PALLIATIVE AND HOSPICE CARE ASHP REPORT ASHP Guidelines on the Pharmacist’s Role in Palliative and Hospice Care Am J Health-Syst Pharm. 2016; 73: alliative care arose from the mod- bers of the interdisciplinary team.4,5 1351-67 Pern hospice movement and has Previously, health professionals ob- evolved significantly over the past tained the necessary skills and knowl- Christopher M. Herndon, Pharm.D., 50 years.1 Numerous definitions ex- edge for participation in the interdis- BCPS, CPE, FASHP, School of Pharmacy, Southern Illinois University ist to describe palliative care, all of ciplinary delivery of palliative care via Edwardsville, Edwardsville, IL. which focus on aggressively address- encompassing specialty areas (e.g., Douglas Nee, Pharm.D., M.S., Hospice ing suffering. The World Health Or- internal medicine, geriatrics, oncol- and Palliative Care, OptiMed, San Diego, ganization and the U.S. Department ogy).6,7 Numerous efforts to enhance CA. of Health and Human Services both professional education on palliative Rabia S. Atayee, Pharm.D., BCPS, Pain and Palliative Care Service, stipulate the tenets of palliative care care largely drove its eventual recog- University of California, San Diego, to include a patient-centered and nition as a medical subspecialty in Skaggs School of Pharmacy and 8,9 Pharmaceutical Sciences, La Jolla, CA. family-centered approach to care, 2006. with the goal of maximizing quality Specialized training programs and David S. Craig, Pharm.D., Department of Pharmacy, H. Lee Moffitt Cancer of life while minimizing suffering.2 In board certification opportunities exist Center & Research Institute, Tampa, FL. its clinical practice guidelines, the Na- today for most members of the pallia- Julie Lehn, Pharm.D., Palliative tional Consensus Project for Quality tive care interdisciplinary team.10-14 As Medicine, Banner University Medical Center, Phoenix, AZ. Palliative Care of the National Qual- the model of palliative care has pro- ity Forum (NQF) describes palliative gressed, so too has each team mem- Pamela S. Moore, Pharm.D., BCPS, CPE, Pain and Palliative Care, Summa care as “patient and family-centered ber’s potential for contribution. De- Health System, Akron, OH. care that optimizes quality of life by spite representation within the first Suzanne Amato Nesbit, Pharm.D., anticipating, preventing, and treating hospice demonstration project in the BCPS, CPE, Department of Oncology, Center for Drug Safety and Effectiveness, suffering . throughout the continu- United States, participation of the Department of Pharmacy, Johns Hopkins um of illness . addressing the physi- pharmacist as an essential member Hospital, Baltimore, MD. cal, intellectual, emotional, social, of the interdisciplinary team has been James B. Ray, Pharm.D., CPE, James and spiritual needs and to facilitate traditionally overlooked.15-18 Evidence A. Otterbeck OnePoint Patient Care, Department of Pharmacy Practice, patient autonomy, access to informa- of the pharmacist’s contribution to University of Iowa College of Pharmacy, tion, and choice.”2 NQF further speci- the delivery of palliative care and sup- Iowa City, IA. fies the foundation of palliative care portive care services beyond the origi- Bridget Fowler Scullion, Pharm.D., to include professional and family nal role of medication dispensing and BCOP, Palliative Care, Dana-Farber Cancer Institute, Boston, MA. collaboration, the availability of ser- compounding has garnered growing Robert G. Wahler Jr., Pharm.D., CPE, vices regardless of pursuit of curative recognition across numerous practice School of Pharmacy and Pharmaceutical or life-extending care, and, most im- settings.15-17,19-27 Sciences, University at Buffalo, The State University of New York, Buffalo, NY. portantly, the provision of care coor- Perhaps no other practice set- dinated by an interdisciplinary team.2 ting presents as diverse a collection Julie Waldfogel, Pharm.D., CPE, Pain and Palliative Care, Department The continuum of care provided by of potential roles and responsibilities of Pharmacy, Johns Hopkins Hospital, palliative care pharmacists (Figure 1) for the affiliated palliative and hos- Baltimore, MD. incorporates the concepts that cura- pice care (PHC) pharmacist. Here, tive and palliative care should coexist the PHC pharmacist may support the and that hospice care is an extension PHC services in an administrative of palliative care that occurs when cu- role (policy and procedure, formulary Address correspondence to Bruce rative care is no longer part of the pa- management), in a consultative role Hawkins ([email protected]). tient’s plan of care.3 (order set development, treatment al- The practice of palliative care, gorithm development, best practices Copyright © 2016, American Society of while rooted in traditional hospice education), and in advanced clinical Health-System Pharmacists, Inc. All rights and hematology and oncology pro- practice (medication therapy man- reserved. 