PHARMACY COMMUNICATIONS

ETHICAL ISSUES IN PATIENT COUNSELING

ETHICAL PRINCIPLES: REVIEW

• Beneficence:“…and first, do no harm…”• Acting in the patients best

interest• Past models doctor made decision and

current thinking is to involve patient - as with MI

• Patient determines what is in their best interest

• Autonomy (self rule)• Letting the patient have the final decision,

even if it is not in their best interest – i.e. refusing treatment, being adherent

• Honesty• The patient has the right to the truth

• Pharmacist code of ethics: “the pharmacist has the duty to tell the truth and to act with conviction of conscience”

• Rapport is built on trust, which is based on honesty

• Informed consent• All relevant information has been

provided• The patient understands the

information• Consent is freely given and there is

no coercion• The patient is capable of

understanding the information

• Confidentiality• Privacy and trust: rapport

• Fidelity• The right of patients to receive

services that are in the patients best interest• Infidelity from a pharmacist could be:

• Recommending vitamins patients don’t need

• Failing to confront a doctor with an inappropriate prescription out of fear that the doctor will direct his/her patients elsewhere

CASE APPLICATIONS OF ETHICAL PRINCIPLES

MY NEW JOB

• After graduation you studied hard for the boards and somehow, you passed! You were instantly promoted to staff pharmacist at the chain pharmacy where you work. Fast forward 3 months. You’ve gotten into a routine. You are patient centered and always look for opportunities to help patients through counseling and providing excellent pharmacy care. Today, a woman who appears to be in the middle of an asthma attack comes in, literally begging for a rescue inhaler (albuterol).

I’D GIVE HER THE INHALER

A. AgreeB. Disagree

Agree

Disagre

e

50%50%

I DON’T KNOW ABOUT MY MEDICINE

• ME is starting on a new medication for schizophrenia. (Zyprexa) The drug has a number of side effects, some of which are serious. She asks you several questions about the purpose of the medication and possible side effects. When you ask her what the physician told her about the medication, she reports that he said “I’ve got a lot of patients on this medication and they are doing fine.” It is obvious to you that she is unclear about the purpose of this drug or any possible problems. Your concern is that ME may be noncompliant if told about possible side effects.

DISCUSSION POINTS

• Ms. Edwards does not understand the purpose / side effects.• No informed consent can exist under these

circumstances.• If she knew, she might not take the

medication. (beneficence)• May see it as the doctors duty to inform her

about the disease and treatment• Fear about doctor getting mad at you if you

tell the patient things s/he didn’t.• Autonomy would require you to tell her

because she has a right to choose what happens to her body.• May need to call doctor to discuss – how to

approach this – assertiveness?

DO IT MY WAY?

• Your district manager requires techs to say: “It may be a while before you can talk with the pharmacist, do you want to talk to the pharmacist about the medicine?” You’ve argued with the DM saying this approach is not sufficient, even citing a letter from the state board. You actually remind the DM that it is supposed to be the pharmacist that makes the offer. You want to talk to patients personally to verify what they know about their medications. The DM’s position is clear: your store is too busy to do more and financially the company can’t afford any more staff to solve the problem. The store’s numbers are down and it is in danger of being closed due to competition in the area. But, he encourages you to counsel, in depth, anytime you have time and no other patients are waiting.

411 OR 911

• JB is a 17 YO male who was diagnosed with epilepsy and prescribed Dilantin ® (phenytoin) 6 months ago. He is embarrassed by his disease after having seizures at school. He is not convinced the doctor is right about the diagnosis. He thinks he does not need the drug. You have tried to educate him about phenytoin and the importance of taking it properly, to no avail as he omits doses frequently. He also continues to drive, and was recently in an accident where he brushed a telephone pole, knocking the mirror off the passenger side of the car. His father sometimes picks up his meds, but does not seem to have knowledge of his son’s denial of the disease or his non-compliance. Should you disclose to the father, physician, or the police that the patient is not taking the medication?

I WOULD CALL…

A. FatherB. PhysicianC. PoliceD. Only JB

Fath

er

Physician

Police

Only JB

25% 25%25%25%

SUFFER IN SILENCE?

