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Caring Collaboratively for the Palliative Patient


Caring Collaboratively for the Palliative Patient. Learning Objectives: ... Palliative Care Team is defined as group of people with diverse but related ... – PowerPoint PPT presentation

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Title: Caring Collaboratively for the Palliative Patient

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

Elements of Collaboration in Palliative Care
  • Successful collaboration has basic elements
    cooperation, assertiveness, responsibility,
    communication, autonomy, coordination, trust and
  • 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

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
  • Pharmacist only person able to dispense
    medications Count and pour, lick and stick
  • Reference HPRAC Submission Scope of Practice of
    Pharmacy June 2008

Evolving Role of the Pharmacist
  • Today (2008) person-centered pharmaceutical care
  • expected standard of practice that there is a
    provision of information and education respecting
    the use of drugs, health care aids and devices
  • 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

Patient Focused Care - Pharmacist
  • Initiatives
  • Pharmaceutical Care Plans Drug related problem
  • Medication Safe Practices Required
    Organizational Practice (Hospital Accreditation
  • 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

Palliative Care Team Members
  • Center Patient family/friends
  • Physician staff MD, medical learners, family
  • 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

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
  • 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

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
  • 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

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

Challenges for the Palliative team
  • Rapid turnover of patients common to admit up
    to 3 to 4 patient per day during the week, plus
  • 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
  • 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

Benefits for the Palliative team
  • Sharing team experiences and providing support
    difficult patient/families (stresses, tensions,
  • Enhanced communication, common purpose goals of
  • Recognizing the challenges and achievements as a
  • 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

Palliative Pharmacist environment
  • Accessibility to teams my office is located on
    palliative care unit, pager, telephone, computer
  • 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
  • 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)

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

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

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,
  • Medication calendar development LOAs/passes,
  • CQI, Pharmacist discipline meetings twice
  • Grasp daily workload measurement

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
  • Increased research activities for drug therapy
    and patient care improvements

Growing together