The practice of pharmacy in a hospice setting is very different to that in an acute setting. As time is short, focus on long-term effects of medicines may not be such a concern so we can use medicines such as co-danthramer, which has carcinogenic properties, if given long term. Symptoms can be very challenging and first and second line treatments are not always effective, so we turn to less obvious solutions and share ideas from other centres in the UK and beyond.
It has long been the practice to use medicines ‘off licence’. Getting a UK product licence for a medicine is a huge and costly process and clinical trials must show the medicine to be safe and effective for a specific symptom. However, many have additional properties, so we use licenced medicines in conditions they were not originally intended for. There is no legal barrier for a prescriber to prescribe, a pharmacist to dispense or a nurse to administer a medicine off licence if in our professional judgement it is appropriate.
Common examples are the use of antidepressants and anti-epilepsy medicines for neuropathic pain and antipsychotics for nausea and vomiting. Most injections used in symptom control are not licensed for the subcutaneous route, but most have been in use successfully for decades. It has also long been our practice to mix injections in syringes for 24-hour infusions and in all these areas of practice, we have a huge body of clinical experience to back up our practice. More observational and chemical stability laboratory data for the safety of mixing is emerging and positive (1).
Unlicensed medicines, which is a wide term, describes any medicine which has not gone through the full regulatory process for it to have an MHRA licence. Our most usual usage of unlicensed medicines is the use of ‘specials’; commonly liquids that are no longer made by a manufacturer but made to order.
Clinical trials in palliative care
Palliative care has been slow to become evidence based. Carrying out clinical trials in palliative care is challenging for several reasons: patients are so diverse that it’s hard to collect enough to recruit to give clinically significant outcomes; there are ethical questions which actually can be overcome with most patients, but families can be resistant to their dying relative being ‘used for research’; and of course, people may not survive long enough to be able to take part in studies.
Despite the barriers, there is a gathering body of literature to support practice long carried out, and palliative care as a speciality of its own is now becoming more evidence based. It continues to break ground with novel ways to solve problems and this is what makes it so fascinating. I see part of our role as being the safety net to guide practitioners on the introduction of new treatments from the pharmacy and governance point of view.
Palliative care as a speciality of its own is now becoming more evidence based
Finding the best solution to help an individual patient’s symptoms is a lovely mixture of science and art, in my opinion. It is a area where pharmacists can really show their skills in seeking out the right drug for the right patient and sometimes can mean thinking ‘outside the box’.
It’s a very sharing speciality with discussion forums available to interrogate to see how others may have managed problems as diverse as malodorous wounds in inaccessible places to intractable vomiting in a patient with Parkinson’s disease alongside cancer.
We have a national organisation for pharmacists working in palliative care, which I am proud to say I initiated, where we ‘meet’ online and sometimes in person to share good practice and discuss issues both clinical and procedural. Find out more here.
Palliative care has changed a great deal in the past few years as people are living longer with their disease and often have to deal with multiple co-morbidities. Gone are the days when we would cross off all their regular medicines on admission to the hospice and just use symptom control medicines. Now we realise that their regular medicines can contribute to their symptom control, but we need to be mindful of rationalisation and drug interactions.
Medicines rationalisation will be a topic covered in a future newsletter.
Dickman A, Schneider J. The Syringe Driver: Continuous subcutaneous infusions in palliative care