Virtual Pharmacy Improves Medication Use and Patient Safety in Palliative Care

Avoiding adverse drug interactions that worsen conditions at best—and are lethal at worst: pharmacists know how

Palliative care involves making people who have chronic or terminal illness as comfortable as possible. While this care does not focus on treatment, palliative care patients are often on many medications. These patients’ physiological changes—due to advanced illness, the natural aging process, and multiple-drug treatment—affect their ability to metabolize drugs. Their need for medicine changes, too; for example, sleep may improve after a person moves from an inpatient facility to his or her home, yet medications are rarely deprescribed.

Being on many medications puts patients at high risk of adverse drug-drug interactions (DDIs), the fifth-leading cause of death in the United States. Yet, as Dr. Janet Bull, a clinician at Four Seasons, a palliative and hospice care organization in rural North Carolina, acknowledges, “As a clinician it’s so hard to keep up with how one medication interacts with another. Some of our patients are on 20 different medications.”

The addition of a virtual pharmacist to a CBPC team improved medication and symptom management, resulting in providers updating dosing or timing changes and adding or deprescribing a medication approximately 65 percent of the time.

Incorporating a medication expert virtually on the team

Dr. Bull and her colleagues provide community-based palliative care (CBPC) to meet the physical, psychosocial, and spiritual needs of patients with serious illnesses. But while pharmacists are part of hospital-based teams, they are rarely part of CBPC teams in the United States. With the goal of reducing DDIs, Dr. Bull and her team tested a telehealth application that included a virtual pharmacist consultation. Pharmacists assessed each patient’s medication list, identified DDIs, and made recommendations to clinicians. The pharmacists were also available for telecounsel with clinicians and patients.

“For me to be able to dial up a pharmacist and say, ‘Hey, can you help me understand the best way to treat pain in this patient who’s already on these different medications and pain medications?’ is wonderful.”
- Dr. Janet Bull

Rounding out a care team: everybody benefits

Patients in the study had an average of three DDIs each, and more than 90 percent of these were moderate or severe. The clinicians welcomed the pharmacists’ expertise and implemented their recommendations, which usually involved dosing or timing changes and adding or deprescribing a medication approximately 65 percent of the time.

The pharmacists also loved being part of the clinical interdisciplinary team, which included a physician or nurse practitioner, social worker, and occasionally chaplain, because they had a whole-person understanding of individual patients and access to their medical records, which allowed them to make informed recommendations. Although study enrollment was cut by two-thirds because of COVID-19, it showed that the addition of a virtual pharmacist to a CBPC team improved medication and symptom management, and enhanced patient and provider knowledge.