Expanding Practice: PHARMD and SW Led Palliative Consults

Topic: Staffing Models

Background: Palliative care (PC) teams often rely on traditional medical providers to lead consultative encounters, potentially delaying access to PC expertise and preventing other disciplines from practicing fully within their scope. To illustrate an alternative approach, we describe a series of PC consultations served well by expanded team roles.

Methods: PC consultations for a single center were reviewed from January to May 2016. Patients seen by both a pharmacist (PHARMD) and social worker (LICSW) but not a physician or nurse practitioner in the first 72 hours of consultation were considered for inclusion. PC consultation metrics and chart notes from PC team members were reviewed for common actions and themes.

Results: Eight patients met inclusion criteria. Palliative diagnoses were: cancer, solid (5); heart failure (3). Reasons for consultation included: advance care planning (ACP) only (4); pain only (2); ACP and pain (1); ACP and non-pain symptoms (1). Setting of initial consultation was medical/surgical floor (3); cardiac floor (2); intensive care unit (1); intermediate care unit (1); emergency department (1). Setting of discharge included: home (4); death (2); acute rehabilitation facility (1); home hospice (1). PHARMD activities included: medication initiation, titration and monitoring; opioid risk screening; substance abuse screening and counseling; symptom identification and treatment; medication reconcilliation; deprescribing; family meetings. LICSW activities included: psychosocial assessment and counseling; completion of advance directive; family meetings; nonpharmacologic pain management; reiki; bereavement counseling. Two patients were seen by a physician or nurse practitioner >72 hours after initial consultation. In those cases, recommendations were in concordance with LICSW and PHARMD, and advancements in ACP and were achieved in one case based on preliminary discussions held by LICSW and PHARMD with patient and family. No adverse outcomes of recommendations or interventions were noted to occur during hospitalization.

Conclusions: Non-physician palliative care team members, such as clinical pharmacists and social workers, can provide skilled symptom management and advance care planning in various settings, palliative conditions, and disease stages. Enabling PC team members to work fully within their scope of practice expands the team’s clinical reach and accelerates bedside access to PC expertise.

Author

  • Renee M. Holder, PHARMD
  • Clinical Pharmacist, Palliative Care
  • Medstar Washington Hospital Center
  • 110 Irving Street NW
  • Washington, DC 20010
  • 202-877-7841

Co-authors

  • Anne Kelemen, LICSW
  • Hunter Groninger, MD
  • Regina Tosca, LICSW

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