Palliative Care

How do you balance effective analgesia for terminal patients with regulatory concerns?

Provision of comfort care can seem like a balancing act if the clinician, trying to relieve pain, feels conflicting obligations. Read the thoughts of three providers who share their experience providing pain relief for dying patients.

Phyllis A. Grauer, RPh, PharmD:

Phyllis A. Grauer, RPh, PharmD is President, Palliative Care Consulting Group; Assistant Clinical Professor, The Ohio State University College of Pharmacy; Pharmacist Section Leader, National Council of Hospice and Palliative Professionals, National Hospice and Palliative Care Organization, Dublin, OH

It's not so much an issue of balance as it is just a matter of maintaining good communications and documentation and practicing good standards of care in the treatment of pain. Unfortunately, doing what it takes to provide adequate pain control entails both time and knowledge. From prescribers' perspectives, decreased third party reimbursement leads to decreased time spent with patients. Because of the subjective nature of pain, thorough patient assessment is needed. This is not only physical assessment but also psychosocial and emotional assessment.

In Ohio, there are state laws that support the use of opioids for the treatment of both malignant (terminal) and chronic nonmalignant pain. Most physicians are comfortable prescribing opioids to the dying patient as long as they are satisfied that there is no concern of abuse, diversion or addiction. As stated previously, physicians who do not generally prescribe opioids to their patient population have some level of discomfort of triggering an investigation. I have found that offering suggestions for documentation on both the prescription and in the patient record can alleviate these concerns. Even in those terminally ill patients who have legitimate pain and where there is concern about abuse, addiction or diversion, offering strategies for treating terminal pain can be employed. Although the use of pain management agreements are generally not necessary for the treatment of pain with opioids in the terminally ill patient, in those situations where abuse or diversion is suspected, these agreements will offer boundaries to protect both the patient and the health care team. Along with mandating the use of only one prescriber and one pharmacy, Iimiting the quantity and choosing opioids that provide the least likelihood of abuse are prudent strategies.

Communication among the healthcare team also improves the likelihood that all members of the patient's healthcare team are on the same page with respect to appropriate use of opioids. This is particularly important with respect to the dispensing pharmacist. A pharmacist is liable for insuring that all prescriptions dispensed are for a legitimate medical purpose. A physician should be willing to share information that will legitimize a prescription for opioids when a pharmacist calls the physician.

One strategy we have employed in Ohio is an educational effort directed at pharmacists and physicians to raise the awareness of laws that pertain to the use of opioids in terminally ill patients. This project was a joint effort between the Ohio State Board of Pharmacy and the Ohio Hospice and Palliative Care Organization. The information was disseminated through regional live presentations and audio conferences to pharmacists, physicians and hospice organizations. Additionally, a brochure was developed to equip hospices with written documentation to provide to local healthcare practitioners. This project was also presented at the National Hospice and Palliative Care Organization Conference. Occasionally I find pharmacists and even regulatory inspectors who are still misinterpreting the regulations regarding partial filling, emergency telephone orders and faxing of schedule II prescriptions for terminally ill patients in spite of all the information I provide to them. In those situations, I get them in contact the Ohio State Board of Pharmacy to assist in clarifying the rules. All in all, I find that if I can talk with a pharmacist or prescriber and provide them with the facts, I can eliminate any concerns they have over regulatory scrutiny.