ASHP Guidelines on the Pharmacist’s Role in Palliative and Hospice Care

Palliative care arose from the modern hospice movement and has evolved significantly over the past 50 years.1 Numerous definitions exist to describe palliative care, all of which focus on aggressively addressing suffering. The World Health Organization and the U.S. Department of Health and Human Services both stipulate the tenets of palliative care to include a patient-centered and family-centered approach to care, with the goal of maximizing quality of life while minimizing suffering.2 In its clinical practice guidelines, the National Consensus Project for Quality Palliative Care of the National Quality Forum (NQF) describes palliative care as “patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering … throughout the continuum of illness … addressing the physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.”2 NQF further specifies the foundation of palliative care to include professional and family collaboration, the availability of services regardless of pursuit of curative or life-extending care, and, most importantly, the provision of care coordinated by an interdisciplinary team.2 The continuum of care provided by palliative care pharmacists (Figure 1) incorporates the concepts that curative and palliative care should coexist and that hospice care is an extension of palliative care that occurs when curative care is no longer part of the patient’s plan of care.3 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. The practice of palliative care, while rooted in traditional hospice and hematology and oncology programs, has changed dramatically in its delivery, competency assessment, and methods for preparing future members of the interdisciplinary team.4,5 Previously, health professionals obtained the necessary skills and knowledge for participation in the interdisciplinary delivery of palliative care via encompassing specialty areas (e.g., internal medicine, geriatrics, oncology).6,7 Numerous efforts to enhance professional education on palliative care largely drove its eventual recognition as a medical subspecialty in 2006.8,9 Specialized training programs and board certification opportunities exist today for most members of the palliative care interdisciplinary team.10–14 As the model of palliative care has progressed, so too has each team member’s potential for contribution. Despite representation within the first hospice demonstration project in the United States, participation of the pharmacist as an essential member of the interdisciplinary team has been traditionally overlooked.15–18 Evidence of the pharmacist’s contribution to the delivery of palliative care and supportive care services beyond the original role of medication dispensing and compounding has garnered growing recognition across numerous practice settings.15–17,19–27 Perhaps no other practice setting presents as diverse a collection of potential roles and responsibilities for the affiliated palliative and hospice care (PHC) pharmacist. Here, the PHC pharmacist may support the PHC services in an administrative role (policy and procedure, formulary management), in a consultative role (order set development, treatment algorithm development, best practices education), and in advanced clinical practice (medication therapy management services, pain and symptom management consultations, and interdisciplinary team participation). In 2002, ASHP published the ASHP Statement on the Pharmacist’s Role in Hospice and Palliative Care.28 These guidelines extend beyond the scope of that statement and are intended to define the role of the pharmacist engaged in the practice of PHC. Role definition will include goals for providing services that establish general principles and best practices in the care of this patient population. This document is based on literature resources, consensus of pharmacist experts in the field of PHC, therapeutic practice guidelines, and regulatory standards.1,2,4,29 The terms palliative, end-of-life, hospice, and supportive care are frequently, and incorrectly, used interchangeably. While these philosophies of care share similarities, each represents overlapping yet delineable points along the healthcare continuum. For the purposes of these guidelines, the term PHC will be used to describe the common services afforded to with a or in a hospice of PHC services are essential services, which include and services, which include of and The of provided by the PHC pharmacist will based on the of practice of the pharmacist as as the of palliative care services provided in each Services provided by a pharmacist will be and should be to best the needs of the hospice, or other healthcare practice In with the palliative care team or hospice and medical the PHC pharmacist or professional to the that the of services These include the of and to the palliative care or hospice of the PHC pharmacist in other areas of the and the of for administrative and should be Services provided by the PHC pharmacist will practices and should be to best the needs of the and the the of these guidelines, a by the and Palliative within the of Care of literature and to for all published and The literature terms and and in with other care, medication therapy hospice, of palliative care, supportive care, symptom and pain to other