1079-2082/16/0901-1351. grams, has changed dramatically in its agement services, pain and symptom DOI 10.2146/ajhp160244 delivery, competency assessment, and management consultations, and in- methods for preparing future mem- terdisciplinary team participation). AM J HEALTH-SYST PHARM | VOLUME 73 | NUMBER 17 | SEPTEMBER 1, 2016 1351 ASHP REPORT PALLIATIVE AND HOSPICE CARE Figure 1. Continuum of curative, palliative, supportive, and hospice care in disease trajectory. Reprinted under terms of the Creative Commons Attribution License from Guo Q, Jacelon CS, Marquard JL. An evolutionary concept analysis of palliative care. J Palliat Care Med. 2012; 2:1-6. Purpose with a serious or life-limiting illness, in- of pharmacists, and time dedicated In 2002, ASHP published the ASHP cluding those enrolled in a formal hos- to the palliative care or hospice team. Statement on the Pharmacist’s Role in pice program. Corresponding duties required of the Hospice and Palliative Care.28 These Two levels of PHC services are de- PHC pharmacist in other areas of the guidelines extend beyond the scope scribed: (1) essential services, which pharmacy service and the extent of of that statement and are intended include core processes, and (2) desir- time required for administrative du- to define the role of the pharmacist able services, which include higher ties and obligations should be con- engaged in the practice of PHC. Role levels of practice, teaching, and re- sidered. Services provided by the definition will include goals for pro- search. The level of service provided PHC pharmacist will vary among viding services that establish general by the PHC pharmacist will vary based practices and should be designed to principles and best practices in the on the level of practice experience of best meet the needs of the site and care of this patient population. This the pharmacist as well as the level of the patient. document is based on literature re- palliative care services provided in sources, consensus of pharmacist ex- each respective setting. Services pro- Delineation and description perts in the field of PHC, therapeutic vided by a pharmacist will therefore Before the development of these practice guidelines, and regulatory be unique and should be designed to guidelines, a task force was appointed standards.1,2,4,29 best meet the needs of the institution, by the Section Advisory Group, Pain The terms palliative, end-of-life, hospice, or other healthcare practice and Palliative Care, within the Sec- hospice, and supportive care are fre- setting. tion of Ambulatory Care Pharmacists quently, and incorrectly, used inter- In concert with the palliative care of ASHP. A comprehensive literature changeably. While these philosophies team or hospice chief executive officer review was performed using PubMed, of care share similarities, each rep- and medical director, the PHC phar- EMBASE, PsychInfo, Google Scholar, resents overlapping yet delineable macist uses his or her professional and International Pharmaceutical Ab- points along the healthcare continuum. judgment to individually weigh the stracts to search for all relevant articles For the purposes of these guidelines, the factors that determine the extent of published between January 1975 and term PHC will be used to describe the services provided. These factors in- December 2014. The literature search common services afforded to patients clude the population served, number was conducted using MeSH terms and 1352 AM J HEALTH-SYST PHARM | VOLUME 73 | NUMBER 17 | SEPTEMBER 1, 2016 PALLIATIVE AND HOSPICE CARE ASHP REPORT keywords alone and in combination Essential clinical roles and understanding of the pathophysiol- with other terms, including pharma- activities ogy of common life-limiting illnesses cy, pharmacist, pharmaceutical care, Essential clinical roles and activi- and their corresponding symptoms. pharmacotherapy, medication therapy ties for the PHC pharmacist may vary Recent CMS guidance documents management, hospice, end of life, ter- widely, and services may be provided changed the expectations for hos- minal illness, palliative care, support- either directly or indirectly to the pa- pice medication responsibility from ive care, symptom management, and tient, depending on the practice set- those under the current Medicare Part pain management. ting. While not an exhaustive list of D program, and a growing role for Similar to other areas of specialty potential practice sites for the PHC the PHC pharmacist is anticipated, or subspecialty practice within the pharmacist, settings of PHC delivery