Expert Suggests That Pharmacists Should Be Learning Primary Palliative Care Skills

Pharmacy Times extends a warm welcome to Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM, Professor with the School of Pharmacy at the University of Maryland, Baltimore. McPherson discusses the vital role of the pharmacist when caring for those with advanced illness or in hospice care. She advocates for increasing knowledge about what palliative care offers and its multidisciplinary benefits.

Pharmacy Times: When it comes to pharmaceutical agents that are gaining notoriety for improving end of life care which one's jumped out to you?

Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM: I would say when we're thinking about analgesics, particularly the opioids, Methadone and Buprenorphine really are coming into their own, I believe. And there are multiple advantages to both drugs. Buprenorphine, for example, is effective in cancer and noncancer pain, including neuropathic pain, and obviously, by extension, pain of mixed pathology. We see less tolerance and dependence, we see a ceiling effect on the respiratory depressant effect, less constipation, and so forth. And it does not significantly prolong the QT interval.

Methadone is also becoming more and more popular with people who know how to dose that drug, which goes (without speaking) to buprenorphine as well. But methadone has multiple mechanisms of action. It's a mu (μ) kappa- and delta- agonist. It inhibits the reuptake of serotonin in the central nervous system (CNS). And likely, at higher doses, it blocks the N-methyl-D-aspartate (NMDA) receptor.

What does this mean? It means it's a good drug for pain- again, mixed pathology including neuropathic pain, and for difficult pain syndromes because the NMDA receptor may be involved. And 1 thing I particularly like about methadone is it's available as an oral solution that comes as a 10-per-5 and a 10-per-1. And methadone is an inherently long-acting opioid. So, we can dose it twice a day, maybe 3 times a day. And it's an oral solution. Even for people who have difficulty swallowing, it's a beautiful thing. It's quite nice.

I would say we've also seen an increase in Olanzapine for nausea. There's some very good data supporting that. And I would be remiss if I did not mention that we are kind of rebels about using medications off-label but are evidence-based recommendations. For example, as I just mentioned, Olanzapine for nausea. We have fabulous data on that Pregabalin or Gabapentin for end-stage renal disease (ESRD). And we use an awful lot of Methylphenidate for depression. So, a lot of off-label but evidence-based use of medications.

Pharmacy Times: Thank you. Now, when it comes to pharmacists and those who help the families of loved ones make informed drug choices, how can pharmacists do a better job of assisting them and easing the process?

Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM: That's a great question. I think I spend as much or more time recommending stopping drugs, deprescribing, as I do start medications. Deprescribing is kind of a technical term for what I consider to be gold concordant prescribing.

"What are the patient's goals of care? Is it just simply comfort measures? Well then, maybe the medications that slow disease progression are no longer appropriate?"

I think many times, patients and most families do not recognize when the burden of the drug therapy outweighs the benefit. So perhaps we may have a medication that is now futile, but the family doesn't want to give up hope. So, it's important to have those careful conversations. And I think being the most accessible health care professional, the pharmacists play a huge role in in education. So simply being there, answering questions about medications, like, "What do we do with the discontinued medications?" The pharmacist can recommend a therapeutic alternative when the patient has difficulty swallowing at some point, compounding, and just providing education in general to patients to families and other healthcare providers.

Pharmacy Times: That jumps into my next question. How can pharmacists who are in palliative care better educate the patients, pharmacists, and other healthcare professionals about how to help patients?

Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM: That's a great question too. I think the most obvious answer is pharmacists need to build their own knowledge base. So if it were up to me, every school of pharmacy, nursing, medicine, social work, dentistry, etc. would have required content on palliative care. I think that's so important, but unfortunately, that is not the situation. So, pharmacists must seek out their own educational opportunities. Luckily, there are many continuing education (CE) programs, podcasts, all the way up to graduate work at our institution, the University of Maryland, Baltimore. We offer online graduate certificates, a Master of Science (MS) and even a PhD in palliative care, and pharmacists are a very strong contingent in our program.

I honestly think it's important. Since hospice and palliative care are an interdisciplinary sport, pharmacists need to hang around with other people who do this for a living. For example, I have been an active member of the American Academy of Hospice and Palliative Medicine for my entire career. I go to every annual meeting. I'll be in Montreal in March, of course (first time in a couple of years with COVID-19 that they get to go to a meeting in person so I'm very excited about that.) Also, there's a Society of Pain and Palliative Care Pharmacists. So I think it's important that we connect with other pharmacists who do this for a living, but even more importantly, to associate with the other members of the team.