areas of specialty or subspecialty practice within the of of palliative and supportive care knowledge is essential for all pharmacists providing patient care, regardless of scope or The for Palliative Care a document on essential for healthcare and in the delivery of palliative In that for providing general palliative care palliative care services provided by care and care and providing palliative care health professionals on delivery of palliative These guidelines that the of the the pharmacist’s roles and will be as essential or roles and describe the practice of palliative and supportive care roles and delivery of palliative and supportive care services by pharmacist the of advanced as palliative and supportive care in medication therapy and to knowledge of the and roles and as within these guidelines, should be will focus on the pharmacist’s roles and within clinical practice and as as practice and professional clinical roles and for the PHC pharmacist may and services may be provided or to the on the practice While an of potential practice for the PHC of PHC delivery include hospice care or care and and care clinical roles and of the PHC pharmacist are in and of roles and that the PHC practice are and and of and of the PHC PHC palliative, supportive, and hospice care, and The PHC pharmacist providing care within hospice be with symptom management and Hospice services are provided in the hospice and hospice and in to the traditional care PHC pharmacists be of the regulatory with medication and The for and Services as part of the of stipulate that are for the with all services, to the and for which the patient and that are to the the and that to the to include the or by the or treatment of and are to all patient both and a of the of common and changed the for hospice medication from under the and a growing role for the PHC pharmacist is in the of services provided by a PHC pharmacist on hospice on is of to the of or symptom The PHC pharmacist should be in the medication and of hospice with to and of or should to of treatment each potential and to based on each patient’s should to the of and treatment is the of to the patient and of that the interdisciplinary with an education and training in management to this of that these services be provided by a pharmacist. and family education should extend beyond the patient’s on of to and is a on the health and The PHC regardless of practice be with and as as for (e.g., The of palliative care is common in U.S. and health may be engaged in numerous from or team members to the PHC team to participation and when PHC PHC pharmacists should be in symptom management as as medication and providing education to and and for and of scope of practice for the PHC the necessary knowledge and skills growing of palliative and supportive care to PHC to pain and symptom management in an These services may be within oncology and other practices as as care services under the patient-centered medical In and health are palliative care programs to symptom in yet to hospice or are yet hospice The PHC pharmacist in this setting be with the used to with and and with the in in and hospice care. In the the PHC pharmacist’s is when medication and are of or are the to PHC are while the and of a therapy is (e.g., with a therapeutic may be in this from the PHC pharmacist the of and for (e.g., patient or family of or in may be for PHC or under the care of a hospice in a to these may significantly symptom In for may be is roles of the PHC pharmacist in this include of as for pain or other symptom for and a of the regulatory and the needs of the patient (e.g., for in an in or compounding services PHC an role in the provision of care. The and of preparing medication support the provision of care to the The dispensing pharmacist will or education and knowledge to that the patient and family members the role of and necessary with to a or pharmacist for of all within a hospice These pharmacists with the hospice care team in a of medication therapy clinical and medication regulatory and clinical roles and of a PHC pharmacist for the pharmacist engaged in palliative or supportive care These in most the of provided by the pharmacist by the scope of practice and practice the PHC pharmacist will in the care of with to symptom assessment, medication and in that to pharmacists practice PHC pharmacist should and in practice by the and the of professional in this will facilitate provision of care to may the for will be with patient and family education to support of and with the plan of care. clinical roles and of the PHC pharmacist are in and of roles and that the PHC practice are and and of and of the PHC PHC palliative, supportive, and hospice care, care. The care model in care hospice programs, in which the patient’s in that has evolved to the PHC pharmacist as the hospice team member medication a consultative These PHC pharmacists are as in palliative care and are with palliative medication provision and and that are by The PHC pharmacist should patient care services of within the These services may from specialty team from or as part of (e.g., of in care patient care services provided to by the PHC pharmacist will be by the and and medical The or health the and of PHC pharmacists in the of board certification of the PHC pharmacist include medication the principles