Reflections

A North Carolina Pharmacist in the Middle East

Lisa F. Brennan

Abstract

Globally, clinical pharmacy practice is advancing. This article describes the working experience of a North Carolina pharmacist in two countries in the Middle East, Saudi Arabia and the United Arab Emirates (UAE). Both commonalities and challenges are emphasized, with a reflection on the personal value of cross-cultural practice.

Introduction

“The Middle East” for many people conjures up images of camels, sand dunes, flowing robes and women with veiled faces. For others, it is synonymous with oil and fantastic wealth. Yet, a third more sinister image is the face of terrorism. But the region has undergone tremendous growth in the past several decades, reaching for equality in all aspects of life including healthcare. I was able to observe their system firsthand in my recent sojourn as a clinical pharmacist in Saudi Arabia and Abu Dhabi, UAE.

Why Do It?

efit to working in the Middle East, although this advantage is shrinking with budget tightening throughout that region. I was able to pay off my student loans within 2 years. But more importantly, I wanted to explore this area that unfortunately has come to engender fear in many Americans after the experience of 9/11, the Gulf Wars, and more recently, the horrors of Syria and the refugee crisis that war has created. As Mark Twain said, “Travel is fatal to prejudice, bigotry, and narrowmindedness, and many of our people need it sorely on these accounts.”1

Pharmacy Practice

Saudi Arabia

In Saudi Arabia, I served as an internal medicine clinical pharmacist in King Abdulaziz Medical City in Riyadh from June 2012 to June 2014. This is a 1200-bed teaching hospital affiliated with both medical and pharmacy schools in the King Saud bin Abdulaziz University for Health Sciences. The hospital has an ASHP-accredited PGY1 pharmacy practice residency and a well-trained clinical staff. My first surprise was in the similarity of practice with what I had experienced in the United States. Team rounding occurred daily, starting in the emergency department, and then progressing to the medical wards. Pharmacists manage vancomycin and other pharmacokinetic dosing, run an anticoagulation clinic, and are expanding their practice just as pharmacists in the US are doing. Many of the same health issues took priority as well. Diabetes and its complications constituted a large proportion of the reason for hospitalization for many of the patients admitted to our medicine service. According to the WHO country profiles for 2016, the prevalence of diabetes is 63% higher in Saudi Arabia at 14.4% vs. 9.1% for the US.2,3 Ischemic heart disease was the leading cause of death in 2012 in both Saudi Arabia and the USA.4,5 It was eerily simple to transfer my practice to this hospital.

Abu Dhabi

I moved to Abu Dhabi in July 2014 to July 2016 to become part of the team opening the Cleveland Clinic Abu Dhabi (CCAD) hospital, which opened in May 2015. This was a unique opportunity to build the relationships and culture of the hospital from the ground up. Under the leadership of Osama Tabbara, RPh, BCNSP, the pharmacy team established the most professional and dedicated department I have ever had the pleasure to work with, building the reputation for the best department in the hospital. The pharmacy practice at CCAD mirrors the models here in the US with pharmacists as integral team members in all aspects of patient care, such as

team rounding, clinic management, and policy and procedure development. CCAD pharmacy is leading the country in promoting the advancement of pharmacy education with programs such as the first ASHP PGY1 pharmacy residency in the UAE, as well as taking a leading role in the region in pharmacy practice.

Challenges in Practice

There were definite challenges in my practice in the Middle East compared to the US. The most difficult was the language barrier. The working language of both hospitals was English. However, the patient population in both hospitals spoke Arabic as their primary language. There are two ways to manage this: first, learn the language, and second, use a translator. I did attempt to learn Arabic, but in order to speak professionally this would have taken at least several years of intense study, so I was unable to move beyond a rudimentary interaction in Arabic. Translators were readily available at least via telephone. However, using a translator bypasses that crucial information a healthcare professional receives beyond the words a patient speaks, such as the pause when asked if they take their medication regularly, or facial expressions in answer to any questions. Culturally, patients’ rights to know about their healthcare were viewed differently, with family members often deciding whether a patient should be told about their diagnosis or prognosis. Another instance of cultural difference was in end-oflife decision-making. There was little acceptance of withdrawal or withholding of care. These cultural differences led to misunderstandings and frustration for many healthcare practitioners. A cultural awareness program at CCAD targeted this gap. In Abu Dhabi, formulary establishment created unique challenges. First, the physicians came from a wide range of nationalities and practice backgrounds. This situation led to requests for unfamiliar medications and interesting discussions on establishing standardized order sets. But the most challenging aspect of formulary management was supply chain establishment. The goal for medication procurement was to acquire US FDA-approved manufactured medications as much as possible to ensure quality generics as well as brand name medications. However, in order to be imported into Abu Dhabi, the drug had to be registered with the UAE Ministry of Health, and also with the Health Authority of Abu Dhabi. Unfortunately, many of the medications chosen for their approval status were either no longer available or for a much different price. Severe delays were overcome by sourcing temporary alternatives locally or making permanent changes to the formulary. The hospital was able to open with all critical medications available. Long-term inventory planning was complicated, hindered by long or unknown delivery times, and thus a need for large reserve stock storage. The incredible cooperation between the logistics and pharmacy personnel surmounted these obstacles by working together to find alternative solutions while prioritizing patient care.

