More Than Just Meds: What a Palliative Care Pharmacist Learned From the Bedside

Précis

A palliative care pharmacist highlights a spectrum of clinical opportunities for patients, caregivers, and clinicians when rounding at the bedside.

Image credit: Meeko Media | stock.adobe.com

Patient Story

One of my patients, Dave, died at home in his wife’s arms after his illness with metastatic prostate cancer. I always loved his sense of humor, including the various T-shirts he wore with witticisms like “My oncologist does my hair” and “God gives us only what we can handle. Apparently, God thinks I’m a badass.”

I got to know Dave and his wife, Liz, during his hospitalizations. Dave was newly married, and he was preoccupied with how he could live his best life with his new family while we were busy managing his cancer pain and preparing for the “what-if” scenarios. With each admission, there would be a deadline. Speed was always a priority so he could be discharged in time for a belated honeymoon, a birthday celebration, or a couple’s getaway.

Liz was Dave’s greatest love and strongest advocate. She took meticulous notes and asked thoughtful questions. They had to collaborate on complex care decisions, from ultrahigh opioid titration to controversial neurosurgical intervention to management of refractory cancer pain. As a consistent team member, I witnessed them weighing the risks and benefits of each option. It was a privilege to counsel them on medication-related inquiries and facilitate other concerns.

After his final admission, Dave was discharged home to spend the remaining time with his wife and stepsons. Weeks before his death, I received a thank-you card (Image). It reads, “We appreciated your transparency and forward-thinking approach, but mostly just being there for us.” It made me realize I am more than just a provider of medication for patients and their caregivers.

Palliative Care Consultation Team

I hold a unique clinical position. In 2018, the National Palliative Care Registry reported that less than 10% of national palliative care (PC) programs have a dedicated pharmacist.¹ I am a member of the PC consultation service at a cancer hospital affiliated with a large tertiary academic medical center in New Haven, Connecticut. Routinely, we are consulted for at least 40 patients a day, with more than 2000 consults in 2024.

Our clinicians are divided into 3 teams. We have 2 physician-led teams with medical trainee(s). One focuses on patients with cancer, and the second focuses on patients with other diseases. The third team consists of advanced practice providers (APPs) who care for patients with cancer and those with other diseases. Additionally, the PC consultation service includes social workers, chaplains, nurses, a psychologist, and a pharmacist, all of whom provide interdisciplinary expertise to the 3 teams. During our daily morning rounds, we triage our patients based on their specific needs, and then we split up to begin bedside rounds individually or in clusters.

Palliative Care Pharmacist

I joined the PC consultation team in September 2020, and my patient involvement grew over time. Common pharmacist referrals may include patients with high opioid burden, refractory symptoms, history of substance use disorder, or psychosocial concerns either identified by a team member or self-referred.² These patients tend to have higher medication complexity. After the morning round, I join the leading clinician to visit designated patients at the bedside. I continue visiting these patients, often serving as their consistent PC team member. Occasionally, I see patients by myself when we have limited staff or to address specific pharmacy-related needs.

A benefit of having a clinical pharmacist on the interdisciplinary team includes the ability to provide off-label medication to optimize complex medication regimens while honoring patients’ psychosocial, cultural, and spiritual needs.^3-5 Having a pharmacist at a patient’s bedside has additional advantages. Below are examples from my experience of how pharmacists can expand our scope of practice in a transdisciplinary model with positive outcomes for patients, caregivers, and clinicians.

Patient Outcomes

My patient Dave presented to different units and medical services with each hospitalization. The PC team followed him consistently with each admission. Hospitalization can be challenging for patients and their caregivers; thus, a familiar and caring presence can be extremely comforting. In addition, an experienced pharmacist can be a key player in creating a therapeutic rapport. These repeated exposures foster deep connections among patients, caregivers, clinicians, medical services, and medical facilities. An established relationship between patients and clinicians can allow for a smoother transition and acceptance between care, day to day, unit to unit, and inpatient to outpatient. For example, during one of Dave’s admissions for a surgical intervention, we anticipated he would have significant postoperative pain. Our team proactively started a patient-controlled analgesia pump to manage acute and chronic pain. This decision, made possible by consistency of care and rapport between the patient and the team, afforded better symptom management and a shorter stay.