of care and pain and symptom patient and family and and of care to may be on to a PHC which of access to palliative care in an for a PHC pharmacist to symptom management to a of patient The in quality of life and potential in the of to the or for the quality for a pharmacist. The PHC pharmacist should be of the of medication of and the of medication is in the In of when other and are the of to symptom should the patient to hospice care. the PHC pharmacist within a on palliative care the interdisciplinary approach to patient care. is an essential role of pharmacists in practice PHC pharmacists should the and skills necessary to the for and and family While the patient care services of PHC pharmacists in the hospice are on patient care is the provision of hospice services may a PHC pharmacist from as the for a patient or an interdisciplinary An clinical role for PHC pharmacists is the support of from treatment to care. The PHC pharmacist is in an to in the of as the patient the continuum of care. a for when a treatment is no longer or or the to the (e.g., to availability of access or to is the to when a treatment has to and should be (e.g., of For with may be points and and The PHC pharmacist should the and other healthcare in the in medication that are necessary to a and for of should a of The PHC pharmacist is of the members of the interdisciplinary team and has an essential role in this or for of care patient healthcare and a of the of medication PHC pharmacists may be engaged in in the and of PHC from hospice care. PHC pharmacists should be engaged in the education and training of and patient care of knowledge the and of that is in or in clinical or training that to palliative care In to the clinical and administrative by the PHC the PHC and health should be part of these essential of practices and the of or are for the in patient care and of the PHC pharmacist. should be when and in to share best and in palliative care and hospice is and the PHC pharmacist should to the of knowledge when The pharmacist’s essential administrative roles and in PHC should practice that treatment and medication of the PHC pharmacist’s role is of of patient medication and with the as as with the patient or are essential to minimizing and while and engaged in the and of a medication formulary will support palliative and care programs to and medication in therapy to and medication and palliative care programs will to to in the care of of this is the of and to that with medication are across all of care. of patient medication over significantly medication and and be with the hospice or palliative care and as as with the patient or This is essential to establish and a of the patient’s providing the for the PHC pharmacist to and in or medication therapy or the of for symptom An and of the medication occurs hospice interdisciplinary team The PHC pharmacist’s to the of and will to with and and with best are by and which include with medication In of with as the Health and for Health a knowledge of regulatory and on medication pharmacists are to support the and of and to As a of a hospice the PHC pharmacist is in an to support with (e.g., The PHC pharmacist should with to that are to the hospice and with and other quality and regulatory a hospice is of to support a and the PHC pharmacist be an member and in a The pharmacist’s role all of from on under the hospice plan of care, for medication therapeutic medication and or algorithm An essential for PHC pharmacists is all patient on patient to a hospice for under the hospice plan of care. The PHC pharmacist is to the of the hospice and to the the certification of a the PHC in with the or the team will of to be under the hospice plan of care as as and For as necessary to and under the hospice plan of care, a of be (e.g., patient health this the pharmacist for the patient’s medical This medication in for a in healthcare and other opportunities to and formulary development, and by providing that the and of as as other used palliative care roles for PHC pharmacists include in and medication that medication and the of and as a and in the and or as an to healthcare and on the of in symptom management and palliative care, providing and of all and to that best and in the of that of services or In is essential that the PHC pharmacist the or health in with and to the of and other The opportunities for pharmacists to be in and practice that patient and the of administrative roles and include quality and of practice and and As the pharmacist with a set on an interdisciplinary PHC is a to or that or to the quality of care for this goal is a role on the and or in is an essential administrative by a the PHC pharmacist may services as care set to the of or (e.g., or to practices include medication guidelines to for the of or that are to an treatment or setting (e.g., of for palliative or to delivery or medication are an of or may the for practice (e.g., of practices for the of for pain of with the of clinical practice guidelines or algorithm for the palliative care team (e.g., palliative or pain The PHC pharmacist should a or role in the interdisciplinary of to the approach to common palliative care as and and of of palliative care education are to the of the pharmacist’s role in PHC The and of specialty programs that education and training in PHC are