharmacy practice in palliative care from a global viewpoint and aims to provide insight into front-line pharmacist–patient relationships by sharing case studies and personal experiences.