Exploring the potential for pharmacist participation in community-based palliative care services in North West Tasmania

North West Tasmania is a vast and remote region with an ageing population. Since elderly people are prone to cancers and chronic diseases, the need for healthcare services in rural and remote communities is undoubtedly high, especially in the area of palliative care. It has been reported that access to optimal healthcare for rural and remote area patients has been problematic and many are receiving suboptimal palliative care services. Furthermore, drugrelated problems (DRPs) are commonly experienced by patients receiving palliative care; thus an efficient and quality assured standard of palliative care service is needed. We proposed that the inclusion of a pharmacist could be beneficial for palliative care services in North West Tasmania. The main aim of this study was to explore the role of pharmacist participation in communitybased palliative care services in North West Tasmania. Specific objectives were to investigate the nature and extent of DRPs in palliative care patients in North West Tasmania. We conducted the study in two parts; we commenced by retrospectively examining and identifying DRPs from the North West palliative care home-based patients' medication records and then conducted a focus group discussion to gather opinions from the palliative care providers. In the first part of the study, apart from the collection of data related to DRPs, we collected information including patient demographics, medications, medical history and relevant laboratory data. The patients admitted under the palliative team care were reviewed. Their first three clinical assessments and the medication management of the patients were screened for potential and actual DRPs. For DRP assessment, the researchers first identified the symptoms as recorded in the medical notes. DRPs were then categorised using the D.O.C.U.M.E.N.T classification system and their possible causes determined. The first part of the study involved 100 patients. The median age of participants was 68 years. Two-thirds of patients were male, and lung cancer was the most prevalent cancer diagnosis. We found that 52% of our patient sample experienced DRPs when their admission data was assessed. Using the D.O.C.U.M.E.N.T classification system, our findings indicated that the most common DRPs were drug toxicity, dosage problems and patient non-compliance. Dosage mismanagement and patient noncompliance were common contributing factors of DRPs among patients. These unwanted outcomes were mainly due to polypharmacy, when the patients were following multiple medication regimen for chemotherapy and chronic diseases. The study also found that opioid analgesics, benzodiazepines and anti-nausea medications were common causes of DRPs. In the second part of the study, a focus group discussion was conducted to gather opinions from the North West palliative care team. The focus group was conducted with 14 participants to discuss 3 main topics: (1) DRPs encountered during work, (2) experiences to overcome DRPs, (3) opinions about the inclusion of a pharmacist in the team and barriers to implementation. Opinions concerning the team members' experiences of DRPs and their management, and the potential role of a pharmacist on the team were shared and recorded. All qualitative data were audiotaped, transcribed and later analysed using thematic analysis. Participants described patients' drug misadventure, inadequate drug supply, minimal patients education, lack of drug interventions and medication reviews as the main contributing factors of DRPs. During their community- based palliative care practices, they would also rely on GP/pharmacist advice when they needed access drug information. They also participated in regular group review to enhance their knowledge in DRPs management. Several measures were discussed to either prevent or resolve DRPs and their consequences in order to achieve the best possible outcomes for the patients. The involvement of a pharmacist in palliative care, such as pharmacist-conducted home medicines reviews (HMRs) for patients receiving palliative care, were suggested to prevent or manage DRPs. The participants also affirmed the value of an inclusion of pharmacist in the team, as pharmacist involvement was expected to improve patients' medication management and minimise related errors, and at the same time increased the medication-related knowledge of team members and patients. The main barriers to the implementation of a pharmacist-participated palliative care team were funding and State health service policy. The challenges faced by the palliative care team members in this region have highlighted the need of a palliative care pharmacist. The inclusion of a pharmacist was considered to be beneficial to form a multidisciplinary team to support community-based palliative care service, but requires government funding and support.