In this commentary, senior clinical pharmacist Amy Mundell explores the critical role of shared decision-making and deprescribing in palliative care. Drawing from her experience, she highlights the importance of pharmacy involvement in end-of-life care, the challenges posed by polypharmacy and deprescribing, and the value of early experiential placements in preparing the future pharmacy workforce to support best practice in this field.
Palliative care is specialised medical care focused on relieving the symptoms and stress of serious illness when a cure is no longer possible. End-of-life care supports people in the final months or years of their lives.1
During this stage of a patient’s journey, care is often delivered by multiple medical teams, making decision-making complex. Effective communication between these teams is essential. Decisions should be shared with the patient and their families to ensure a collaborative approach. It is recommended that the multidisciplinary team (MDT) work together to involve patients and their carers fully in the process.2
Effective communication between teams is essential to ensure continuity of care and to involve patients in decisions about their treatment, where desired. This includes discussions around preferred place of care and/or death, ‘Do not attempt cardiopulmonary resuscitation’ decisions and medication management.
In practice, however, stigma around palliative care persists. Patients and their families may hesitate to involve palliative care teams, which can hinder shared decision-making. Common fears include the perception that accepting palliative care means death is imminent, or that care will shift towards sedation to hasten the end of life.2
Polypharmacy and the role of deprescribing in palliative care
The palliative population has complex comorbidities, which can impact medication choices. Patients with hepatic or renal insufficiency need different drug regimens to avoid overdosing and harm. Similarly, as patients reach the end of their lives, oral administration may no longer be a safe option.
Polypharmacy is common in palliative care. Polypharmacy can lead to an increased risk of adverse effects, a high medication burden and increased costs.3,4
Deprescribing is defined as the planned and supervised process of reducing or stopping inappropriate medication that might be causing harm or no longer be of benefit.3,4
As part of a patient’s management, palliative care teams work to reduce the medication burden, often deprescribing certain medications that no longer provide benefit for the patient. There is evidence to support the safety of stopping certain preventative medicines in patients with a limited life expectancy.3
Barriers to deprescribing
The practice of deprescribing involves a stepwise, person-centred process that is not about denying effective treatment but reducing the risks and burden of taking multiple medications.
However, deprescribing presents several challenges for both clinicians and patients. Barriers include uncertainty around professional responsibilities, concerns about altering medications initiated by specialists, and patient anxiety – with some fearing that deprescribing signals a withdrawal of care or that ‘we have given up’.
To overcome these obstacles, deprescribing should be a collaborative process involving the patient, with regular reviews to ensure ongoing appropriateness. This highlights the need for greater pharmacy involvement in palliative care, where pharmacists can support safe and effective deprescribing.
Several tools, such as IMPACT and STOP/START, have been developed to guide healthcare professionals through this process.
Deprescribing also creates an opportunity to explore non-pharmacological interventions, which have demonstrated benefits for patients experiencing symptoms such as breathlessness and pain.5
However, the responsibility for deprescribing can be a contentious issue. With newly-qualified pharmacists gaining independent prescribing rights in 2026, there is likely to be a shift toward involving them earlier in the patient journey.
It is important to remember that most newly qualified pharmacists will be seen as generalists, with their nominated prescribing area set as medicines optimisation. There is also the argument that, as pharmacists become increasingly involved in prescribing decisions, the medical workforce is being deskilled.
Managing deterioration in palliative care
Converting medications to alternative routes of administration is a key aspect of a pharmacist’s role, particularly as patients approach the end of life and the oral route may no longer be appropriate. With access to evidence-based resources, pharmacists are well-positioned to guide these decisions.
As a patient’s condition deteriorates, abnormalities in blood results become more frequent – often influenced by medication side effects. Pharmacy teams can support the MDT with their expert knowledge, helping to interpret these changes and optimise patient care accordingly.
Despite these obvious skills, pharmacy involvement in palliative care remains limited. In north-east England, only two of six hospices currently benefit from clinical pharmacy input. Yet, pharmacists and pharmacy teams are well-established in reducing errors related to prescribing, administration and medication governance.
This is particularly important in palliative care, where patients are often prescribed complex drug regimens, including opioids. Errors involving these medications carry a higher risk of harm, underscoring the need for greater pharmacy engagement in this setting.6
Tackling pharmacy underutilisation through experiential learning
Networking within the palliative care field opened doors to contacts at St Oswald’s Hospice in Gosforth, Newcastle Upon Tyne. Working collaboratively with the team, we have created experiential placements for foundation trainee pharmacists.8
The scheme was set up to encourage palliative care learning to occur early within training – a topic typically not encountered until later in a pharmacist’s career. The placements provide trainee pharmacists with the opportunity to experience a week within a hospice setting, offering valuable insight into the provision of palliative care.7
Trainees attend the placement in pairs and dates are arranged with the team to comply with health and safety and training burden. Before the placement, the trainees complete a questionnaire assessing their confidence and knowledge of providing pharmacy care within a palliative setting. The same questionnaire is then completed at the end of the placement.
These questions explore areas such as confidence in discussing care with patients who have life-limiting conditions and the ability to prescribe safely for patients with compromised organ function. Results consistently show a significant improvement, with trainees’ knowledge and confidence levels approximately doubling from pre- to post-placement.
The placements have run for the past four years and continue to do so, providing a positive experience for the trainees and the staff involved. Annual evaluations are conducted to ensure quality, and regular reviews are held with the team to ensure the placement remains fit for purpose and aligned with trainees’ learning outcomes.
Initiatives like these are paramount as the future workforce changes to incorporate prescribing earlier in a pharmacist’s career. Future prescribers will need to appreciate the importance of shared decision-making and holistic patient care.
Our education of the future pharmacy workforce must incorporate these skills. Workplace-based placements across settings such as acute hospitals, hospices and community services are fundamental for developing these core skills in practice.
Palliative care and the future workforce
Raising awareness of palliative care within pharmacy is key to preparing the future workforce and ensuring that palliative care services deliver a truly multidisciplinary approach to patient care.
As healthcare providers, it is paramount that we remain focused on keeping the patient at the centre of our work. Pharmacists and clinicians working collaboratively, and utilising complementary skills such as prescribing, will help to enhance the healthcare system by increasing access to care, improving efficiency and reducing patient harm.
Experiential learning, such as placements in palliative care settings, plays a vital role in developing the clinical confidence, communication skills and compassionate practice needed for effective, person-centred care.
Author
Amy Mundell MPharm ClinDip IPresc CertMedEd FHEA
Senior lead clinical pharmacist – education and training, The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
References
1 NHS England. Palliative and end of life care. [Accessed October 2025].
2 Shen MJ, Wellman JD. Evidence of Palliative Care Stigma: The Role of Negative Stereotypes in Preventing Willingness to Utilize Palliative Care. Palliat Support Care 2019 Aug;17(4):374–80.
3 Thompson J. Deprescribing in palliative care. Clin Med (Lond) 2019 Jul;19(4):311–14.
4 National Hospice and Palliative Care Organization. Hospice Medication Deprescribing Toolkit 2020. [Accessed October 2025].
5 Marie Curie. Pain management in palliative care. 2022. [Accessed October 2025].
6 Francis S-A, Yardley S. Pharmacy teams are essential to driving responsive palliative care. Pharm J 2025;314(7994).
7 Mundell A. Foundation trainees need experiential placements in hospices to help manage an ageing population. Pharm J 2025;06 March.
