Pharmacists do not usually come off very well in the media. Sweeping stereotypes of the pharmacist as a drawer-puller with high pharmacy prices, or the image of mail-order and discount pharmacies, distort the picture of the profession. This distortion is partly self-inflicted and partly politically reinforced. That being a pharmacist - at least as I understand it - should and can involve far more healing-profession aspects than commercial ones is rarely as clear as it is in palliative pharmacy.
The German Society for Palliative Medicine defines palliative pharmacy as the pharmacist's contribution to palliative care. It includes all pharmaceutical aspects of caring for and accompanying palliative patients and their relatives, including medication supply, medication management, pharmaceutical care and patient-specific preparations.
When one looks at these individual points, it becomes clear that palliative pharmacy is pharmacy in its most original meaning. It goes beyond simply selling medicines and includes supporting relatives and patients: explaining dosage forms, being a trusted contact in crisis situations, and serving as an interface between doctor and patient.
To meet these demands competently, establish consistent pharmaceutical quality, ensure scientific accuracy in the transmission of information, and develop the human soft skills indispensable for this diverse task, chambers of pharmacists have for several years offered certificate training in palliative pharmacy. In tightly organized and varied lectures, topics relevant to palliative care are presented in detail, and interested pharmacists are introduced to grief work, patient communication and end-of-life accompaniment.
To be fair, these latter points can only be introduced. Truly adequate support of patients and relatives requires years of practical experience. So far, the theoretical part is followed by a multi-day placement on a palliative care unit, in a hospice or in an outpatient team. There, theoretical knowledge of pain therapy, symptom control and medication at the end of life is put into practice together with physicians and nurses. At the end of the practice phase, with the consent of all involved, an anonymized project report is written in which pharmacists present a case and describe their interventions.
You may ask why I have taken so much time to explain how a pharmacist can become a palliative pharmacist. The answer is simple: pharmacists are underestimated. Through our studies, our profession can do far more than it is currently allowed or expected to do. Palliative pharmacy makes this clear through simple examples.
Our studies enable us not only to assess interactions and side effects, but also to give therapists important information about the drugs they intend to use. Under appropriate conditions, we can point out risks, suggest alternatives and dosages, and provide scientifically evaluated information that helps the doctor - whose therapeutic authority remains untouched - select the most suitable active substance. Pharmacists support doctors in questions of dose adjustment and compatibility.
Another point, alongside information and therapy assistance - politically termed medication management - is the exclusively pharmaceutical competence of preparing individual formulations. No one except pharmacists can do this in this way, and no one has the necessary know-how. Only pharmacists and their pharmaceutical staff can evaluate alternative dosage forms in a meaningful way and provide them safely and therapeutically effectively.
There are now many examples in palliative situations: omeprazole suppositories, nasal midazolam or fentanyl nasal spray. Constructing such preparations, often as off-label use, requires engagement with specialist literature and research in relevant databases. At the very least, studies should be available to support the idea and show that active substances can be used alternatively in a meaningful and safe way.
In lectures I often say that this genuinely pharmaceutical field has become a kind of border pharmacy because we are forced to concern ourselves too much with selling medicines and the commercial environment instead of focusing on our strengths. I would tell pharmacy students not to cling too tightly to package leaflets, but to dare to consider active substances beyond their formal approval: sapere aude - dare to know. What else can the active substance do?
Pharmacists can also explain transparently why a pharmacy cannot always have everything in stock, especially in the era of the German AMNOG law and health-insurance rebate contracts. Doctors, particularly in hospitals, are often unaware that pharmacists are forced to exchange medicines and that the sheer number of rebate contracts, insurers and companies makes it impossible to keep every product in stock. Many are also unaware that dispensing non-rebate products can mean that the pharmacy is not reimbursed.
A shared general house list or a stockroom aligned with specialized outpatient palliative care could help. It could also bridge the frequently felt gap between doctors and pharmacists: talking with each other about problems instead of merely talking about each other. Only together with the doctor can we act for the patient's benefit.
As a palliative pharmacist, he or she can:
- Provide doctors and nursing staff with evaluated information on active substances, side effects and interactions.
- Assess therapies rationally together with the doctor and point out alternatives where appropriate.
- Create individual formulations in specific cases and thus offer therapeutic alternatives that do not exist on the pharmaceutical market.
- Train doctors, nurses and relatives in the use of special dosage forms.
- Improve care in times of legal overregulation by offering house lists or adapting stock sensibly.
- Stand by relatives as a trusted contact in crisis situations.
In summary, pharmacists can be active within palliative care in many ways. They do not have to cover everything at once, but they should possess a minimum degree of professional and human suitability.
Many colleagues ask whether they should train in palliative pharmacy. Perhaps idealistically, I answer that they should do it not for money but for the sake of the subject. If they are willing to invest time and money in an interesting field that pays off more humanly than financially, and if they can accompany patients and relatives, then yes. If they want to do it purely for business reasons, I advise against it - both humanly and economically.
Notes
- Omeprazole suppositories can be an alternative dosage form for disease-related swallowing difficulties.
- Midazolam nasal spray can be used as an alternative to phenobarbital suppositories for seizures.
- Fentanyl nasal spray may be used, among other things, for breakthrough pain.
- Off-label means using a drug or dosage form outside its legal approval.
