Ethical Issues in Patient Counseling

1. Ethical Issues in Patient Counseling 11/27/2012

2. Ethical Principles • Beneficence (and first, do no harm) • 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.

3. 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

4. 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

5. 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!

6. 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

7. Ethical Principles • Fidelity • The right of patients to have practitioners provide services that are in the patients best interest • Infidelity from an Rx’er 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

8. 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 “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 Ms. Edwards may be noncompliant if told about possible side effects. What will you do?

9. 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 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?

10. Case 2 • 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 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 he can’t 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.

11. Points for Case 2: • Conflict of interest • Your self interest (pleasing your boss) and the patient’s 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.

12. 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 an accident where he brushed a telephone pole while driving. 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?

13. 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.

14. 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 disposing of his old meds. You agree. While disposing of the meds you come across his bottle of propranolol. You open the bottle, pour the contents into the waste container, and are surprised to see 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.

15. Points for Case 4: • Beneficence • Autonomy • Honesty • Informed consent • Confidentiality • Fidelity

16. 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. • 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.

17. 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?

18. 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 “relax" 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. 

19. 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 friend’s child with an obvious ear infection?  Would this make a difference?

20. 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 insurance/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.

21. 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!

22. 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?

23. 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-positive 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?

24. 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.

25. 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.