When the System Treats Sick Patients Like Criminals

The Palliative Lens

By Andrew Esch, MD

2/5/2026

There are many hard parts of practicing palliative care. Sitting with grief. Navigating uncertainty. Helping families make impossible decisions. Bearing witness to suffering.

But one of the most quietly infuriating parts of my job has nothing to do with medicine at all.

It’s the pharmacy.

More specifically: trying to get seriously ill patients the medications they’ve already been appropriately prescribed (especially controlled medications) inside a system that increasingly treats them like criminals.

The Hidden Obstacle Course

If you don’t work in palliative care, it’s hard to appreciate how much friction exists between prescription and pill bottle.

Here’s what I see every week:

• Pharmacies refuse to stock common palliative medications “because of policy.”

• Prescriptions are declined without explanation.

• Meds are “out of stock” with no attempt to order them.

• Patients are routinely placed on 30–60 minute hold times just to ask if a medication is available and ready.

• Different pharmacists apply completely different rules in the same chain.

• Families are told: “We don’t fill those kinds of prescriptions.”

These aren’t people seeking early refills or questionable doses.

These are OUR patients:

• Patients with metastatic cancer.

• People with end-stage heart failure.

• Individuals dying of ALS.

• Families trying to manage pain, dyspnea, anxiety, and agitation at home.

And yet they’re treated as if they’re trying to game the system.

Perhaps the most absurd practice of all: many pharmacies now refuse to even confirm whether a medication is in stock unless a prescription has already been sent. So clinicians are forced to, in the most fucked up game i like to call prescription roulette,  electronically fire prescriptions into the void, one  pharmacy after another, while patients sit in pain, waiting to see if this is the one that might say yes. 

No other sector of healthcare, or commerce, works this way. It’s not safety. It’s opacity disguised as policy.

The Emotional and Clinical Cost

The impact is real—and harmful.

For patients:

• Delayed symptom relief.

• Worsening pain, breathlessness, or distress.

• Feeling distrusted, stigmatized, and powerless.

  
  

For families:

• Hours on the phone.

• Multiple trips to different pharmacies.

• Carrying guilt when they can’t “fix” the problem.

• Watching their loved one suffer unnecessarily.

For clinicians:

• Time diverted from care to logistics.

• Moral distress.

• Burnout from fighting systems instead of treating people.

  
  

We talk a lot about access to care in healthcare.

But access to medications?  These are the most basic tool we have and access to medication has quietly become one of the biggest threats to high-quality outpatient palliative care.

How Did We Get Here?

The opioid epidemic reshaped pharmacy culture—and understandably so.

But somewhere along the way, the pendulum swung so far that:

• Risk management replaced clinical judgment.

• Corporate policy replaced individualized care.

• Fear replaced compassion.

The result is a system optimized to avoid liability, not to relieve suffering.

And the people paying the price are the ones with the least time, energy, and leverage to advocate for themselves.

What Can Outpatient Palliative Care Teams Actually Do?

We can’t fix the entire pharmacy system. But we can adapt strategically.

Here are 5 concrete, practical strategies that actually help:

1. Build a “Preferred Pharmacy Network”

Every palliative program should maintain a living list of:

• Pharmacies that reliably stock key meds.

• Pharmacists who understand serious illness.

• Locations that don’t obstruct legitimate prescriptions.

This should be:

• Updated by staff.

• Shared internally.

• Given to patients proactively.

Not all pharmacies are equal. Stop pretending they are.

2. Designate a Pharmacy Liaison on Your Team

This may be a luxury but it can be:

• An RN

• A medical assistant

• A care coordinator

Their role:

• Call ahead to confirm stock.

• Build relationships with specific pharmacists.

• Troubleshoot refusals.

• Escalate issues before patients hit walls.

This one role can save dozens of patient-hours per week.

3. Standardize Your Prescribing Patterns

Pharmacies struggle with variability.

Programs should ( to the extent it makes sense clinically) standardize:

• Typical opioid choices.

• Dosing ranges.

• Formulations.

• Documentation language.

When your team uses predictable, consistent patterns:

• Pharmacists become more comfortable.

• Fewer “policy” objections occur.

• Less time is spent reinventing the wheel.

Boring is beautiful when access is the goal.

4. Proactively Educate Patients and Families

We should be honest with them:

“This may be harder than it should be.”

Give them:

• A list of reliable pharmacies.

• Scripts for what to say.

• Clear instructions on what to do if refused.

• A number to call your team immediately.

Preparation reduces panic—and prevents suffering from being normalized.

5. Advocate at the System Level (even when you don't know where to start)

This is the long game, but it matters:

• Build relationships with regional pharmacy leaders.

• Provide education about palliative care.

• Document access failures.

• Engage professional societies.

We need pharmacy systems to understand:

these medications are not optional in serious illness, they are core medical care.

The Bigger Issue

At its heart, this isn’t a pharmacy problem.

It’s a values problem.

We’ve built a healthcare system that is:

• More afraid of misuse than of untreated suffering.

• More comfortable with denial than with nuance.

• More focused on control than on care.

And palliative patients, by definition vulnerable, exhausted, and time-limited, are caught in the middle.

Closing Thought

If a system routinely makes it harder to relieve suffering than to prolong it, that system is broken.

And if our seriously ill patients are being treated like criminals in their most vulnerable time of life, that’s not a regulatory success story. That’s a moral failure.

Palliative care exists to restore humanity inside broken systems.

But we shouldn’t have to fight this hard just to get people their meds.

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