essential to the of the is that PHC competency is and other specialty the of pharmacists with the skills and knowledge the medication management approach for a palliative care and these should be by the to movement of the education of medical and and palliative care and is role for the PHC pharmacist. the role of the PHC pharmacist for in other skills in medication management of the palliative care patient the of pharmacists in the of future palliative care and from a pharmacist’s knowledge or programs by the health or professional of a palliative care is to the care plan to other and in the patient’s care. of or knowledge of disease and treatment the interdisciplinary PHC team pharmacist is to The clinical and administrative roles of the PHC pharmacist in setting on practice development, and to practice practice development, and are in and the role of a PHC pharmacist within an health or hospice, the of the of the or services, and of a needs are This will the for the focus and potential of the PHC pharmacist. to the of services, regardless of is the of the PHC pharmacist or of the for the services The for the of Palliative Care the first an PHC or to the For the are and the focus of the should be on the the other the focus on or for pain and symptom that be services, the should to services within the should be to the of a which should be the of of (e.g., is are numerous practice for clinical PHC services, information, clinical interdisciplinary team and medication therapy management The needs to the PHC pharmacist will for professional of the for the PHC pharmacist and the of support for the PHC a or of roles and responsibilities will to be and by all potential model on roles and responsibilities of the PHC pharmacist in may include of patient for which the PHC team has been team and and representation on or The of PHC programs in a for model or In the PHC pharmacist an role in the of and as palliative and from Health or to the clinical and of the PHC pharmacist. are common to this no board certification for the PHC pharmacist to knowledge or skills the competency is a of training programs that pharmacists in PHC This a when PHC in for pharmacists to this of practice an and or include the PHC team scope of practice for the PHC and to the will be the or model that is are and for practice as to establish or PHC pharmacist services should and on best practices for both and the of a practice model for the PHC the or team should the and practice by which the pharmacist on the practice the scope of practice may scope of practice pharmacists may roles in patient care under by a and or medical the of pharmacists under may in and is and for in of these may and within the U.S. Department of Health or the within these for a PHC pharmacist is provided in should be to an to on the interdisciplinary PHC pharmacists a health palliative care may be a first to for as the of support of PHC the PHC pharmacist be with and opportunities to further support these are no board certification opportunities for pharmacists with a in the of palliative and supportive care in the United the for board certification to PHC is to for to and other of certification the and of The of a role to the of pain and palliative care as a specialty within the of to pain and palliative care as a specialty when the yet overlapping clinical will in future is opportunities for in numerous palliative care. are opportunities for pharmacists to further enhance training in palliative and supportive care. The ASHP and and Palliative Care a of by training with an PHC pharmacist. are other training programs to further of palliative and supportive care of or and for professional of the PHC pharmacist are in The for the of and Palliative Care in a consensus document on to palliative care education in the of programs, and palliative care specialty are or palliative care or pain management programs and with or in pain or palliative is that are and education programs in the of PHC for in the field to to In is a training for pharmacists in the Palliative Care by the Department of The of the role of a PHC pharmacist needs to be the with pharmacists The palliative care certification include a palliative care pharmacist as a member of the interdisciplinary team as for and The that a clinical pharmacist should be based on patient palliative care medical and are with therapeutic that clinical and to regulatory which should a pharmacist as an part of providing care to the efforts of the PHC pharmacist should be and professional development, practice development, and to and professional and to the of pharmacist in the PHC team be to the of the the that PHC pharmacists on patient care are PHC pharmacists a of essential services to palliative and supportive care to the role of the PHC pharmacist is symptom management participation in patient care, providing that support patient therapy management and the of of care are services pharmacists to in this care practice opportunities the with palliative and supportive care medical PHC pharmacist practice In PHC pharmacists may in and in palliative and supportive care, the of this of The PHC pharmacist should education to pharmacists and and as as members of the interdisciplinary and in these guidelines a and of opportunities for in the management and of across all palliative and supportive