Written by Paul Tait (@pallcarepharm), RePaDD Member and Palliative Care Pharmacist, Rural Support Service.
The delivery of palliative care services has evolved substantially since its simple beginnings in the UK over sixty years ago. In Australia, palliative care is delivered by a complex array of services with significant aspects of care provided in the last year of life in the community. Palliative care relies on availability of substantial support for clinicians working across public and non-government organisations (NGOs). This is particularly important in prescribing, dispensing, administering, and monitoring medications as these functions rely on multidisciplinary teamwork. The role of the pharmacist in the community is essential to effective teamwork in this context.
In the early nineties, Hepler and Strand coined the term pharmaceutical care to describe the whole gambit of duties a pharmacist performs. Pharmaceutical care involves “the process through which a pharmacist cooperates with a patient and other professionals in designing, implementing, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient”. Critically this definition applies as much to the supply of medications as it does to the provision of clinical pharmacy services.
Over the past decade, as a qualified pharmacist I have had the opportunity to work with a range of community-based clinicians to understand the challenges underpinning pharmaceutical care for the dying. This has resulted in over 20 peer-reviewed published articles. As a result, I was offered the opportunity to complete a PhD by prior publication with the support of the Research Centre for Palliative Care, Death, and Dying (RePaDD). Unlike a traditional PhD model, a PhD by prior publication allowed me to use six of my previously published papers to build the thesis and examine my contribution to the literature against the evidence base.
In reflecting upon the contribution and significance of these six publications, it was clear that the delivery of pharmaceutical care for people approaching death has a range of challenges, underpinned by a complex environment in which pharmacists provide care. All complex environments have characteristics in common, including the presence of multiple components with significant interdependency through how they interact. As a result, a single action can lead to unpredictable responses elsewhere within the environment. In studying complex environments, we are reminded that their inherent challenges cannot be met by improving the efficiency of their components individually. Instead, understanding the factors supporting their interaction is critical.
To take the analogy of a school of fish, the group immediately responds when one member identifies a threat. Indeed, with the remainder of the school responding appropriately and instantly, the threat is avoided by all. This serves to remind us that there is no clunky top-down bureaucracy to drive change to immediate threats in complex environments. Instead, the tools to support interaction at the local level are all that is necessary. For instance, my thesis work identified that clinicians – including general practitioners, pharmacists, and aged care providers – develop into teams to support patient care. However, unlike the school of fish analogy, these clinicians cannot rely on visual cues to understand the team’s threats. Instead, various tools, including funding and reporting instruments, must support pharmacists in connecting with the broader team in delivering pharmaceutical care for the dying.
This thesis identified approaches already in place to improve the efficiency in how pharmacists respond to the threat of a person’s functional decline. For example, Commonwealth-funded home medication reviews (HMRs) and standardised lists of medications used in managing terminal phase symptoms improved the interaction between team members. However, just as this thesis identified in-place strategies, it highlighted gaps within the current environment in which palliative services are delivered. For instance, while the Australian government has improved funding for various allied health professionals to participate in case conferences, pharmacists are omitted. Suppose the broader team caring for someone with palliative needs continues to rely on pharmacists to volunteer their time to contribute their clinical skills. In that case, the risk is that pharmacists will not be in attendance, and the team will be blind to threats relating to medication-related problems.
In addition, in looking at the issue of pharmaceutical care for the dying, I identified a range of threats that the evidence simply does not have answers for. For instance, the lack of research into the pharmacist’s role in supporting people receiving aged care services in their home dwelling or the impact of out-of-pocket expenses for caregivers means that we can only speculate on the effects of these issues on care. Therefore, clinicians and researchers must work together to build pragmatic studies aiming to solve problems in the clinical setting, supporting the environment to develop.
Understanding complexity and complex environments were at the heart of this thesis. It has provided insight that in moving forward, organisations charged with funding and delivering care need to consider. This includes the opportunities inherent within the system to support and promote interaction to offer good outcomes for people with palliative needs and their caregivers. This thesis also discusses how complex environments are characterised by dynamic and interdependent connections that evolve with time. Indeed, considering this space by simply focussing on the efficiency of individual components fails to understand the inherent properties of complex environments of which palliative care is one.