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How pharmacy can benefit patients and professionals in palliative care

Margaret Hook has been providing advice and medicines to St Peter’sHospice in Bristol for over 15 years. At first this was from the localcommunity pharmacy but in 1997 the work was offered for tender and shebegan a 12-hour service each week, supplying drugs, discharge prescriptionsand advice to the clinical team and patients. The hours have increasedand, over time, as Ms Hook’s clinical skills have developed andas the hospice has come to realise the value of pharmacy input, the servicehas expanded to cover 35 hours over four days.

Ms Hook is self-employed and is contracted to provide pharmaceuticalservices to the hospice. Three clinical pharmacists currently offer theirservices to St Peter’s, which is the only hospice in the UK tohave its own pharmacy that is independent of the NHS, and it is currentlyrecruiting a fourth pharmacist to the team (see pA20).

The pharmacists at the hospice provide a full pharmaceutical assessmentof patients, reviewing their medicines when they are admitted to thehospice and again after their first inpatient prescription is written.

They are also able to facilitate contact with community pharmacists,who are often the best people to answer queries about patients’ treatmentbefore their admission. “Patients with a serious illness, one thatmay be terminal, often stick to the same community pharmacist. It isusually more productive to contact them rather than their GP where theissue is about a drug not included on their repeat medication list becausethe prescribing doctor is quite likely to have been an on-call doctor,” sheexplains.

The hospice supports patients who want to self-medicate and Ms Hook providesadvice on how patients can best manage their medicines at home and atthe hospice. “If patients are less fit, one of the last bits ofcontrol they have is what goes in their mouth. Some patients want thatcontrol, so we support them in that,” she says.

Supplementary prescribing

Ms Hook qualified as a supplementary prescriber in 2004, having completedthe prescribing course at Bath University. “It seemed a logicalstep to take and I could see how it would support my work,” shesays.

One of the biggest changes to Ms Hook’s role since qualifying asa supplementary prescriber has been taking on responsibility for dischargeprescriptions. And Ms Hook is keen to stress that St Peter’s isnot just about terminal care. “Seventy per cent of our patientsgo home,” she says. But in the hospice setting discharges can beunpredictable— either because a patient due to be discharged becomestoo unwell to leave or because a patient suddenly wants to return home.With a pharmacist supplementary prescriber on board there is no longera need to chase a junior doctor to sign a discharge prescription — usuallythe last thing on their list of priorities. “This is importantbecause symptom control is often fine-tuned in the last 48 hours beforea patient is discharged.”

So how does the supplementary prescribing process work at St Peter’s?Ms Hook is involved in most ward rounds, which happen twice weekly. Patientswith stable disease who have been admitted to the hospice for symptomcontrol or respite are identified since they are likely to be patientsfor whom supplementary prescribing is appropriate. Ms Hook then talksto the patient with medical director at St Peter’s, Carol Dacombe,and introduces the idea of supplementary prescribing. “Most patientsare open to the idea of a pharmacist prescribing in this way,” saysMs Hook. “St Peter’s is very much a multidisciplinary unit — weshare information and have access to patients’ records.” Patientsare used to a mix of professionals providing care — doctors, pharmacists,nurses, social workers, not forgetting the hospice’s chaplain.

“Patients often tell their story in different ways depending on who theyare talking to — a doctor, nurse or pharmacist,” says MsHook, who is able to discuss patients’ needs fully and allay fearsand misapprehensions about various aspects of drug therapy. “Iuse the skills I learnt on the prescribing course to explain in detailwhat is happening in terms of a patient’s condition and how certaintherapies may help. In this way a patient is more likely to try the treatmentbeing recommended to them and when they feel the benefits will have confidencein the next thing I suggest.”

Recently one of the hospice’s patients was admitted with fibrosingpulmonary alveolitis and who had been reluctant to try any differentdrugs to help relieve his symptoms. “He thanked me for spendingtime with him to explain in detail how each drug may help. I reviewedmy intervention after the weekend and he said he had had his best night’ssleep in months after using a salbutamol nebule.”

She acknowledges that she is able to spend more time with patients thanother prescribers working in general practice or secondary care. “Atthe hospice we are trying to have a real partnership with the patient.This is the place where such a partnership works best. It’s concordancein action.”

As with all supplementary prescribing, the hospice uses a clinical managementplan to set out the Ms Hook’s prescribing responsibilities. Theplan contains specific information as to what indications she can prescribefor and lists aims for the prescribing process.

The plan has not, however, limited the drugs that Ms Hook can prescribe,except for Controlled Drugs. “Because of the nature of patientsreceiving palliative care, many have co-existing diseases. We wantedto ensure that this did not preclude them from supplementary prescribing.My mentor is confident that I am aware of my own competencies.”

Developing role in Controlled Drugs

An amendment to the Misuse of Drugs Regulations,due to come into force on 14 March, will mean that supplementaryprescribers are able to prescribe Controlled Drugs in secondarycare settings. A further amendment to relevant NHS regulationswill mean supplementary prescribers working in primary care cando the same from April or May.

Ms Hook’s role looks set to develop as further responsibilitiesare agreed. Proposed changes to the Misuse of Drugs Regulations madeby the Home Office mean that supplementary prescribers will soon be ableto prescribe CDs (see Panel), something that could bring obvious benefitsto hospice patients. “This will revolutionise my prescribing andallow me fully to use my new skills. At the moment I cannot prescribeall the medication some patients need and have to ask one of our doctorsto take responsibility for CD prescribing.”

Dr Dacombe welcomed this news: “Margaret has, since qualifying,been able to prescribe for four fifths of her patients’ needs andthe hospice welcomes the extension —both the organisation and patientswill benefit from her prescribing to complete a period of inpatient careand improve communication at the point of discharge.”

Pharmacy’s role in the palliative care of hospice patients in 2005may be unrecognisable to some who were providing pharmaceutical services15 years ago. By embracing the opportunities on offer to the profession,Ms Hook has helped shape a service that has brought untold benefits topatients and other professionals working in the sector.

Citation: The Pharmaceutical Journal URI: 10018069

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