Community pharmacy service provision to adults with palliative care needs in their last year of life: a scoping review

Introduction

In Aotearoa New Zealand (NZ), the demand for palliative care is predicted to increase by 51% from 2017 to 2039.¹ The NZ Ministry of Health’s Palliative Care Action Plan emphasised the importance of equitable access to palliative care services, aligned with recent health reforms aiming to eliminate disparities and provide equity-focused health care.^1,2 Despite government efforts and collaboration with stakeholders, social and structural inequities remain in end-of-life care because of the challenges front-line health care professionals face in forming effective partnerships between generalists and specialists.^3,4 Research indicates that individuals who lack access to community health or social services, including hospice community services, are ‘less likely to feel supported by their general practitioners and less likely to spend their last 2 days of life at home, or die at home.’⁴ Many Māori, indigenous people of NZ, also prefer to die at home.⁵

A recent NZ study identified inconsistent access to after-hours specialist palliative care services and cultural support for Māori and other ethnic groups, including Pacific, East Asian, and South Asian people. It also highlighted a gap in hospice care relating to meeting the palliative care needs of people with disabilities and children.⁶ Health care professionals providing palliative care, therefore, need to use a culturally appropriate and holistic model that strives to address the needs of all individuals at the end of life.^7–9

Community palliative care in NZ is delivered via a primary-specialist model utilising hospices.⁶ There are 33 independently governed and managed hospices and just over 1000 community pharmacies across NZ. Community pharmacies are well-placed to support the palliative care needs of those spending the last days of their lives at home because of the long-standing relationships their staff often have with their patients.^10,11 The term community pharmacy includes the environmental (physical) space and all the staff – technicians, assistants, as well as pharmacists. The staff of community pharmacies help to navigate the health journey of many, often acting as carer supporters for those in the terminal phase of their health journey.^11–13

This scoping review sought to answer the questions: What services are provided by community pharmacies worldwide to adults with palliative care needs in the last year of life? and What are the challenges to providing and expanding these services? The review used the Te Whare Tapa Whā Older Person’s Model of Palliative Care to frame the literature review and analysis.⁹

Te Whare Tapa Whā model, developed by leading Māori health advocate Sir Mason Durie in 1984, compares health to the four walls of a house (Fig. 1). It is a widely acceptable bicultural health and well-being model in NZ, where all four walls represent a different dimension: taha tinana (the physical wall), taha whānau (family wall), taha wairua (the spiritual wall), and taha hinengaro (thoughts and feelings wall).^9,14

Fig. 1.

Te Whare Tapa Whā (Four-sided house) health model designed for and published with permission from Dr Tess Moeke-Maxwell as part of The Kōwhai Study, Māreikura Tū Kōwhai: Younger Māori Women’s Wellness programme after Breast Cancer report.¹⁴

Methods

A scoping review is the most suitable type of review to map the evidence for this specialised community pharmacy service, as it allows for the examination and comparison of the scope of palliative care-related community pharmacy services and activities worldwide. Scoping reviews are broader than systematic reviews, allowing researchers to examine the extent of activity without a formal quality assessment of the evidence, such as a critical appraisal or risk of bias assessment.^15–17

This scoping review used the five-stage framework of Arksey and O’Malley and refined by other researchers.^{15,16,18–23} It used the PRISMA-ScR checklist to guide how the scoping review and findings are reported.²⁴ The review protocol was developed iteratively by the research team in consultation with a university librarian and prospectively registered on Open Science Framework in October 2023 (https://doi.org/10.17605/OSF.IO/CVJ7X).

The inclusion and exclusion criteria are described in Table 1. The logic grid with keywords is found in Table 2. Relevant grey literature identified by searching the first 10 pages of hits from Google Scholar searches were included in the scoping review. The websites of the New Zealand Ministry of Health, Hospice New Zealand, World Health Organization, the National Institute for Health and Care Excellence, NHS Scotland Community Pharmacy Website, palliAGED and Caresearch Australia, End of Life Directions for Aged Care (ELDAC), Canadian Hospice Palliative Care Association, and the International Pharmaceutical Federation (FIP) were searched for relevant information.

This scoping review includes all relevant papers published up to 30 April 2024. The grey literature was searched between 1 May 2023 and 30 April 2024. The lead author (SC) retrieved studies and stored them in Mendeley referencing software, where duplicates were removed. Titles and abstracts were screened by SC for each paper retrieved using the inclusion and exclusion criteria to assess eligibility. The remaining papers were then read by SC in full to determine their eligibility. Papers were included if they addressed the aim of the review rather than being included based on quality scores (Fig. 2).

