456 Medication Therapy and Patient Care: Specific Practice Areas–Guidelines ASHP Guidelines on the Pharmacist’s Role in Palliative and Hospice Care Palliative care arose from the modern hospice movement and and in advanced clinical practice (medication therapy man- has evolved significantly over the past 50 years.1 Numerous agement services, pain and symptom management consulta- definitions exist to describe palliative care, all of which fo- tions, and interdisciplinary team participation). cus on aggressively addressing suffering. The World Health Organization and the U.S. Department of Health and Human Purpose Services both stipulate the tenets of palliative care to include a patient-centered and family-centered approach to care, In 2002, ASHP published the ASHP Statement on the with the goal of maximizing quality of life while minimiz- Pharmacist’s Role in Hospice and Palliative Care.28 These 2 ing suffering. In its clinical practice guidelines, the National guidelines extend beyond the scope of that statement and Consensus Project for Quality Palliative Care of the National are intended to define the role of the pharmacist engaged in Quality Forum (NQF) describes palliative care as “patient the practice of PHC. Role definition will include goals for and family-centered care that optimizes quality of life by an- providing services that establish general principles and best ticipating, preventing, and treating suffering . throughout practices in the care of this patient population. This docu- the continuum of illness . addressing the physical, intel- ment is based on literature resources, consensus of pharma- lectual, emotional, social, and spiritual needs and to facilitate cist experts in the field of PHC, therapeutic practice guide- 2 patient autonomy, access to information, and choice.” NQF lines, and regulatory standards.1,2,4,29 further specifies the foundation of palliative care to include The terms palliative, end-of-life, hospice, and support- professional and family collaboration, the availability of ser- ive care are frequently, and incorrectly, used interchange- vices regardless of pursuit of curative or life-extending care, ably. While these philosophies of care share similarities, and, most importantly, the provision of care coordinated by each represents overlapping yet delineable points along the 2 an interdisciplinary team. The continuum of care provided healthcare continuum. For the purposes of these guidelines, by palliative care pharmacists (Figure 1) incorporates the the term PHC will be used to describe the common services concepts that curative and palliative care should coexist and afforded to patients with a serious or life-limiting illness, in- that hospice care is an extension of palliative care that occurs cluding those enrolled in a formal hospice program. when curative care is no longer part of the patient’s plan of Two levels of PHC services are described: (1) essential care.3 services, which include core processes, and (2) desirable ser- The practice of palliative care, while rooted in tra- vices, which include higher levels of practice, teaching, and ditional hospice and hematology and oncology programs, research. The level of service provided by the PHC pharma- has changed dramatically in its delivery, competency as- cist will vary based on the level of practice experience of sessment, and methods for preparing future members of the the pharmacist as well as the level of palliative care services interdisciplinary team.4,5 Previously, health professionals provided in each respective setting. Services provided by a obtained the necessary skills and knowledge for participa- pharmacist will therefore be unique and should be designed tion in the interdisciplinary delivery of palliative care via to best meet the needs of the institution, hospice, or other encompassing specialty areas (e.g., internal medicine, ge- healthcare practice setting. riatrics, oncology).6,7 Numerous efforts to enhance profes- In concert with the palliative care team or hospice chief sional education on palliative care largely drove its eventual executive officer and medical director, the PHC pharmacist recognition as a medical subspecialty in 2006.8,9 uses his or her professional judgment to individually weigh Specialized training programs and board certification the factors that determine the extent of services provided. opportunities exist today for most members of the palliative These factors include the population served, number of phar- care interdisciplinary team.10-14 As the model of palliative macists, and time dedicated to the palliative care or hospice care has progressed, so too has each team member’s poten- team. Corresponding duties required of the PHC pharmacist tial for contribution. Despite representation within the first in other areas of the pharmacy service and the extent of time hospice demonstration project in the United States, partici- required for administrative duties and obligations should be pation of the pharmacist as an essential member of the in- considered. Services provided by the PHC pharmacist will terdisciplinary team has been traditionally overlooked.15-18 vary among practices and should be designed to best meet Evidence of the pharmacist’s contribution to the delivery the needs of the site and the patient. of palliative care and supportive care services beyond the original role of medication dispensing and compounding has Delineation and Description garnered growing recognition across numerous practice set- tings.15-17,19-27 Before the development of these guidelines, a task force Perhaps no other practice setting presents as diverse was appointed by the Section Advisory Group, Pain and a collection of potential roles and responsibilities for the Palliative Care, within the Section of Ambulatory Care affiliated palliative and hospice care (PHC) pharmacist. Pharmacists of ASHP. A comprehensive literature review Here, the PHC pharmacist may support the PHC services was performed using PubMed, EMBASE, PsychInfo, in an administrative role (policy and procedure, formulary Google Scholar, and International Pharmaceutical Abstracts management), in a consultative role (order set development, to search for all relevant articles published between January treatment algorithm development, best practices education), 1975 and December 2014. The literature search was con- Medication Therapy and Patient Care: Specific Practice Areas–Guidelines 457 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. ducted using MeSH terms and keywords alone and in com- Essential Clinical Roles and Activities bination with other terms, including pharmacy, pharmacist, pharmaceutical care, pharmacotherapy, medication therapy Essential clinical roles and activities for the PHC pharma- management, hospice, end of life, terminal illness, pallia- cist may vary widely, and services may be provided either tive care, supportive care, symptom management, and pain directly or indirectly to the patient, depending on the prac- management. tice setting. While not an exhaustive list of potential practice Similar to other areas of specialty or subspecialty prac- sites for the PHC pharmacist, settings of PHC delivery in- tice within the profession of pharmacy, some level of pallia- clude various hospice settings, hospitals, outpatient clinics, tive and supportive care knowledge is essential for all phar- outpatient community pharmacies, home care or long-term macists providing patient care, regardless of scope or setting. care (LTC) facilities, and consulting and managed care set- The European Association for Palliative Care (EAPC) re- tings. Essential clinical roles and activities of the PHC phar- cently updated a two-part guidance document on essential macist are presented in Table 1, and aspects of those roles competencies for healthcare and social workers involved in and activities that traverse the various PHC practice settings 1,4 the delivery of palliative care. In that guidance document, are discussed below. EAPC delineates recommendations for those providing gen- eral palliative care (i.e., palliative care services provided by Hospice Programs. The PHC pharmacist providing care primary care and nonpalliative care specialists) and those within hospice must be thoroughly familiar with symptom providing specialist palliative care (i.e., health professionals management and reduction. Hospice services are provided whose main activity focuses on delivery of palliative care). in the following settings: standalone hospice inpatient units These guidelines also incorporate that dichotomy. and hospice residential units, LTC facilities, and hospitals, To address the heterogeneous nature of the pharmacy in addition to the more traditional home care paradigm. PHC profession, the pharmacist’s roles and activities described pharmacists also must be cognizant of the many regulatory herein will be categorized as either essential or desirable. requirements associated with controlled substances, medica- Essential roles and activities describe the practice of pallia- tion reimbursement requirements, and commonly managed tive and supportive care pharmacy, whereas desirable roles symptoms. The Centers for Medicare and Medicaid Services and activities denote delivery of palliative and supportive (CMS), as part of