Ethical Issues in Patient Counseling

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Ethical Issues in Patient Counseling
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Ethical Principles

• Beneficence
• Acting in the patients best interest
• Past models doctor made decision
• Current thinking is to involve patient letting
  the patient determine what is in their best
  interest
• Autonomy
• Letting the patient have the final decision, even
  if it is not in their best interest i.e.
  refusing treatment, surgery, etc.

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Ethical Principles

• Honesty
• The patient has the right to the truth
• Medical condition, course of the disease
• Treatments
• Code of ethics states
• A 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

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Ethical Principles

• Informed consent
• Requires honesty and autonomy to exist
• Patients have the right to full information of
  all relevant facts and must give explicit consent
  before treatment

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Ethical Principles

• Informed consent exists when
• 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
• Note Often, practitioners rely only on the
  disclosure part of this list!

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Ethical Principles

• Confidentiality
• From the patients perspective this is
  self-disclosure and they should be the ones
  making this decision.
• Patients are expected to divulge information to
  practitioners, the only choice is which one
• Trust in confidentiality becomes very important

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Ethical Principles

• Fidelity
• The right of patients to have practitioners
  provide services that are in the patients best
  interest
• Infidelity from an Rxer could be
• Recommending vitamins patients dont need
• Failing to confront a doctor with an
  inappropriate prescription out of fear that the
  doctor will direct his/her patients elsewhere

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Case 1

• Ms. Edwards is starting on a new medication for
  schizophrenia. 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 Ive 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 Ms.
  Edwards may be noncompliant if told about
  possible side effects. What will you do?

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Points for Case 1

• 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 didnt.
• 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?

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Case 2

• Your district manager requires techs to say It
  may be a while before you can talk with the
  pharmacist, do you really want to talk to the
  pharmacist about the medicine? Youve argued
  with the DM saying this approach is not
  sufficient. You want to talk to patients
  personally to verify what they know about their
  medications. The DMs position is clear his
  method meets the legal requirements, your store
  is too busy to do more and financially he cant
  afford any more staff to solve the problem. The
  store 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.

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Points for Case 2

• Conflict of interest
• Your self interest (pleasing your boss) and the
  patients need for information.
• Should hold the patients interest as paramount.
• Decision to counsel should be based on patient
  need, not time, waiting lines, managers
  preferences, etc.

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Case 3

• James Bently, a 17 year old patient was diagnosed
  with epilepsy and prescribed phenytoin 6 months
  ago. You understand that he is embarrassed by
  his disease and is not convinced the doctor is
  right about the diagnosis. He thinks he does not
  need the drug. You have tried to educate him on
  the med and the importance of taking it properly
  but it has not worked he still omits doses
  frequently. He also continues to drive, and was
  recently in a non-injury accident. His father
  sometimes picks up his meds, but does not seem to
  have knowledge of his sons 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?

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Points for Case 3

• Confidentiality
• Should be up to James on whether or not the
  information is shared with his parents or doctor.
  (self-determination)
• Beneficence (acting in patients best interest)
  could justify breaking confidence in this case
  to protect the patient.
• Also have a duty to protect the innocent people
  he could harm if his behavior continues.
• May want to press James to give you permission to
  tell his doctor. You could do this without his
  permission and without breaking confidentiality,
  but you would break trust.

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Case 4

• You are a pharmacist who works for a chain. A
  close family friend recently lost her father to a
  heart attack. She calls you and asks you if you
  would mind coming over and disposing of his old
  meds. You agree. While disposing of the meds
  come across his bottle of propranolol. You open
  the bottle, pour the contents into the waste
  container, and are surprised to see what looks
  like Coumadin 5mg. You check the label and find
  that the wrong meds were in this bottle. The
  prescription was filled at another outlet of your
  chain you recognize the pharmacists name.

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Points for Case 4

• Beneficence
• Autonomy
• Honesty
• Informed consent
• Confidentiality
• Fidelity

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Case 5

• Mary is a school teacher at a local public
  school.  You have known her for years.  You know
  she has a handicapped child who she must provide
  most of the care for, since her husband chooses
  not help.  You also know she has fought a very
  minor, self perceived, weight problem for a long
  time.  You are also aware that she has tried
  plenty of fad diets in attempts to loose some
  weight.  She has also purchased diet aids from
  the OTC isle on occasion. When prompted, she
  confides that she thinks she needs to loose 10-20
  pounds to look the way she wants to look.

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Case 5

• 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, "What is she getting this
  for?"  You know her profile well and are
  concerned that the phentermine is not going to be
  compatible with her thyroid or BP medications,
  even though there are not outright
  contraindications or interactions.

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Case 5

• Questions
• Should you tell the patient you don't think she
  needs the medication or not?
• Will you be able to communicate without being
  judgmental?
• How do you approach communication with the
  patient since you already know her well?
• What do you say to the patient - to get the
  message to her that you don't think she needs
  this medication?
• How will you handle the problem of the doctor's
  view on all of this?  Will you call her MD?

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Case 6

• A good friend of yours stops by the pharmacy one
  day - right before a big vacation they are
  planning.  They've booked a flight to San
  Francisco, and admit to you that they are afraid
  to fly because of all the media attention to the
  airlines and all the controversy over security. 
  Your friend asks if you can give them 2 valium
  10mg so they can "chill out" before they get on
  the plane on the way out and back.  You know, and
  your friend does too, that no one will ever miss
  the 2 pills.  You think to yourself that a real
  friend wouldn't ask - and are mad that they have
  put you on the spot like this. 

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Case 6

• Questions
• What do you do?  If you choose not to give the
  medication how will you tell your friend no?  If
  you do give the pills, how do you justify this?
• What if the request was for antibiotics for your
  friends child with an obvious ear infection? 
  Would this make a difference?

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Case 7

• Mr. Heyward is one of your favorite customers. He
  lives alone, but his 20 year old grandson Mark
  visits him almost daily. Mark helps Mr. Heyward
  with chores, picks up groceries, etc., and just
  seems to like spending time with his grandpa. Mr.
  Heyward's grandson is probably his best friend
  and he talks about him all the time. One
  afternoon, Mark stops by the pharmacy to pick up
  some Maalox, Tylenol and has a note with a number
  on it that he hands to you and asks you to refill
  his grandpa's prescription. It's a refill, so you
  tell Mark to have his grandpa call if he has any
  questions. You have him sign the counseling log
  book. About a week later, Mr. Heyward calls and
  tells you his arthritis is acting up and he needs
  to get a refill on his Lortab. You pull up Mr.
  Heyward's profile and instantly realize this is
  the same prescription Mark had picked up just a
  few days ago.

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Case 8

• Mrs. Sheen 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 fallen at least
  a time or two. It's been a while since she has
  been in, but today she presents with 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!

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Case 9

• A 16 year old make customer comes by to pick 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 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 first
  - 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?

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Case 10

• You have a male patient at the community pharmacy
  who has several prescriptions filled for 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 an HIV patient at
  your pharmacy.  From her comments, you are able
  to discern Susan has no idea that he is HIV
  positive.  What, if anything can or would you do?

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Case 11

• 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
  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.

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Case 12

• A female patient presents you with a prescription
  for Plan B, the 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 which is vague and could go
  either way - for or against you.  Your good
  friend Tom at CVS has made it clear that he has
  no problem with the medication.  Having never
  been faced with actually making a decision you've
  not really decided what you would do under these
  circumstances.  The pharmacy does carry Plan B.  
  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 CVS, and 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.