Having a dedicated PC pharmacist means that any changes from a patient’s baseline can be assessed and addressed in a timely manner. Observations of such changes can be related to improvement of symptoms or adverse effects (AEs); for the latter, this can be particularly associated with PC interventions. Identifying any medication effects early in the high-paced and aggressive titration environment is advantageous for the patients and clinicians. Addressing symptoms or AEs early helps that ensure patients do not needlessly experience pain and can have a timely and safe discharge.⁶

We usually conducted rounds at Dave’s bedside twice a day. There were occasions when Dave awoke to find one of our APPs and me hovering over him in the early morning hours to ensure safety and efficacy after an aggressive pharmacologic adjustment overnight.

When pharmacists are familiar with patients’ specific needs, we can better advocate and align care plans. Certain needs may be revealed only when patients and caregivers are engaging with someone with whom they have an established and trusted relationship. The pharmacist can collaborate with other interdisciplinary team members to address patients’ holistic needs beyond pharmacological interventions. Knowing that Dave highly prioritized his time, we were strategic in our pharmacologic selection—its onset, duration of action, and AE profile—to produce timely results and reserve energy and mentation. I collaborated with providers in other disciplines to ensure he had enough medication upon discharge so he could better enjoy his next getaway.

During Dave’s final admission, ketamine was recommended after he had an inadequate response to escalating opioid requirements. I provided details about ketamine infusion and addressed his and Liz’s questions and concerns. Dave responded well to ketamine initially, but he could not be discharged home with it. Cingulotomy was introduced as a last resort for refractory pain, which we hoped would lower his need for opioids and pills. It is a neurosurgical intervention that severs the part of the brain associated with processing emotions, cognitive control, and pain. We had limited clinical experience with this surgical intervention since we had only 1 patient prior to Dave who had undergone cingulotomy. I was able to share with Dave and Liz that this patient had a significant opioid reduction after the procedure. However, I acknowledged we were charting the unknown together, especially the potential for emotional and cognitive AEs. After lengthy discussions, Dave decided to undergo cingulotomy. It provided very brief pain and opioid reductions. Days later his pain and opioid requirement escalated back to his previous requirements.

Pharmacists have expertise and authority over intervention for pain management, and they have established rapport with patients and caregivers; we can address any medication inquiries historically, in real time, and for future needs. This knowledge and a trusted patient relationship enable us to better collaborate and advocate effectively to align the plan of care and patients’ priorities. Pharmacists not only manage medications but also build trust and advocate for our patients and caregivers, which leads to patient-centered care and better outcomes.

Pharmacists are keepers of patients’ histories, socially and medically. This is an asset during medical updates and goals-of-care discussions. Traditionally, pharmacists are less likely to be included in these discussions, and our involvement is often perceived as outside our scope of practice. However, when patients have an established relationship with a pharmacist, this association can be leveraged to build trust with new clinicians. Dave and Liz had openly discussed the results of the cingulotomy with our consultive team and newer members of the primary team. They decided to focus on comfort care. We optimized all resources for safe discharge and to keep Dave at home. His discharge medication list consisted of multiple medications with different mechanisms of action to effectively manage his pain while minimizing AEs. In other words, it was rational polypharmacy.

Clinican Outcomes

Palliative consultations often involve symptom management, which often revolves around medications and the 5 rights (patient, drug, time, dose, and route). Pain is one of the most common cancer-associated symptoms, and opioid analgesic is a conventional treatment modality. Opioid calculations and conversions are not straightforward, so PC recommendations may be influenced by not only the patient’s condition but also the clinician’s knowledge and experience. Therefore, pharmacists can validate and moderate extreme recommendations to ensure safety and efficacy. It is standard practice for our team to self-calculate and then openly discuss our recommendation, as we did with Dave’s complex opioid requirement and analgesics. It is rarely a black-and-white answer when it comes to opioid calculations. We openly discussed our recommendations with Dave and Liz, which allowed for transparency and inclusiveness.

