ETHICAL ISSUES IN
PATIENT COUNSELING
PHARMACY COMMUNICATIONS
ETHICAL PRINCIPLES: REVIEW
• Beneficence:“…and first, do no
harm…”
• Informed consent
•
• 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
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
gr
ee
50%
Di
sa
50%
Ag
re
e
A. Agree
B. Disagree
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…
JB
25%
On
ly
25%
e
an
25%
Ph
ys
ic i
Fa
t
he
r
25%
Po
lic
A. Father
B. Physician
C. Police
D. Only JB
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®?
50%
No
50%
Ye
s
A. Yes
B. No
“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 HURT
CHRISTI 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?
Se
nd
Ot
he
r
Su
sa
Do
n.
n’
tt
th
el
lS
eg
us
uy
an
Ca
an
.
ll
an
yo
o
ur
ny
Un
...
c le
Gu
id
o
in
...
20% 20% 20% 20% 20%
Te
ll
A. Tell Susan.
B. Don’t tell Susan.
C. Send the guy an
anonymous note.
D. Call your Uncle
Guido in
Cleveland.
E. Other
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 copayment 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?
50%
No
50%
Ye
s
A. Yes
B. No
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
50%
No
50%
Ye
s
A. Yes
B. No