Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE, is a Professor and Executive Director, Advanced Post-Graduate Education in Palliative Care, University of Maryland. She is also a very popular and appreciated speaker at the McGill International Palliative Care Congress.
Devon Phillips (DP): Tell me about the role of pharmacists and why they are so integral to the palliative care team.
Mary Lynn McPherson (MLM): Number one reason why pharmacists are so important is because they are so good looking! I think the two big reasons are drug selection and goal-concordant care when we deal with palliative symptoms. Believe me, I am the biggest supporter of nondrug interventions that you’ll ever find in a pharmacist. I think that is critically important. I think that so many times we run across a patient in pain and the pharmacist says, “This sounds like total pain to me, this sounds like existential pain. You need to send in the god squad for this person. Morphine will not fix this. Ativan will not fix this.”
In the care of those at the end of life, we need to be much more skilled at integrating pharamacological and nonpharmacological approaches. We do use a lot of drugs to palliate pain and nonpain symptoms certainly, but I think that the appropriate selection of medication is a critical role for everyone and pharmacists are very skilled at that. At the same time, prescribing in a goal-concordant fashion is critical.
DP: What is a goal-concordant approach?
MLM: A goal-concordant approach to prescribing looks like this: “Let’s talk about your mother who has Alzheimer’s Disease. Mom has been on Aricept for five years. I will ask, how was your mom a year ago? And you answer, oh a year ago she knew my name and she could walk up the steps by herself and she knew the grandchildren and she could take a shower on her own. And then I say, so despite being on these medicines, does it seem like you mom has deteriorated? Yes, she has really deteriorated over the past year. So, can I share my thoughts with you? I am worried because she has fallen three times in the past couple of months. These medications can lower your heart rate and increase the risk for falling so I am concerned that the medications are not really providing any benefits at this point and as a matter of fact, I think they are increasing the risk of harm. You told me that your mom said her goal, and you agreed with this goal, is for her to be comfortable, so if we provide goal-concordant care, I think stopping these medications would be a wise thing to do. We will taper the dose down to make sure that there are no untoward effects and within a couple of weeks, we can stop them. What are your thoughts about this plan?”
So picking the right drug for the patient at the right time and knowing when to say “when” and how to stop medications, is goal-concordant care. You can’t just stop cold because you can have a rebound effect.
I am very sensitive to the condition for which we were using the drug and the prevention of rebound effects. People get physically dependent on drugs- opioids and benzodiazepines, antidepressants and antipsychotics, so you should taper down if you can. Pharmacists are very good a that- picking drugs, and knowing when to back away from certain drugs.
Pharmacists are also every good at conversions. I must get a call a day from a doctor or a nurse because a patient can’t swallow anymore and they want to know what to do next? We ask first, “Do we even need that drug anymore?” And sometimes there’s good news. For example, if a drug doesn’t come as a liquid, say you were on Celexa, an antidepressant, and could not swallow anymore then I would say, you know what, we happen to have a conversation from Celexa to Zoloft and Zoloft comes in a pretty concentrated oral solution. And if the patient can still swallow a teaspoon of liquid solution, then I would explain how we would do it. Nurses are amazing at being able to say, “This patient will not be able to swallow in 2 weeks, 14 days and 7 minutes; they are amazing at predicting that, and they know to reach out to a pharmacist to say I know what’s coming and I don’t want to be caught with my pants down.” So pharmacists help them make the conversion.
DP: Skilled communication and answering tough questions must be a very important part of the pharmacist’s role. Do pharmacists face challenges in this area?
MLM: All members of the team have the responsibility for good communication. Pharmacists aren’t generally the ones to say, “I have bad news; you are going to die from this”, but it is bad news or perceived bad news to say, “I don’t think this medication is working anymore.” And anyone on the team is subject to comments such as, “The doctor said I am going to die in four to six weeks, do you believe that?” So everyone, including pharmacists, has to be ready to handle those tough questions. There are always tremendous communication issues.
DP: What about deprescribing? Can there be communication challenges involved there as well?