Between admissions, Dave’s medication list changed frequently. We focused on medication reconciliation during new encounters to ensure medications were resumed appropriately and timely. Pharmacists can facilitate complex medication order entries that are not standard (eg, nonformulary, restricted, off-label). Palliative care patients may require nonconventional approaches to medication and dosage form to optimize refractory symptom management and improve quality of life. The pharmacist is the team member most capable of reconciling discrepancies when computerized provider order entries are inconsistent with PC recommendations. Additionally, a pharmacist can serve as a liaison and educator to other clinicians to address clinical or operational barriers.

Changes in patients’ medical conditions as well as the rotation of clinicians occur frequently. The pharmacist’s ability to update team members in real time can provide clinical insights or nuances that may not be captured in electronic medical records. For example, the APP team primarily covered Dave’s admissions, and the leading nurse clinician rotated every few days, but I had the opportunity to follow Dave daily. Whenever a new clinician rotated on, I would provide clinical updates to get everyone on the same page.

Lastly, pharmacists can facilitate a consistent level of care as providers rotate on and off the consultation service. Having pharmacists present at the bedside empowers clinicians to be transparent with each other, patients, and caregivers. I also had opportunities to connect with Dave and Liz at outpatient follow-ups, directly or indirectly, via collaborations with his clinic PC provider. We provided patient-centered care throughout Dave’s care at our institution and ensured his best quality of life, even as his terminal illness progressed.

Conclusion

Available literature illustrates the beneficial outcomes, data points, and return on investment for pharmacists. This is powerful, evidenced-based, quantitative support. However, the statistics do not highlight the human experience shared among patients, caregivers, and clinicians.

I am honored to have cared for Dave and to have supported Liz throughout their journey of life, love, and laughter. Being an active member of Dave’s team helped motivate, elevate, and transform me into a better clinician.

In palliative care, teamwork is imperative for transdisciplinary collaboration to meet the demands of patients and caregivers. I recommend not only increasing the pharmacist representation on the PC team but also embedding pharmacists into the service. Attending rounds at the bedside with other clinicians allowed me to assess Dave directly. These interactions offered great insight into the person, which allowed me to formulate a pharmacologic plan that would respect not only his physical but also his psychosocial, cultural, and spiritual being.

When pharmacists are acknowledged as equally essential members of the team, it enables us to practice at our highest clinical potential. Pharmacists can benefit patients, caregivers, and clinicians. Together, we can deliver whole person care to our patients with serious illness and their caregivers.

REFERENCES

1. McPherson ML, Walker K. How to include a pharmacist in the palliative care mix. Center to Advance Palliative Care. Updated October 18, 2021. Accessed March 18, 2025. https://www.capc.org/blog/how-include-pharmacist-palliative-care-mix/

2. Palmer-Hoffman J, Bui T, Cronin K, Holt C. More than just meds: a pharmacist-APRN collaboration to optimize care of the “difficult patient” on a palliative care consult service. J Pain Symptom Manag. 2023;65(5):e561-e562. doi:10.1016/j.jpainsymman.2023.02.105

3. Herndon CM, Nee D, Atayee RS, et al. ASHP guidelines on the pharmacist’s role in palliative and hospice care. Am J Health Syst Pharm. 2016;73(17):1351-1367. doi:10.2146/ajhp160244

4. Moody JJ, Poon IO, Braun UK. The role of an inpatient hospice and palliative clinical pharmacist in the interdisciplinary team. Am J Hosp Palliat Care. 2022;39(7):856-864. doi:10.1177/10499091211049401

5. Walker KA, Scarpaci L, McPherson ML. Fifty reasons to love your palliative care pharmacist. Am J Hosp Palliat Care. 2010;27(8):511-513. doi:10.1177/1049909110371096

6. Mattos LFV, de Sousa ARN, Teixeira JF, Costa MF, de Castilho SR. The role of the pharmacist in the hospital discharge of cancer patients: an integrative review. J Oncol Pharm Pract. 2023;29(5):1196-1205. doi:10.1177/10781552231160678

Funding/Disclosures: No funding was received in relation to the study/article. There are no relevant disclosures.

Acknowledgements: Thank you to Dave and Liz, who inspired this work; Leah Tenenbaum, DMin, BCC-PCHAC, for narrative feedback; Smilow Cancer Hospital pharmacy leadership for the clinical vision; and the Smilow Palliative Care Program leadership and colleagues for the continual professional and scholarly support.