Pharmacy Times: Thank you, very well put. I read in one of your papers that you talk about comfort-focused palliative care. You mentioned this earlier when it came to deprescribing. Can you give some examples of how that can impact quality of life and what that means versus medications (which in theory prolong life but may not be the best for quality of life)?

Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM: Sure. I think it's important for people to understand what the difference between hospice and palliative care is. All of hospice is palliative care, but not all palliative care is hospice. So really, it's a continuum of care. And it's important to remember that you can, and should, implement palliative care early in the disease process, when someone has been diagnosed with a serious illness. And study after study after study have shown that integrating early palliative care with curative treatment, chemotherapy or whatever it may be, has led to superior outcomes. We've seen this with advanced cancer, neurologic diseases, lung disease, heart disease, multimorbidity.

Everybody talks about the Tamil studies, where they looked at lung cancer, usual care, and usual care plus the inclusion of palliative care. And the patients (with palliative care) actually had a longer median survival, better quality of life, and they had a lower depression score. So study after study has shown the benefit of early integration of palliative care. And then, when the patient gets to within 6 months of death, and they no longer interested in curative therapy, that's where it'd be appropriate to refer to hospice.

Pharmacy Times: How do you work with a patient when they want to change something their doctor has prescribed, or maybe they want to add something, but they're not licensed?

Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM: I think this all boils down to a having a good knowledge base about the benefits and burdens of these drug therapies. And another hugely important skill set is good communication skills. We face this every day in our practice.

Example (dialogue between palliative care professional and patient):

• Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM: "[Why don't we] stop the cholinesterase inhibitor in your mom because she has end stage Alzheimer," the family often does not want to give up on that medication because it was medication the doctor said was slow the progression of the Alzheimer's disease. So, I may have a conversation saying, "Yeah, I certainly see where that would be distressing. But tell me this. How was your mom a year ago, compared to now?"

• Patient: "Oh, a year ago she knew who I was, she could walk up the stairs by herself, she was awake all day, she would eat without me having to fight with her..."

• Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM: "Okay, so she's been on the medication as slow the disease since last year. But you're telling me she has declined and gotten worse, even though she's still been on this medication?

• Patient: "Yeah, that's true, too. That's true, too."

• Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM: “Can I share with you my thoughts and concerns? Here's what I'm worried about. This medication can lower the heart rate. And you told me your mom's already fallen a couple of times. So I'm thinking it's worth a trial to taper down the dose of this medication. I do not anticipate she'll get worse. Sometimes people feel a little bit better. What do you think about that trial?"

So having that conversation is critically important. I mean, you must realize this is this, this is a big deal for family stopping medications. And sometimes patients do want to have patients who take a lot of herbal products and unless it's causing harm, we're not going to pick up too much of us.

And being empathetic, that is so important. This is a really, really difficult time in people's lives. So being empathetic to what they're going through and acknowledging their fears and their concerns. People just want to be heard, but then say, "May I provide you some information, here's what I'm concerned about." And just explain it, just lay it out. People often come around. I mean, they understand what you're saying, but you can't just go in there like a bulldozer and say this is what we're going do.

We're a team and the patient and the family are an important part of the team. Hospice and palliative care is a patient and family centric model.

Pharmacy Times: What is a word of wisdom that you would offer to families who are going through this and must work with a pharmacist or a health care practitioner?

I think patients and families need to be reminded of what pharmacists bring to the table. Pharmacists are an excellent resource of information, not just the product, but education along with that. So, again, I strongly believe that all schools of pharmacy as well as other professional schools should include this in their curriculum, we need to teach all providers what we call primary palliative care skills, the basics of pain and symptom management communication skills.

I even think pharmacists should be involved in psychosocial and spiritual support, just like I think the chaplain should know how to recognize and treat constipation. We are a team, and we need to be able to cross cover each other but just being aware of everything that the pharmacist brings to the table. They're an amazing source of information, and often are very reassuring to the patient and family because the pharmacist will reinforce the message from the whole team.

When we all interviewed for pharmacy school, the interviewer said so why do you want to be a pharmacist everybody said, because I want to help people. There is no aspect of medical care where you can help people more than hospice and palliative care.

I take enormous pride in my role that even if it's a child, that the last thing that parents see is not the vomiting, ceaselessly or in pain. I take enormous pride in that. This is a very gratifying career. I love what I do. I can't imagine anything better to do with my life than this. It's an honor to walk the last steps with someone, it is.