• A close family friend recently lost her father to a heart attack. She calls you and asks you if you would mind disposing of his old meds, since you are a pharmacist. You agree and your friend drops off a large box of medications to you at home. While disposing of the meds you come across one of his prescriptions which was for propranolol. You open the bottle, pour the contents into the waste container, and are surprised to see the bottle actually contained Coumadin® 5mg. You check the label again and it says propranolol. As it turns out the deceased patients prescription for propranolol (which was filled with Coumadin® was filled at another outlet of the chain where you work. You recognize the pharmacists initials.

JUST SPLITTING HAIRS?

• A long time patient SM presents a prescription for her Lipitor®. While filling it you notice the dose has increased to 20mg from 10mg. The “sig” is 1 QD, quantity 30. While counseling SM you comment: “I see your doctor has increased your dosage…” SM replies: “Oh, no. He still wants me to take 10mg. He just wrote for the 20 so I could just use a half-tablet and save money on copay’s. That medication is so expensive.”

WORTH LOOSING A FRIEND?• ML is a school teacher at a local public school.  You have known her

for years and consider her a friend.  You know she has a handicapped child who she cares for without much help from her husband. ML has also struggled with a self-perceived weight problem for a long time.  ML has tried several fad diets in attempts to loose some weight.  She has also sought your advice and even purchased diet aids from the OTC isle on occasion. When prompted, she confides that she thinks she needs to loose 10-20 pounds. Doing a little quick math based on her estimated height reveals her BMI to be 24. Today she presents a prescription for phentermine 15mg capsules.  The tech took the prescription in while you were on the phone.  You become aware of the prescription when the tech can't find the medication on the shelf.  You immediately react and think to yourself, “She does not need this stuff…” You know her medication profile well and are concerned that the phentermine is not going to be compatible with her thyroid or BP medications.

A FRIEND IN NEED…IS A FRIEND INDEED? (EDGAR BERGEN)

• A very good friend of yours stops by the pharmacy one a day before she is leaving for a vacation to the islands. She’s booked a flight and admits to you that she is terrified to fly. She asks if you will give her “…a couple Valium®…” so she can deal with her fear of flying. You know, and your friend does too, that no one will ever miss the 2 diazepam pills.  You think to yourself that a real friend wouldn't have asked and you are mad that she has put you on the spot like this. 

GIVE HER THE VALIUM®?

A. YesB. No

YesNo

50%50%

“ALL THE WORLD IS MADE OF FAITH, TRUST, AND PIXIE DUST…” (J.M. BARRIE)

• John M. Heyward, Col. USAF, Ret. is an 83 YO male and one of your favorite customers. Everyone just calls him the Colonel. Until very recently, he was one of a few WWII hero’s still with us. He and his wife of nearly 70 years are buried together in Arlington National Cemetery. As a pilot during the war, he was shot down but commandeered a Japanese “Hamp” fighter and flew himself back to friendly airspace. The Colonel lives alone, but his 20 year old grandson Mark visits him frequently. Mark helps the Colonel with chores, picks up groceries, etc., and just seems to like spending time with the Colonel. Mark is probably the Colonel’s best friend.

• One afternoon, Mark stops by the pharmacy to pick up Maalox, Tylenol a refill prescription for the Colonel. it's a refill, so you tell Mark to have his grandpa call if he has any questions. You have him sign the insurance/counseling log book. About a week later, the Colonel calls and tells you his arthritis is acting up and he needs to get a refill on his hydrocodone. You pull up his prescription profile and instantly realize this is the same prescription Mark had picked up just a few days ago.

LOVE ISN’T SUPPOSED TO HURTCHRISTI PAUL AND SANJAY GUPTA

• MS been using your pharmacy for a couple of years. During this time she has been on antidepressants, tranquilizers and occasional pain medications. You have noticed that she seems to be very accident prone. She has reportedly been in at least two traffic accidents where she was injured and she has reportedly fallen on a couple of occasions. It’s been a while since she has been in and today she presents in sunglasses with obvious bruises on her face. While writing the check to pay for her prescriptions you notice that she has significant bruising on her wrists. You ask if she is OK and she just looks at you and says, "I'll be fine". She takes her prescriptions and leaves quickly. Your technician leans over and says - you need to report this! GA Statute

IS THIS NORML?