Practical Considerations

Both hospitals have participated in the ASHP Midyear Meeting, and in the past have listed positions on several US career websites. I found the Saudi Arabia position through ACCP, then the CCAD position through networking. Both contracts were considered permanent. The pharmacy boards of Saudi Arabia and Abu Dhabi accepted my US pharmacist license, but required extensive documentation, such as transcripts and attested translated copies of my diploma. The process took 4-6 months, but communication with my employers allayed my fears at the delay. The contract in Saudi Arabia came with furnished housing on a Western-style compound, while Abu Dhabi came with a generous housing allowance and a settling-in bonus to use for furniture. Compound living was an adjustment, feeling much like dorm life in a university, and frequent embassy balls contributed to a social whirl, although sadly these circumstances insulated me from everyday Saudi life. Abu Dhabi provided more freedom, although with Emiratis making up less than 15% of the population, traditional culture was difficult to experience. Safety is always a concern as an expatriate, but I personally did not feel threatened in either country and felt comfortable out at any time of day or night even as a single female in Abu Dhabi.

Conclusion

vides opportunities for professional growth in an evolving environment. I have not discussed the personal growth or travel opportunities I experienced, as this is a pharmacy article. However, I would say that was what I valued most from my time abroad. Life is about connections, not just work and career. I keep a small globe on my desk to remind me of all the people I call colleagues and friends around the world. And as Maya Angelou said, possibly in answer to Mark Twain, “Perhaps travel cannot prevent bigotry, but by demonstrating that all peoples cry, laugh, eat, worry, and die, it can introduce the idea that if we try and understand each other, we may even become friends.”6 Lisa F. Brennan, PharmD, BCPS, BCGP, is Assistant Professor, Wingate University School of Pharmacy, Levine College of Health Sciences, 515 N. Main Street, Wingate, NC 28174, L.brennan@wingate.edu No conflicts of interest or financial disclosures to make.

References

1Twain, Mark. The Innocents Abroad [by] Mark Twain. London: Collins Clear-type Press, 1869. 2 World Health Organization. Diabetes country profiles, 2016 - Saudi Arabia. www.who.int/ diabetes/country-profiles/sau_ en.pdf?ua=1 (accessed 2017 January 9). 3 World Health Organization. Diabetes country profiles, 2016 - United States of America. www.who.int/diabetes/countryprofiles/usa_en.pdf?ua=1 (accessed 2017 January 9). 4 World Health Organization. Saudi Arabia: WHO statistical profile. www.who.int/gho/countries/sau.pdf?ua=1. (accessed 2017 January 9). 5 World Health Organization. United States of America: WHO statistical profile. www.who.int/ gho/countries/usa.pdf?ua=1. (accessed 2017 January 9). 6Angelou, Maya. Wouldn’t Take Nothing for My Journey Now. Toronto: Random House of Canada, 1993.

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In Memory of the Patient We Never Knew

Michael Manolakis, Meagan Scott, Whitney Smith

Her story

Her life, as it turns out, was a mystery. She had one real friend from her place of work, but her job ended in 2008, when the recession began. Her other work colleagues didn’t like her much; she was a bit too quirky. She lived alone, but we never knew how alone she was. Her work friend became her life friend. Sharing a monthly meal was part of their routine, as was loaning her the car. She was sick, but those who knew her didn’t know how sick. She went to her pharmacy to get medications and paid in cash. She died last week. There was only one person to call.

