Caring Collaboratively for the Palliative Patient

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Caring Collaboratively for the Palliative Patient

• Learning Objectives
• Elements of Collaborative Team person centered
  practice.
• Evolving role of the pharmacist
• Understanding each team members role and scope
  of practice
• Practicing collaborative care as a Palliative
  Team

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Elements of Collaboration in Palliative Care

• Successful collaboration has basic elements
  cooperation, assertiveness, responsibility,
  communication, autonomy, coordination, trust and
  respect.
• Interaction self introduction, statement of my
  role in relation to the patient/client, sharing
  of details of any planned interventions for the
  patient/client or family, discussing the points
  of view of the fellow professional/team member.
• Communication use of patient/clients notes
  for documenting interactions, comments,
  observations, plans, use of common vocabulary
• Reference Hospital Pharmacist May 2008 vol 15

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Evolving Role of the Pharmacist

• 40 years ago Prescription focused model
• 1960s pharmacist was prohibited from putting
  name of the drug on the prescription label and
  discouraged from speaking to people about their
  drugs
• Pharmacist only person able to dispense
  medications Count and pour, lick and stick
• Reference HPRAC Submission Scope of Practice of
  Pharmacy June 2008

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Evolving Role of the Pharmacist

• Today (2008) person-centered pharmaceutical care
  approach
• expected standard of practice that there is a
  provision of information and education respecting
  the use of drugs, health care aids and devices
  MEDICATION THERAPY MANAGEMENT (1)
• technical functions now assumed by pharmacy
  assistant personnel compounding and dispensing
• Regulated pharmacy technicians with the College
  (OCP) Health System Improvement Act, 2007
• Ont Pharmacy Degree change Pharm D by 2010 (2)
• Reference (1)HPRAC Submission Scope of Practice
  of Pharmacy June 2008
• (2) OCP Pharmacy Connection
  July-August 2008

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Patient Focused Care - Pharmacist

• Initiatives
• Pharmaceutical Care Plans Drug related problem
  issues
• Medication Safe Practices Required
  Organizational Practice (Hospital Accreditation
  Guidelines)
• Medication Assessments and Reconciliation upon
  admission, transfer and discharge involving the
  patient as required.
• Goals
• accurate and current medication lists
• correction of discrepancies of what is ordered
  and what the person actually takes
• prevention of adverse events and potential harm
• Clinical monitoring and teaching to patients, team

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Palliative Care Team Members

• Center Patient family/friends
• Physician staff MD, medical learners, family
  MD
• Nurse includes APN, RN, RPN (Nurse
  Practitioner not available)
• Pharmacist
• Social Worker
• Chaplain
• Psychologist (when available)
• Dietitian
• Physiotherapist
• Occupational Therapist
• Rehab Assistant
• Recreational Therapist
• Porter
• Ward Clerk
• Volunteers

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Palliative Care team - meaning

• Palliative Care Team is defined as group of
  people with diverse but related skills who come
  together to work towards a common goal or
  purpose.
• Appreciation of the values/tenets of each
  professional member and we share these using a
  common language and understanding in order to
  meet palliative care goals.
• Common philosophy and value systems of care for
  the patient and their family holistic care
  that unites the team in common goals of care.
• Team Work Circle of Care

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Essentials of palliative team collaboration

• Attributes
• Proximity located on 36 bed Pall Care Unit
  Community Outreach program Consultation Service
• Time together e.g. planned collaborative team
  rounds weekly (Wed and Thurs pm) daily
  interactions
• Clinical Knowledge education of self and team
  members (e.g.. weekly journal club, Interesting
  case presentations, monthly city rounds)
• Shared practice interests- development of
  practice guidelines, information exchange,
  research activities, attendance of conferences.
• Professional equality - fundamental respect and
  trust

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Palliative Care Team the setting

• Environment teaching hospital, 36 bed inpatient
  unit plus community palliative care teams
• Teaching opportunities SPEP undergraduate
  pharmacy students, pharmacy residents rotations,
  Pharm D candidate rotations medical students,
  residents, fellows nursing students social work
  and chaplaincy students, and others.
• Education Weekly intra-professional journal
  club, monthly city rounds, conferences, guideline
  instruction and interaction, networking in city,
  province, nationally and internationally
  resources in library and internet.
• Research CQI (continuous quality improvement)
  participation in research projects, development
  of collaborative ideas, guideline development