MLM: When I think about the whole deprescribing thing, often it’s not the patient who is resistant. It’s the adult children. They say, “The doctor said we have to check mom’s blood sugar four times a day until the day she dies, so if don’t do this, are you saying she is dying tomorrow? And I say, “No, but we really don’t have to check the sugar four times a day. As a matter of fact, if I have had diabetes and I knew I was dying, I hope to choke to death on a donut for god’s sake.” We have to look at goal-concordant care.
DP: What approach do you recommend when introducing the topic of desprescibing at the end of life?
MLM: I think that all of us, and I certainly stress this with pharmacists, need to be prepared to have that sensitive, general conversation that is evidence-based. So for example if we were talking about your mom who has diabetes and the doctor says to check the blood sugar four times a day, I would say, “Can I share some information with you? We have really good data that the most important thing with diabetes is controlling it early in the disease. There have been studies showing that when you look at people right when they are diagnosed and then a couple of years later, the people who have really tight blood glucose control versus those who did not, even 20, 30 years down the road, that early control was still paying off. So early tight control is like putting money in the bank. Now that your mom is pretty sick and we both know that she is pretty close to the end of the road here, you can loosen the reins a little bit because frankly, she is at much higher risk from low blood sugar than the complications of high blood sugar. It takes years to get complications from high blood sugar, but low blood sugar that can harm her within an hour. So I think we can liberalize her blood sugar, we can go up to 200, even 250. I think we should liberalize her eating for pleasure. It’s not that comfortable to have your finger stuck four times a day. So I recommend we back off to three times a week. Let’s make sure that we are both very knowledgeable about the signs and symptoms of low blood sugar and high blood sugar and watch her carefully. I think we can liberalize things at this point to make her more comfortable without have any risk of additional complications.” That’s a very important conversation for everybody.
DP: I imagine it can be difficult for families because as their loved ones become increasingly ill, they must adapt to the changing situation. Is there a need for a clear, unified message?
MLM: I explain that when the doctor says to monitor blood sugar four times a day, what the doctor really meant was while your mom is well. He or she was really speaking about the time when your mom had dementia or cancer but now a terminal event. So I say, “If you called your doctor today, and you are welcome to do that, he or she would agree with what I am saying.”
DP: At the last congress you about the importance of deprescribing and we know that attendees find your presentations extremely helpful. For the congress coming up this fall can you give me a little snapshot of what you will be addressing.
MLM: My approach will be to address topical issues in pharmacotherapy in advanced illness. I will focus on a couple of hot topics that I think are really important in therapy: goal-concordant care along with deprescribing as well as a little bit on conversions and methadone dosing which I think is important. I think it will be current and contemporary and always, highly, highly practical.
DP: What do you think about the McGill International Palliative Care Congress. Is this a valuable meeting for you?
MLM: Oh yes, I love this meeting! I have been going to this meeting for years and years. I think the first or second time I went I was able to meet Dr Balfour Mount and that was one of the highlights of my career along with meeting Dr Sebastian Mercadante when I was in Texas years ago. To meet one of the greats in our field is such an honor.
The reason I like the meeting, and I know this sounds corny, is it’s such a warm and fuzzy meeting. It’s not 8 million people. People are very friendly at this meeting and the sessions are all so practical and applied. There is something for everybody. Often I will step out of my comfort zone and go to a session that really is not in my ballpark at all but it is just so refreshing to learn something new. I just enjoy the heck out of this meeting and wouldn’t miss it!
DP: Any message you would like to give to people who might want to come to your pharmacology session or to the congress? This year our congress will by hybrid- so people can join in person or virtually.
MLM: I know it’s been a giant pain in the neck with COVID and the limitations of travel and so forth. But if you can go in person, that’s great. But with the virtual option this year, there is no excuse for anybody not to attend. I think that the sessions are so stellar and so practical and so applied that whether you can come in person or virtually, it is absolutely worth your time. I encourage everyone to attend.
The McGill International Palliative Care Congress takes place at the Palais des Congres in Montreal, Oct 18-21, 2022. Registration is ongoing.