Little did anyone know going into her apartment that this mystery was about to unfold. The thick layer of dust that covered everything told part of the story. Masks were needed when the cleaning began. There was so much stuff in the apartment. We wonder why she collected so much. Was it out of fear? Shame? Was she waiting for someone? Hiding something? Tax forms revealed a different surname used years earlier. Other papers revealed a maiden name. The friend had never known either of these names. Her current name was a simple one; there were just three syllables. It was a new name that separated her from an older, unknown past.

The items in the apartment shed no light on who she was in her prior life. She had albums full of pictures from the places she visited. The images were of beautiful places, but not a single image included a person. Did she travel alone? Who was this person? Internet searches for all of her known names – in every possible combination – came up empty. It was as if she vanished one day from one place and reappeared here the next. On a wall calendar in her apartment, she had circled dates and wrote about these being her final days. She didn’t mention to her friend that her health had become a very serious issue, but the method of her ways suggests she knew more than she would tell. Her friend had called the week before she died and heard the weakness in her voice. She urged her to get to a doctor. In reply, she said she would call the next morning at 10. In hindsight, we wonder if maybe she thought she would die before 10. She didn’t, and when the friend called back to check on her, she convinced her to call 911. This was the last time they spoke.

The first call from the hospital was from a physician. Upon admission, the friend had been listed as the emergency contact. The physician explained the gravity of the situation. She was intubated. Cancer had metastasized to the lungs, which were so deteriorated that little oxygen was being exchanged. She was very ill. A follow-up call came the next day that confirmed she had died.

She left her last will and testament taped to her wall in her apartment. It was a hand-written copy that was not found until after she died. In her will, she apologized to God for being a disappointment, and to those she had hurt. Who were these people and what had she done? Hurt them by leaving? The mystery continued to deepen.

The apartment manager called because the friend had been listed as the emergency contact for the apartment as well. When her will was found, the friend was listed as the executor of her estate. No next of kin were identified. There was no one else to contact. A neighbor stopped by while her apartment was being cleaned out. He expressed his sympathy and noted that he had seen her begging for money on the street. Her friend found a handwritten sign in her apartment. The simple sign read, “NEED $ FOR MEDICINE. PLEASE HELP IF YOU CAN. THANK YOU.” The message on her sign breaks our hearts because we are familiar with a Charlotte-based, not-for-profit pharmacy that serves the residents of North Carolina who can’t pay for their medicines. They charge nothing and serve thousands of individuals, but they never served her. No referral was ever made by

Her friend was out of town when she died, so there was no final opportunity to learn her story. No chance to connect her with the past she left behind. Perhaps this is a good thing, but we will never know. The mystery remains unsolved.

The concept of suffering

Eric J. Cassell wrote on the concept of suffering in 1999.1 He tells his reader that diagnosing suffering is different than the usual process of diagnosing a medical condition because “suffering is an affliction of the person, not the body.” In making a diagnosis of suffering we must “listen to what is said and unsaid, watch face and body for expression and actions, smell (fear, hygiene, or perfume), learn to let it all come in without interpreting or judging, and stay silent inside and out (beyond small talk).” As we reflect on Dr. Cassell’s words, we wonder if any health care provider knew that this woman was suffering, and if so, to what extent. Dr. Cassell’s call to action includes asking about suffering and acting with empathy when providing care. We wonder if her pharmacist acted with empathy. As a young pharmacist who began my practice in a community pharmacy [Dr. Manolakis], I struggle to think if I would have known she was suffering. Whether I would have asked? I can’t say for certain that I would have; however, with the benefit of hindsight and accumulated wisdom, I can say with certainty that we must ask. We must do all we can to learn the narrative of our patients’ lives.

Our profession’s Code of Ethics reinforces our moral obligations to “respect the dignity of each patient” and to act with a “caring attitude and compassionate spirit” as we “promote the good of every patient.”2 Sadly, this women’s story reminds us that sometimes we let these essential aspects of our practice slip away in our daily transactions. To put it in Dr. Cassell’s terms, we treat the body and not the person. We get caught up in the moment or in the process requirements that challenge our time, and we avoid or forget to ask the patient how they are doing. A search of the pharmacy and medical literature reveals a number of articles on suffering; however, the balance of these lean toward therapeutic concerns rather than the broader concept of suffering we are considering. Jouini et al highlighted the positive contribution the community pharmacist can make in the pharmacotherapeutic treatment of primary care patients with chronic non-cancer pain.3 The authors conclude that “pharmacists can provide information about treatment and discuss barriers, beliefs, and attitudes about pain and its treatment.” However, their focus is about “optimizing effectiveness and minimizing adverse events.” It’s about the body and not the person.