Fig. 2.

PRISMA flow diagram of the study selection process.

Included papers were reviewed, and key information from each paper was extracted and then added into an Excel spreadsheet under the headings: author(s), title, year, country, study setting, population studied, aim, study design, sample size, pharmacy service or activity, study results, challenges described, implications, and study limitations. See Supplementary Table S1 for a summary of the included studies.

Pharmacy activities described in the literature were categorised into practice types according to the American Society of Health-System Pharmacist (ASHP) guidelines on the pharmacist’s role in palliative and hospice care,²⁵ the advanced practice pharmacist roles for specialist palliative care services in South Australia,²⁶ and the ELDAC Care Model.²⁷ They were then mapped against the bicultural Whare Tapa Whā Older Person’s Palliative Care model.⁹ This model was used based on the holistic nature of palliative care that is profoundly relationship-oriented and applicable to indigenous and non-indigenous people. It was chosen as a method of producing insights into achieving equitable palliative care services through community pharmacies in NZ (see Table 3 for more details).

Results

Twenty-five studies were included in the review, published between 2002 and 2024 from seven countries: United Kingdom (n = 9), Australia (n = 9), United States of America (n = 2), Japan (n = 2), Ireland (n = 1), Germany (n = 1), and South Africa (n = 1) (Fig. 1). Study designs consisted of quantitative studies (n = 10), qualitative interviews (n = 8), mixed methods (n = 3), mixed phase or multiphase mixed methods (n = 2), a non-randomised cohort study (n = 1), and a pilot program evaluation (n = 1). The study populations were predominantly community pharmacists (n = 17) from the service provider perspective and patients from specialist palliative care centres (n = 10) from the service user perspective (see Table 4 for more details).

Two broad topics relating to the roles of community pharmacy with respect to adults with palliative care needs in their last year of life were explored:

Discussion

This review scopes out the literature around the current role of community pharmacy in providing palliative care to adults in their last year of life living at home or in residential facilities. The review describes various services offered in community pharmacies that complement the holistic nature of palliative care, utilising a well-established bicultural health care model from NZ.

When mapped to the Te Whare Tapa Whā Older Person’s Palliative Care model, the services provided to adults in their last year of life described in the studies fell mainly in the physical health domain – Taha Tinana. The activities of responding to medication access and shortages in the community, especially during body deterioration and dying, are crucial and recognised roles of community pharmacies.^53–55 Community pharmacies demonstrated a pivotal role in providing direct patient care. Clinical interventions showed improvements in patient outcomes, emphasising the importance of community pharmacies in primary care settings. In the study conducted by Needham and colleagues in 2002, 81% of interventions were deemed beneficial to patient outcomes, demonstrating the value of community pharmacists in primary care.²⁸ In another study conducted in 2008, 98% of pharmacist medication recommendations were accepted by the primary care oncologist, resulting in additional time spent with patients, and better pain and symptom management and psychosocial support.³⁰ Palliative care pharmacists’ abilities to independently assess patients and expand the clinical reach of the service impacted not only palliative care medication access but also pharmaceutical palliative care educational resources and training for community pharmacy staff and other health professionals.^30,40 A more recent study by Edwards and colleagues in 2019 reported that despite 17 out of 19 participating patients receiving specialist palliative care in the community, pharmacist medicine consultations identified a substantial number of drug-related problems (on average 2.5 drug-related problems (DRPs) per patient). This suggests the existence of unmet medicines-related needs for people with palliative care needs.⁴⁶ Almost three-quarters of DRPs in this study were concerned with treatment effectiveness, and pharmacists could address and resolve most of them. Furthermore, Wilson and colleagues demonstrated that prescriber acceptance of pharmacists’ recommendations is high in palliative care settings and strongly associated with the patient achieving the desired clinical outcome.³²

The expanding role of pharmacists in providing pharmacy services that lead to beneficial health outcomes further supports the need to involve pharmacists in the multidisciplinary care of people with palliative care needs.^56–58

Community pharmacies can act as hubs for holistic care, facilitating communication between health care providers, aiding patients through care transitions, and offering services that relieve stress during the end-of-life journey, such as home delivery of medications and blister packing medicines. The gap identified in this review was in the Taha Hinengaro (mental and emotional well-being) and Taha Wairua (spiritual well-being) domains, underscoring the value of and current lack of staff continuing professional education to provide emotional and spiritual support.^{31,34,36,37,40,43,52}

