Community Pharmacists: A Forgotten Resource for Palliative Care

Community Pharmacists: A Forgotten Resource for Palliative Care

Paul Tait, John Gray, Paul Hakendorf, Bel Morris, David Currow & Debra Rowett

Repatriation General Hospital

Aim

> Identify likelihood of community pharmacies having medicines for symptom control in the terminal phase

> Identify community pharmacy’s level of awareness of palliative patients/carers

> Understand the demographics of the community pharmacies

> Develop a distribution list of community pharmacies

Building a platform for improved access to palliative medicines in the community


Terminal Phase Medicines (TPM) List

> Symptoms:• Dyspnoea• Pain• Nausea• Delirium ±

agitation; and • Noisy

secretions.

> Physical ability• decreased

energy levels;• reduced ability

to swallow; and • impaired

mental state



Terminal Phase Medicines (TPM) List

• Ordered on d/c from hospice

1084

• Separate medicine formulations

286

• Evidence exists for use in terminal symptom

80

• Available on the Australian market & require a prescription

71

• Administered subcutaneously or as an oral liquid

26

• The most commonly issued formulation

13



TPM List

> Clonazepam 1mg inj*> Clonazepam 2.5mg/mL oral drops*> Dexamethasone 4mg/mL inj*> Fentanyl 100mcg/2mL inj> Haloperidol 5mg/mL inj*> Hydromorphone 10mg/mL inj*> Hyoscine Butylbromide 20mg/mL inj*> Hyoscine Hydrobromide 400mcg/mL inj> Metoclopramide 10mg/2mL inj*> Midazolam 5mg/mL inj> Morphine 10mg/mL inj*> Morphine 10mg/mL oral mixture*> Oxycodone 10mg/mL injBuilding a platform for improved access to palliative

medicines in the community


The Survey

1. Demographics of the pharmacy • Role of the person completing the survey;• Postcode (→socioeconomic scales, rural/metro);• Pharmacist FTEs;• Usual opening hours; and• Clinical and supply services offered.

2. Awareness of palliative patients • How many palliative patients had used pharmacy

over the previous 12 months;• How they became aware of palliative status; and• The range of issues affecting timely access to these

medicines.



The Survey

3. Access to stock• Date of completing the survey;• Existence of medicines from the TPM List in

their dispensary; and• Shortest expiry date of each item held within

the pharmacy.

4. Willingness to be part of an email distribution list



Methodology

> Southern Adelaide Clinical Human Research Ethics Committee (SAC HREC)

> Each community pharmacy was allocated an individual code.

> Survey was mailed with a cover letter to 455 pharmacies across SA

> All responding pharmacies were allocated to a decile of the Seifa Index

> No reminders were sent out



Likelihood Of Having Stock

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 1011050

1

2

3

4

5

6

7

8

9

10

11

12

13

Pharmacies

Num

ber o

f Med

icin

es o

n th

e TP

M L

ist



Likelihood Of Having Stock

Hydro

morphone 1

0mg/mL in

j

Oxycodone 1

0mg/mL in

j

Hyosci

ne Hyd

robromide 400mcg/

mL inj

Clonazepam

1mg inj

Fentan

yl 100micr

ogram/2mL in

j

Dexameth

asone 4

mg/mL in

j

Hyosci

ne butyl

bromide 2

0mg/mL in

j

Clonazepam

Oral

Drops

Midazolam

5mg/mL in

j

Haloperi

dol 5mg/m

L inj

Morphine 1

0mg/mL o

ral so

lution

Morphine 10mg/m

L inj

Metoclo

pramide 1

0mg/2mL in

j0%

20%

40%

60%

80%

100%

Likel

ihoo

d of

Acc

essin

g M

edici

ne


Awareness

Aware of pal-lia-tive pa-

tients

87%

un-aware of pal-lia-tive pa-

tients

13%

Patien

t/care

r inform

ed

Identified

thro

ugh pres

cription

Informed

by another

health

servi

ceOther

0

15

30

45

60

75

90

105

How Pharmacist Identified Palliative Status

Num

ber o

f Res

pons

es



Expiry Date Data

Metoclo

pramide 1

0mg/2mL In

j

Morphine 1

0mg/mL In

j

Morphine 10mg/m

L Oral

Solution

Haloperi

dol 5mg/m

L Inj

Midazolam

5mg/mL In

j

Clonazepam

2.5mg/mL O

ral Dro

ps

Hyosci

ne (Butyl

bromide)

20mg/mL In

j

Dexameth

asone 4

mg/mL In

j

Fentan

yl 100micr

ograms/2

mL Inj

Clonazepam

1mg Inj

Hyosci

ne (Hyd

robro

mide) 400micr

ogram/m

L Inj

Oxycodone 1

0mg/mL In

j

Hydro

morphone 10mg/m

L Inj

0

12

24

36

48

60

Mon

ths t

o Ex

piry



Recommendations

> Prescribers: • Involve community pharmacists in discussions

about care planning > Palliative Care Organisations:

• Develop a core medicines list to guide prescribers and community pharmacists alike

> Policy Makers:• Create incentives for community pharmacies to

hold a small range of medicines


Reflections

What Worked Well• Sending survey in paper form

with reply paid envelope• Surveying all pharmacies

across SA• Asking about expiry dates• Choice of medicines matched

the WA essential medicines document

What We’d Do Differently• Enquiring about a single

strength for each medicine may have skewed data


Community Pharmacists: A Forgotten Resource for Palliative Care

Paul Tait, John Gray, Paul Hakendorf, Bel Morris, David Currow & Debra Rowett


Core Medicines

For noncomplex adult patients

> Clonazepam 1mg injection;> Morphine 10mg/mL injection;> Haloperidol 5mg/mL injection;> Metoclopramide 10mg/2mL injection;> Hyoscine butylbromide 20mg/mL injection.



Demographics

Role

Proprietor 44 (41.9%)

Manager 34 (32.4%)

Pharmacist 26 (24.8%)

Locum 1 (0.9%)

Pharmacy Intern -

Technician -

Location of Pharmacy

Metropolitan postcode 63 (60.0%)

Rural postcode 42 (40.0%)

Services

Dose administration aid service (e.g. Dosette® or Webster-pak®) 97 (92.4%)

Home Medicines Review (HMR) 96 (91.4%)

Home Delivery Service 80 (76.2%)

Aged Care Facility (Dispensing) 43 (41.0%)

Residential Medication Management Review (RMMR) 39 (37.1%)

Aged Care Facility (Clinical) 23 (21.9%)

After-hours/on call 18 (17.1%)

Hospital (Dispensing) 16 (15.2%)

Hospital (Clinical) 13 (12.4%)



Issues

No issues Pharmacy did not stock sufficient

Pharmacy did not stock medication

Problem with the prescription

Other0

15

30

45

60

75

90

105


Community Pharmacists: A Forgotten Resource for Palliative Care

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