While this approach is consistent with our training, it falls short of the empathy required to diagnose suffering. Interestingly, Jouini et al point out an association between emotional wellbeing and patient satisfaction, but their conclusion is to take steps to optimize antidepressant therapy through improved adherence and persistence, as well as making referrals to physicians and psychologists when needed. Again, this aligns with sound clinical practice, but it does not push the pharmacist to connect with the patient at a level where a conversation about suffering will occur.

Marlowe and Geiler argue that adequate communication between patient and provider is essential for treatment. They point out that “Providers need to reassure patients that they are not being judged and should initiate discussion regarding tolerance and addiction.”4 Further into their article, they discuss the patient’s right to autonomy and the associated requirement to understand the risks and benefits of therapy. This discussion must include “expected side effects, potential treatments for these effects, and the benefits of therapy.” Marlowe and Geiler do not extend the communication role for the pharmacist to include exploring subjective concerns that may be causing suffering.

Wallace envisions the pharmacist as part of the interdisciplinary team, managing chronic opioid therapy. The result of this collaboration would be “to improve therapeutic outcomes, reduce health care costs, and relief of human suffering.”5 Wallace highlights the subjective nature of a patient’s pain level, and further that serving patients’ needs requires “compassion, communication, contribution, and common sense.” These insights are essential for providing care that attends to health

and wellbeing. To achieve this end, which includes the relief of physical and existential suffering, we must internalize Wallace’s insights and then be prepared to push our delivery of care into places that may not be comfortable. We must push beyond our training to achieve positive therapeutic outcomes and the mandates of a health care system that demands cost reduction. This will be the point where we come to know the patient’s fears, concerns and worries as if they were our own. This is the point of providing empathic care; the point where existential suffering can be known and attended to.

DeBar et al draw our attention to the 2011 Institute of Medicine report, “Relieving pain in America: A blueprint for transforming prevention, care, education, and research,” which “identifies effective pain management as a ‘moral imperative.’”6 These authors also describe an interdisciplinary approach that incorporates pharmacists to educate patients in an effort to reduce adverse events and improve satisfaction with their pain care. They are quick to point out that this kind of inclusion has been “largely unexplored.” Debar et al describe strengths and challenges associated with this team structure for delivering care. Their analysis includes the following challenge: “Careful attention to training and supervision is likely important to enable less highly trained frontline clinical staff to successfully intervene with patients, many of whom have had multiple previous treatment failures and complex multimorbid difficulties.” It is our contention that the kind of questioning and patient dialogue required to understand if, and to what extent, a person is suffering aligns with the training suggested by Debar et al. We should expect that student pharmacists are learning to question patients about suffering as part of their experiential training, and that practicing pharmacists are being enabled with tools and training to assist them with their delivery of patient care and determining patient suffering.

Rabow and Lee provide guidance on attention to patient suffering in an article published outside of the pharmacy literature, but which included pharmacists. They identify the pharmacist as part of the interdisciplinary, palliative care team that treats men with castrate-resistant prostate cancer. In addition to the treatment of physical symptoms, Rabow and Lee characterize the aspects of suffering that can be experienced by the patient. These include “uncertainty, loss of control, challenge to self-image and identity, and fear of dying.”7 The authors point out that answering these “deep existential questions” may not be necessary or appropriate for the clinician providing care, but being open and responsive to these questions and making the referral to the palliative care team may be sufficient. It is this idea of “openness” that can elevate the level of care we are capable of providing. This is a care level that is beyond simply treating physical symptoms. Knowing where in your community to refer a patient with these questions is an important tool to help treat their suffering. These resources can include spiritual or pastoral care, charitable support services, social support services, or access to a food pantry.

The distinction between treating existential and physical suffering with sedation was explored by Blondeau et al in 2005.8 Their research looked at how a patient’s type of suffering can change clinicians’ attitudes about end-of-life sedation decisions. The clinicians in this study (n=142) included physicians (80.5%) and pharmacists (19.5%) working in the palliative care setting. Existential suffering was defined to include types of suffering that are not characterized as pain and physical suffering. Examples include existential anguish or emotional, psychological, or spiritual distress. As it pertains to a distinction between treating existential and physical suffering, the authors write “… the nature of the suffering imposes a barrier.” This barrier shows in their results as the reluctance to use sedation with existential pain as compared to physical pain. The authors suggest that providing support to someone who is suffering existentially “means supporting the human condition.”