• RK is a 16 YO male who is picking up his prescription for erythromycin which he uses to fight acne. His mom, a long time friend of yours, usually comes in with him, but today he is alone. Since he has been taking the erythromycin he has been having stomach pains. He does not know that the erythromycin can cause this, and he does not mention the stomach pain to you. While counseling him on the refill you remind him to take the medication with food and ask if he has any other questions or concerns. He hesitates, the asks "What will happen if I used any other drugs with this? Your response is that it would be very important for him to check with you or his doctor before using any other medication. He says OK then leaves. A few minutes later he comes back in and very hesitantly asks if smoking pot with his prescription could be causing his stomach to hurt?

THE TOWN GOSSIP

• You have a male patient at the community pharmacy who has a combination of prescriptions filled for his HIV infection.  Your long time friend Susan is over for dinner one night and she tells you about this great new guy she has met.  She's falling fast, and through the course of the conversation you realize that this new fellow is your HIV-positive patient. You kind of probe, very generally, and from her comments, you are sure Susan has no idea that he is HIV positive. 

WHAT WOULD YOU DO?

A. Tell Susan.B. Don’t tell Susan.C. Send the guy an

anonymous note.D. Call your Uncle

Guido in Cleveland.

E. Other Tell Susa

n.

Don’t tell S

usan.

Send the guy an

anony...

Call your U

ncle Guido in

... Other

20% 20%20%20%20%

CHILD SUPPORT?

• You are a pharmacist for CVS.  A 15 year old high school student presents her prescription for birth control pills to you at the pharmacy drop off window.  You fill it, counsel her and provide an information leaflet on the medication.  She pays the $25 medication co-payment with a Visa card.  A few days later, the young girls dad notices the Visa charge from CVS in the exact amount of his co payment, while reviewing his monthly charges.  He is confused and thinks a mistake has been made because he uses another pharmacy for his prescriptions.  So, the Dad picks up the phone and calls CVS to ask about the charge. 

• The call is directed to you.  When he (the dad) asks about the prescription, you look it up for him, then notice that it was for the daughter - and you apologize, but, refuse to provide any further information about the situation.  The father insists, but, you hold your ground.  His last words had something to do with getting you fired.

TO “B” OR NOT TO BE

• A female patient presents you with a prescription for Ovral ® and the directions read: “Two tables after unprotected sex”. You figure its being used as a “morning after” pill.  You have thought a lot about this, and even talked to your colleagues and your boss.  Your boss has told you company policy could go either way. Your good friend Tom at a nearby chain has made it clear that he has no problem filling prescriptions like this, or selling the OTC Plan B. with the medication.  Having never been faced with actually making a decision you've not really decided what you would do under these circumstances.  You look at the prescription and then simply state that you can not fill the prescription because of your beliefs and direct the patient to Tom at the nearby store. You apologize for any inconvenience. The patient is furious.  She insists you have no right to refuse to fill her prescription and demands that you fill it.  You hold your ground.  She threatens to sue you and the pharmacy if you do not comply.

WILL YOU FILL THE PRESCRIPTION?

A. YesB. No

YesNo

50%50%

GOOD COUNSEL

• You’ve been a pharmacist for 15 years now and have learned the ropes pretty well. You try to do a good job and take excellent care of your patients. Sometimes it is challenging, sometimes impossible: because matters are just out of your control. Recently, a lawyer called to ask you about a case she was working on. She got your name from a friend who is a patient at your pharmacy and who brags about the time and care you take with your patients. The attorney tells you a child was mistakenly given a very high dose of codeine by a pharmacist. It was prescribed as 1 teaspoonful and filled as 1 tablespoon full. As you listen to the story you are appalled and saddened by the lack of care the pharmacist provided. The attorney asks if you would be willing to evaluate all the facts in the case, including the autopsy records of the child, and testify as to the standard of care the pharmacist should have applied in taking care of the child.

I WOULD TESTIFY AGAINST THE OTHER PHARMACIST

A. YesB. No

YesNo

50%50%