Clinical and Oncologic Pharmacist
Cancer is one of the principal causes of mortality, and the methods employed to fight it are numerous. With new drugs regularly being developed, the importance of optimising care while minimising side-effects has never been greater and has created many possibilities for pharmacist involvement. In addition to adequate medical treatment, supportive care and psychological support for patients and relatives are increasingly important aspects of cancer management. Oncology must be one of the most rewarding specialties that a pharmacist can work in. The work is both stimulating and challenging, and offers the opportunity to build relationships with patients and relatives.
I am employed within the pharmacy department in the Sana Klinikum Remscheid with all the duties and responsibilities of a clinical pharmacist. My office is located in the pharmacy department, which is convenient and also enables me to keep track of what’s going on. It is not easy to give an example of one typical working day, but I have chosen three tasks that give a flavour of my role within our pharmacy department.
Member and coordinator of a scientific team
Since 2001 I have been coordinator of a study concerning the treatment of colorectal cancer with oxaliplatin, fluorouracil and leucovorin. In this study the Sana Klinikum is cooperating with the Institute of Pharmacy, Clinical Pharmacy, University of Bonn and the University of Essen Tumor Centre.
Oxaliplatin is a platinum complex that significantly delays tumour progression in patients with advanced colorectal cancer when combined with fluorouracil and calcium folinate. It is known to cause neuropathic side-effects by reaching cumulative doses. The aim of this study is to investigate interindividual differences in oxaliplatin pharmacokinetics and perhaps to find a correlation between pharmacokinetics and response on the one hand and side-effects on the other. We analyse platinum concentrations in total plasma, ultrafiltered plasma and erythrocytes in patients with advanced colorectal cancer treated with 50mg/m(2) oxaliplatin in combination with fluorouracil and calcium folinate. Each patient is examined in two different cycles. Blood samples are analysed for platinum by a validated flameless atomic absorption spectrometry method. Pharmacokinetic parameters are estimated using a two-compartment model for ultrafiltered and total plasma and a noncompartmental approach for erythrocytes.
Besides coordinating this study between the physicians and the medical staff in Remscheid and our colleagues in Bonn and Essen, it is also my task to talk to patients about the aims of the study and the advantages of participation. During our initial conversations it is usually possible to identify two very different types of individuals: those who are fighters and those who are more anxious and have many questions. It is important for me to understand these patients’ concerns in order to help them effectively manage their cancer treatment.
I also collect the blood samples from patients and separate them into fullblood, plasma, ultrafiltered plasma and leukocytes, after which the samples are frozen. I do this in the hospital’s clinical laboratory. Later, colleagues at the University of Bonn will measure the platinum content of the samples, allowing me to calculate parameters such as AUC, clearance of platinum and half-life using a special computer program.
Pain pumps: a new challenge in pharmaceutical care for palliative patients
Patients with cancer often require palliative care in the last months of their life. They frequently experience severe pain, which is difficult to alleviate, making it hard to discharge them from hospital to die in their own homes. Our aim is to provide such patients with the best possible symptom control, so they can be discharged to an ambulatory care unit.
One of our patients, a 49-year-old female with metastatic breast cancer in her last months of life, suffered from violent pain especially in the thorax following metastasis in the lung. Therapy with oral morphine caused heavy constipation and difficulty swallowing. We next tried fentanyl patches, but the dosage needed was so high that it became difficult to find enough body area to adhere the plasters. In the end we used an electronic pump that was filled regularly with a morphine solution and allowed the patient to move to an ambulatory unit and to be at home with her family for most of the time, with tolerable pain.
My role as pharmacist in such cases is to:
- Consult with the physician as to whether a pain pump is indicated.
- Organise the best pump for the patient: sometimes it must be one that the patient can use so they are able to give themselves additional bolus shots of morphine on top of the continual volume.
- Calculate the quantity of morphine that has to be filled into the bag.
- Programme the pump.
- Explain to physicians, medical staff and the patient how to deal with the pump.
- Contact the family doctor to explain the main functions of the pump.
- Help change the bags (sometimes).
- Contact the drug store outside the hospital to explain how to continue with the weekly filling of the bags.
I always experience great gratitude from patients in their last days of life and from their relatives for having time for them and for taking care of them.
A new duty: EFQM Assessor
Sana Holding, an organisation of several hospitals in Germany, is a member of the European Foundation of Quality Management (EFQM). This year the Sana hospital in Remscheid is starting self-evaluation according to the EFQM standards. Our aim is to continue to improve in all aspects of our work. I am proud to be a member of a team of 45 EFQM assessors in our hospital, who will be surveying all work carried out in the hospital and then make suggestions for improvement.
At the end of the day
After carrying out my routine tasks in the pharmacy department, giving lessons at the staff school and seeing patients, I can start documentation, answering emails and returning telephone calls. After work and on weekends I often spend a lot of time at my “second profession”, as freelancer and chief editor of Onkologische Pharmazie. However, I always try to make time for my twin daughters and my husband, so they realise that they still have a mum and a wife!