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Challenges for the Palliative team

• Rapid turnover of patients common to admit up
  to 3 to 4 patient per day during the week, plus
  emergencies
• Changes in staff MD learners (weekly and
  monthly) teaching, communicating and monitoring
  for palliative issues. Learners have wide variety
  of training, experience and exposure to death
  situations Nursing shifts changes,
  reassignments, float RNs part time allied health
  PT/OT
• Fragility of patients/ families emotionally,
  physically, psychologically, spiritually
  Total Pain syndrome.
• Shifting Goals of Care ongoing changes need
  for rapid response
• Anticipation of End of Life issues grief, loss,
  anxiety, anger, pain, delirium, cognitive
  awareness, dyspnea
• Staying in comfort zone versus growth, open to
  change

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Benefits for the Palliative team

• Sharing team experiences and providing support
  difficult patient/families (stresses, tensions,
  demands)
• Enhanced communication, common purpose goals of
  care
• Recognizing the challenges and achievements as a
  team
• Compassionate support and valuing of each other
  in our strengths and weaknesses.
• Developing palliative guidelines to improve
  patient safety and care
• Equality and respect for team members experiences
  and participation in care plans
• Diversity complimentary styles beneficial or
  challenge

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Palliative Pharmacist environment

• Accessibility to teams my office is located on
  palliative care unit, pager, telephone, computer
  supplied
• Two medical teams 18 patients for total of 36
• Two nursing stations nurses, patient charts
  located in different areas, MARs on medication
  carts on ward
• Drug distribution system Unit dose, 10 carts,
  replenishment 3 times weekly, ward stock on
  medication carts, supply room, locked cupboards
  (2), Documed (Night cabinet) when pharmacy is
  closed
• Dispensary duties 20 per week shared with 3
  other Rehab clinical pharmacists to check Rxs
• Pharmacy technicians centralized full scope of
  practice (computer entry, prepacking,
  compounding, refills, etc)

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Palliative Pharmacist my role

• Assessment of admission medication regimen in
  collaboration with MD ( MD learners), Nurse
• Consider - drug and other allergies special
  administration of meds e.g. Infusions CADD pump
  with single or combined medications (IV or sub Q
  or spinal infusions)
• Determine with patient info team condition of
  the patient, symptom control issues (e.g. Pain
  (types), delirium (possible disease, drug and/or
  metabolic related), dyspnea, nausea vomiting,
  constipation, bowel obstruction, wound/skin care,
  dysphagia, primary and other co-morbid illnesses
  (e.g.. diabetes, DVT, renal)
• Awareness - contributing factors poor family
  coping/anxiety social issues (smoker,
  addictions, mental illness, body image, grief
  reaction) communication barrier, literacy

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Palliative Pharmacist my role

• Reconciliation of meds written records,
  verbal/written communication with MD where
  possible patient / family members, obtaining
  information from external sources if needed.
• Develop care plan with team re e.g.
  polypharmacy (need to simplify regimen), opioid
  toxicity (reduction in dose, opioid rotation,
  supportive meds), delirium (past contributing
  factors, drug related problems), renal/ hepatic
  dysfunction, routes of administration of drugs
  (oral, buccal, sub-Q, rectal, vaginal,
  transdermal, topical, inhalation, IV, spinal
  infusion, intranasal)
• Document written pharmacy assessment,
  reconciliation, DRPs (drug related problems) in
  chart

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Palliative Pharmacist team member

• Intra-professional weekly rounds
• Family Meetings (Patient Care Conferences)
• Discharge planning with team (SW, MD, RN,
  allied health)
• Medication Reviews
• Patient/Family teaching (along with team) re
  medications e.g. Methadone, opioids, laxatives,
  etc.
• Medication calendar development LOAs/passes,
  discharges
• CQI, Pharmacist discipline meetings twice
  monthly
• Grasp daily workload measurement

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Future Team Plans

• Updating and development of palliative care
  protocols locally, provincially, nationally
• E-learning opportunities and development
• Preprinted admission orders to stream line work,
  reduce errors and preparation for computerized
  physician order entry
• Computerized Intra Professional Care Plan, team
  documentation
• Increased research activities for drug therapy
  and patient care improvements

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Growing together