Palliative Medication: The Need for Common Sense
Issue 13, August 2004
Lesley Martin is no longer on the front page of every newspaper but the issue of euthanasia will not go away. At the Hospice New Zealand AGM, June 2004, Peter Brown MP, said the "Death with Dignity" bill, promoting euthanasia, may have been defeated but the issues are still alive. At that meeting, hospice personnel present commented that patients in hospice palliative care services die with dignity.
Critical to the management of any terminal illness in its later stages is palliative care, which becomes the best option when curative treatment is no longer possible. Palliative care concentrates on improving quality of life, addressing pain management and relief of other causes of suffering. The challenge in the current climate is for all New Zealanders to have access to these services. This is the humane and compassionate option that must be developed in this country.
The New Zealand Palliative Care Strategy signed off by the Hon Annette King in 2001 states:
The New Zealand Palliative Care Strategy sets in place a systematic and informed approach to the future provision and funding of palliative care services. This Government is concerned that all people who are dying and their family/whanau have access to palliative care services provided in a co-ordinated and culturally appropriate way. That is why the Government has committed additional funding to ensure the strategy can begin to be implemented immediately." 
Despite this laudable intention, palliative care continues to be under funded; some palliative care services still rely on their community for 70% or more of their funding, an enormous ask. While the Government has given money to the District Health Boards for palliative care, it has not been passed on consistently throughout New Zealand. The problems extend into the decision making and funding processes relating to the specialist drugs required for good palliative care.
Those who have a terminal illness tend to require multiple medications. In the short time they have left, the ideal is to provide the best medication profile possible for all their symptoms. Their disease is progressing, their medications are complicated, and side effects are common. Balance is the aim. This is when science becomes an art form, because to balance the appropriate treatments is to tread a very narrow path. Patients with physical pain may have numerous different types of pain, including soft tissue, bone pain or nerve pain, each of which require different drugs depending on diagnosis and the pain type.
In New Zealand when someone needs stronger pain relief the choices that are funded are minimal. For instance, morphine and methadone are available funded, morphine being the opioid of choice as its action is predictable. Not everyone tolerates morphine. Methadone, the alternative, has a very long half-life and is therefore more difficult to manage. The other two opioid medications available in New Zealand for the relief of severe pain are Fentanyl transdermal (through the skin) patches and Oxycodone tablets. Neither is funded in New Zealand, yet both have been funded overseas for many years. Fentanyl patches have the advantage of being useful when the patient has swallowing difficulties.
Some adjuvant drugs (used to enhance the effectiveness of medical treatment ) which are essential for patient well-being are also restricted in their availability. Thus, Octreotide can be very successful in reducing excessive secretions in intestinal obstruction, something for which it is not funded. Similarly, Gapapentin, registered and restricted by special authority to epilepsy only, is an extremely effective tool in the management of nerve pain. It is not available free for this use in New Zealand.
For those who react adversely to the drugs that are funded, or those for whom the funded drugs are inappropriate, their only choice is to pay for their own medication, or to go through the bureaucratic hoops to obtain possible funding. This happens at a time when coping resources are low or non existent, with the knowledge that the outcome is most likely to be negative.
Science has moved on, and the improved medications are available elsewhere, fully funded. However, New Zealand's 'special authority' requirements limit their funded availability to a narrow range of specified conditions, or they are not funded at all. The reason for these restrictions often has more to do with finance than medical complexities, and thus dying people and their families are being denied optimum treatment. The effect of alleviating this problem on the nations' medical budget would be minimal since only a relatively small group of people are involved.
At the level of drug funding policy the thinking appears to be narrow and short term. Those responsible for overseeing the medicines budget are so focused on their own 'basket' that the consequences of their decisions on other parts of the health care budget appears to be ignored. An example of this is a second-generation bisphosphonate, pamidronate, being funded on special authority for hyper calcaemia caused by a malignancy for which it is moderately successful. Research however shows a third generation bisphosphonate, zoledronic acid, is far superior for this and other processes in the treatment of certain metastatic disease. It is not funded because it is more expensive in the 'medicines' basket. The consequences of this are a poorer control of the symptoms of disease, greater demands on resources of other supportive treatment such as radiotherapy, greater expenditure of staff resources, more pain, a lower quality of life for the patient - ultimately a greater overall cost to the taxpayer.
Under the present regime patient confusion is rampant, with tablet name, shape, size colour and strength changing as brands are substituted in the continuing chase for the cheapest alternative. Frequently, as a result of the changing funding environment, patients require more outpatient appointments and admission to in-patient units for reassessment, reassurance and adjustment in medications. We are fortunate our clinicians manage the situation as well as they do.
A decade ago, New Zealand led Australia and the United Kingdom in its choice of medicines for the care of the dying patient. Currently because of blinkered cost cutting we now trail some of the OECD countries.
Large sums are spent on programmes such as those addressing diabetes, obesity and smoking but when life is coming to an end, resources are very limited. There are two things which are certain in life, birth and death. The current wellness strategies seem to ignore the fact that dying is a real and normal part of life. The actively dying are few and temporary. Why can we not fund certain medications useful specifically to the dying patient with restrictions appropriate for those patients?
If a patient dies well, the surviving family, while naturally mourning and missing their relative, continue to live through their distress. A 'bad death' however has on-going repercussions for the survivors and for the health system and the community. If people cease to function then depressive disorders are a strong possibility and more counselling services are needed.
Uncontrolled suffering in the terminally ill should be considered a medical emergency, not an indication for euthanasia.  Removal of the barriers that frustrate the provision of adequate medication is essential for good palliative care and will allow people with terminal illness to die with real dignity. The terminal stages of life can be a time of reconciliation and personal growth, particularly if pain and physical symptoms are controlled. Palliative care is the most humane and compassionate option for New Zealanders.
With appropriately directed funding from Government for palliative care services, sensible and appropriate funding of drugs for people who are dying, and the educated expertise of palliative care clinicians, the expectation of a good death should be available to all New Zealanders.
 Hon Annette King. (2001). The New Zealand Palliative Care Strategy foreword p. iii
 Woodruff, Roger. (2004). Palliative medicine (4th ed.). Oxford University Press.
Anne Denton M.N.Z.M., M.P.H.C (palliative care), M.P.S is a Clinical Pharmacist at Cranford Hospice, Hastings and a past president of Hospice New Zealand. She also tutors Palliative Care Pharmacology through Victoria University.