care patient while The no potential of by the ASHP of on the ASHP of Care ASHP the and for these guidelines of and Palliative Care of and The of to this document are the or of PHC services, a needs assessment, and be or scope of practice as as should be for all pharmacists providing PHC services providing PHC services should practice to the of and practice to and practice and PHC pharmacists should an role in best and other efforts to further the within PHC PHC pharmacists the education of and all of PHC services The PHC pharmacist is for representation of services on the palliative care team and representation of the palliative team within services in the provision of PHC services to the care and as a to the and the and management of used in the treatment of pain and other on all with for palliative and supportive care all interdisciplinary PHC team clinical or to palliative care hospice and on symptom pain medication therapy palliative and of care. to from and to palliative and supportive care all medication of all hospice or palliative and supportive care services for or medication to and medication for palliative and supportive care medical literature for or treatment guidelines, formulary management or and or and for for used by in the hospice to the of to include and as to palliative and supportive care and and in and to palliative and supportive care, of care, and and or PHC services when as of services or palliative and supportive care services for or and to support as to palliative and supportive care. quality and to palliative and supportive care on palliative and supportive care services to hospice or of services all PHC and of and that to and of Health and of as for practice advanced practice and necessary professional or specialty to the of care to of the health or This practice as a of and by the to the palliative and hospice care pharmacist with the and and within the scope of practice of the these guidelines, the will with the in an practice to palliative and hospice care (PHC) services provided to of The is to services and with for in and may as in The of or and the of the The may for of the or These guidelines be and by the and of these guidelines along with the on all the The for the and for the Services and by the are to the guidelines that are to the practice The and the and practice of the in a to and patient care. The is to services and to the pain and symptom management within the scope of this palliative and supportive care practice as part of a to include and care The management of by the will be provided based on an patient medical and plan of care and under the and of the and include the The to the for the patient care will medical and medication with on symptom assessment, and of may include as as the and of and to therapy management in with and of to of and of or of in of of to when based on or of care. to include or of the and of in for pain or based on medical the disease and the patient’s and, treatment guidelines and pharmacist under the and the is to to patient care. The pharmacist will the patient’s to the treatment plan with and to include and of and for pain will an on will be to a and for a of as are education on to patient or and The within of the a or with a of of of patient to treatment and treatment plan This be in the of a general the patient or medical The or and on each patient by the pharmacist. The or may treatment or by the with to the via in the patient and will in with and set in the and for the may this via This practice is to the and of both the and to practice in the of clinical training clinical in patient care delivery education or to the field of practice This practice is on the of For For This of medication and is yet of by the PHC pharmacist for the palliative and supportive care and and in the treatment of and pain and in the treatment of and or other and in the treatment of and and in the treatment of and in the treatment of and pain and in the treatment of in the treatment of and in the treatment of and pain potential by patient will be and in the treatment of pain potential by patient will be and and in the treatment of and potential by patient will be and and in the treatment of and in the treatment of pain and or in the treatment of and The may in with the scope of services in the The is to and for in and and for general in with the scope of services of Hospice and Palliative Care of Palliative Palliative Care and Palliative Care in and Palliative Care of Palliative of and of and Palliative Care of Hospice and Palliative of and Palliative Care of and of Palliative Care of Palliative Care and of Palliative of Palliative Care Palliative Palliative and Care Palliative and Care Care in and hospice and palliative care. palliative care of of palliative and supportive care. Palliative skills and clinical palliative care. practice of palliative of palliative a for of based palliative a Palliative care of palliative care. of Hospice and Palliative management and palliative a palliative in Palliative care. of of hospice and palliative of Hospice and Palliative of and Palliative Care and to Palliative Care of and Palliative Care for Palliative Care for Hospice and Palliative Care National Hospice and Palliative Care Organization National Palliative Care of Palliative Care Consensus from the for and Care J 2012;