The value of community pharmacy staff in multidisciplinary palliative care teams, while not widely recognised, was acknowledged in several studies because shared care was found to be essential for providing successful palliative care in the community.^28,39,44,52 However, the studies in this review demonstrated that the potential of community pharmacy in palliative care tends to remain unrealised. Maidment and colleagues³⁹ reported that this was because community pharmacists are often left out of the clinical communication loop that occurs between other palliative care providers. Therefore, effective provision of palliative care in community pharmacies relies on a flexible medication management system that integrates primary and secondary care and involves patients, families, and care supporters. Communication plays a pivotal role in engaging stakeholders, such as patients, families, and other health care providers, in the palliative care process. The absence of robust communication negatively impacts palliative medication stock management, patients’ medication access, and care coordination across settings.⁴⁸ There is also a need for community pharmacies to have an awareness of the cultures of local ethnic groups specifically with end-of-life caregiving preferences and cultural and spiritual needs, as this will likely help to support good relationships leading to better communication and care.

Doctoral studies completed by Quinn in 2020 in Northern Ireland generated similar themes to this review: the current and future roles of community pharmacy, integration and communication issues, and pharmacists’ beliefs about confidence, knowledge, and training.⁵⁹ Additionally, their work highlighted the emotional role that pharmacists play in supporting the bereaved, along with pharmacists’ sense of isolation from other health care professionals. The emotional aspects of caring for patients with cancer were also described in nursing literature, where the personal toll of caregiving echoes similar struggles to pharmacists.⁶⁰ However, the change in scope and public perception of nursing practice in recent years, especially with the role of nurse practitioners, demonstrates that specialist palliative care can successfully be provided in the community by health professionals other than medical doctors, widening access to palliative care and benefitting more people with palliative care needs.⁶¹

Over the past two decades, community pharmacy services have transformed significantly, expanding from traditional medication supply to encompassing physical assessment, medication administration, and medication consultation.^{11,13,62–64} However, a study examining the evolution of pharmaceutical care reported that misconceptions about pharmacists’ roles among other health care professionals can hinder collaborative efforts.⁶⁵ The shift in the roles of pharmacists and community pharmacies aligns with the changing needs of the community. Community pharmacies are well-positioned to bridge the gap and serve as important points of liaison between generalists and specialist palliative care providers in this evolving landscape.^43,44 They play a crucial role in guiding patients toward available community-based palliative care services and facilitating improved interactions with palliative care providers.^6,34,36

In the studies included in this review, palliative care service users mostly access specialised palliative care within the community (see Table 4). However, not all individuals with palliative care needs seek out specialised services.⁴ This highlights an unmet need that could be addressed through medication consultations and support from highly accessible community pharmacists. It also highlights a broader issue: underserved populations are often excluded from research studies, resulting in unheard voices and unaddressed needs.^7,66,67

Furthermore, the care needs of underserved populations in palliative care align with challenges seen in rural and remote community settings, where limited access to care is a common barrier. A recent study exploring expanded rural pharmacy practice emphasised the necessity for a paradigm shift in the pharmacy profession to tackle health disparities in rural areas.⁶⁸ The expanded role of community pharmacies and pharmacists is expected to enhance care access and equity for underserved populations and fill a significant gap in palliative care provision. This highlights the potential for community pharmacies to contribute meaningfully to palliative care, particularly for those people who may not typically engage with specialist services.

Integrating community pharmacies into the broader palliative care network offers an opportunity for enhanced access and quality of care; with improved patient outcomes. However, this potential is currently hindered by prevailing perceptions among the public and other health care providers around the role of community pharmacies and pharmacists being limited to medication supply.⁶⁹ With a well-defined role in palliative care and government recognition and support including funding, pharmacies could develop new services that cater to the community’s palliative care needs. This would help to address the inequitable access to palliative care services experienced by many communities through medicines supply and serve as a knowledge hub in primary care.⁷⁰

Conclusion

This scoping review highlights the valuable role community pharmacies play in palliative care provision in the community. The findings indicate that to foster culturally safe practices, promote improved patient outcomes, and improve their ability to preserve personal dignity at the end of life, pharmacy staff need education in advanced communication, symptom management, and a better way to ensure access to palliative care medicines.

Supplementary material

Supplementary material is available online.