We read Blondeau et al as suggesting to pharmacists that we move beyond the traditional medication therapy management parameters when we treat individuals who are suffering, since our collective human condition includes physical and existential suffering along with its manifestations. This interpretation aligns with the idea that we must ask our patient if they are suffering. It requires attention to the person, and this is not an easy transition for pharmacists who as students

were primarily trained to look for the objective and measurable data as the measures of success, change, and possible reasons to worry. While this transition may be difficult, it is worth the investment of effort as our patients will benefit.

There are obstacles to providing care that attends to the body, as well as the person with the disease. In an article based on presentations by Kenneth C. Jackson II, PharmD and Andrew Mannes, MD, the challenges of treating persistent pain are described. In describing one of these challenges, Dr. Mannes noted that outward appearance may not reflect severe persistent pain, which is “a situation that often contributes to miscommunication between patients and providers.”9

Oliveira and Shoemaker considered the “natural attitude” that pharmacists maintain, which is described as our “reliance on pharmacologic knowledge for an understanding of medications, a focus on the product, the use of counseling as the major approach with patients, and an emphasis on medication adherence and persistence as a goal.”10 The strategies of listening to the patient’s story, acknowledging their uniqueness, and wondering with the patient about their dreams or fears, for example, can be used to achieve a state of “openness” with patients. It is at this point that pharmacists are able to learn from their patients the “meaning [they] ascribe to their illness as well as their medications.” I [Dr. Manolakis] recall a conversation I had with a woman many years ago who was living with rheumatoid arthritis (RA). We met at 9 o’clock that morning, which required me to be up by 7:45 to prepare for the day. Upon greeting her at 9, I asked how her day was going so far, and she shared that it has been good but it started early. In an effort to simply make conversation, I asked how early, and she told that she had to start her day at 4 AM to be ready for our meeting at 9. I was stunned as I had no idea how much her arthritis impacted her life. I knew it would slow her down as RA is associated with joint pain and stiffness, but my realization that this much challenge and associated distress accompanied her disease forever altered my perspective of it. I gained an incredible insight into her suffering, and it is at this place where pharmacists can gain insights on their patient’s suffering. This is the place where healing can truly begin to occur for the person where medications may be part, but not all of the care they need.

Lemay articulated Dr. Cassell’s vision in a beautiful essay she wrote titled, “A Pharmacist’s Gift.”11 She describes her relationship with a family whose two daughters have cystic fibrosis and the lessons she learned through the experiences they shared, which included the funeral for one of the daughters. The lesson she took away from these experiences, which is one she works to impart to her students, is that “it is not enough for [her students] just to know the facts about medications; they must also consider the humanistic aspect of patient care.” Lemay captures with clarity and precision the attitude that must guide our practice roles if we are to eliminate situations like the begging and suffering previously described.

Build context

Just as we strive to help every patient achieve maximum therapeutic benefit from their medication regimen, which for the patient with physical pain translates to a reduction in pain to a manageable level, we must strive to mitigate existential suffering in the patients we encounter in practice. We are well trained for the first part of this practice ideal, but the second part is challenging. We propose the following framework for achieving this in our practice settings.

First, be prepared to ask questions of your patient. This idea sounds simple and straightforward, but it may be difficult as our training may not have built competency in this communication area, and we may lack confidence in our ability to question effectively. It is at this awkward juncture that stepping forward and giving our best effort must be our professional mandate for we know patients are suffering and we can be part of a remedy. Begin by asking how they are feeling. Then follow that question by asking if their medications are working. This conversation should be comfortable since success measures may be objectively available. For example, you might hear about a lab result or a comment about feeling better. Continue to

probe on side effects, adherence or missing doses. At this point, the content of your conversation is moving away from objectively measurable data to subjective concerns. Consider the possibility that something just doesn’t feel right at this point in your conversation; perhaps your gut is telling you that something isn’t quite right. You might check a refill history if it’s available for an additional data point, or you could get specific with your questioning. Assume prescription refills not acquired on time, or if difficulty with adherence is mentioned by the patient as a problem. You might ask if cost is a problem or if they have an issue with transportation to the pharmacy.

Essentially, you are building context in an attempt to ascertain a glimpse into the patient’s narrative. This attempt will take the development of trust, and it may take time, but if the goal is to determine if the patient is experiencing some level of suffering, then the investment is worth the time, effort and energy. Should you reach that point where your patient begins to share their fears, worries, or questions, then you must be prepared to respond. This is where your knowledge about referral resources to social services, spiritual or pastoral care, or charity support for medication costs will be called upon. As was mentioned earlier, it’s not that you have to be able to answer every question a patient may have. Being ready to support, to listen, and to refer may contribute directly to the improvement of a patient’s wellbeing.

Conclusion

Returning to her story, she wrote to a prominent journalist with our local newspaper to share her story. We have a copy of her letter, but to our knowledge, it was never published. Her words describe the interaction she has with the drivers who pass by and the daily challenges she faces. She tells the reader about a woman who gave her $5, which generated the following reflection: “I thank her for the $5, fold my sign and feel tears trying to come through. I have tears of gratitude for these angels who have stopped to talk to me and to help. And I have tears of shame that my life has come to this point. And a prayer that if and when my situation improves, I will remember this day and these tears and will not look away when confronted by a She was a patient in a pharmacy. They would have known her name, but they didn’t know her story. The pharmacist likely understood her medical condition based on her medications, but this did not tell what else was going on in her life. Maybe a pharmacist or technician attempted to help her, but the release of personal information to take advantage of a social service was simply out of the question. There is so much that we don’t know, but what we do know is that she was suffering immensely. And by appreciating the suffering she endured, we reveal the even larger tragedy that in a city with ample health care resources, she died disconnected. The pressures of timed prescription filling, tremendous prescription volumes, and other practice challenges may have stood in the way. These are legitimate concerns, but they must not stop pharmacists from striving to connect with patients in order to learn about their circumstances and their experiences.

There is no blame here, rather a lesson to be learned from her story. Serving patients to our fullest capacity requires the intentional effort to learn the narratives of our patient’s lives. Getting to know your patients is essential in the effort to keep them from suffering. This may be a mandate of your faith, as it is ours. It is a mandate of our profession’s ethical code as we strive to promote our patient’s good with care and compassion.

Michael Manolakis, PharmD, PhD, is Associate Professor and Director of Interprofessional Education, Wingate University School of Pharmacy.

Meagan Scott, PharmD, is a PGY-1 Ambulatory Care Resident, Wake Forest Baptist Health.

Whitney Smith, PharmD, is Staff Pharmacist, CVS Pharmacy.

At the time of writing, Drs. Scott and Smith were PharmD students at the Wingate University School of Pharmacy. No funding support was received for this manuscript. Excerpts of this paper were presented at the 2015

Christian Pharmacists Fellowship International Annual Meeting; June 4, 2015. There are no conflicts of interest to report.

References

1. Cassell, EJ. Diagnosing suffering: A perspective. Ann Intern Med. 1999;131:531-534. 2. Code of Ethics for Pharmacists. http://www. pharmacist.com/code-ethics. Accessed February 22, 2017. 3. Jouini G, Choinière M, Martin E, et al. Pharmacotherapeutic management of chronic noncancer pain in primary care: lessons for pharmacists. J Pain Res. 2014;7:163-173.

4. Marlowe KF, Geiler R. Pharmacist’s role in dispensing opioids for acute and chronic pain. J Pharm Pract. 2012;25(5):497-502.

Epub 2011Apr5. 5. Wallace JM. The pharmacist’s role in managing chronic opioid therapy. Curr Pain Headache Rep. 2006;10(4):245-252. 6. Debar LL, Kindler L, Keefe FJ, et al. A primary care-based interdisciplinary team approach to the treatment of chronic pain utilizing a pragmatic clinical trials framework.

Transl Behav Med. 2012;2(4):523-530. Epub 2012Aug30. 7. Rabow MW, Lee MX. Palliative care in castrate-resistant prostate cancer. Urol Clin North

Am. 2012;39(4):491-503. Epub 2012Aug27. 8. Blondeau D, Roy L, Dumont S, et al. Physicians’ and pharmacists’ attitudes toward the use of sedation at the end of life: influence of prognosis and type of suffering J Palliat Care. 2005;21(4):238-245. 9. Jackson KC, Mannes A. Persistent pain management for improved quality of life. J Am Pharm Assoc. 2003;43:S30-S31.

10. Oliveira DR, Shoemaker SJ. Achieving patient centeredness in pharmacy practice:

Openness and the pharmacist’s natural attitude. J Am Pharm Assoc. 2006;46:56-66. TD, Zellmer WA (eds). Nourishing the Soul of Pharmacy: Stories of Reflection. Lenexa, KS: American College of Clinical Pharmacy; 2011:11-13.