In this four part series, the College will focus on the four domains of the community pharmacist practice assessment, highlighting trends that we are seeing in practice. Part two of this series focuses on decision making. Review Part one on patient assessments in the spring 2018 edition of Pharmacy Connection.
NOT ALL DECISIONS FEEL LIKE DECISIONS
Pharmacists, as important members of a patient’s healthcare team, are always making decisions. These decisions, such as ones made in the context of renewals or adaptations, are evident in a pharmacist's everyday practice.
Decisions are made during the patient assessment, in the process of filling the prescription, in creating documentation and in counselling the patient. They are also made when determining whether follow-up and/or monitoring is appropriate, such as to engage more frequently with a patient that has chronic health issues or to conduct a more regular evaluation of the effectiveness of a drug therapy.
Think about the many decisions made throughout a day’s practice, such as determining when the following may be required:
- Pharmacist intervention (e.g. adaptation, alternate therapy)
- Additional patient assessment
- Informed consent
- Consideration of additional therapeutic options
- Management of drug interactions
- Patient education or communication
- Collaboration with a prescriber or healthcare professional
- Follow-up and monitoring
- Additional research or information gathering
Whether the decisions are related to a complex medication management question or a simple operational matter such as adapting workflow assignments for a day, the decisions that pharmacists – and indeed all pharmacy professionals – make can have a dramatic impact on patient outcomes.
USING PROPER JUDGMENT
As healthcare professionals, pharmacists must use proper judgment when making decisions, taking into account the patient’s best interest, their own knowledge and expertise and whether the decision is reasonable and acceptable. Regardless of the decision, the rationale and actions taken (or not taken) should be documented.
Decisions that are made in practice should be considered appropriate for the individual patient and the circumstances. Decisions about appropriateness may be based on a number of factors, such as a pharmacist’s clinical knowledge, data gathered from resources, and information collected through the patient assessment process. There should be a clinical rationale to dispense or sell any drug therapy – the focus of the pharmacist should not just be on achieving technical accurateness or completeness.
When issues with a patient's prescription or therapy is identified, it's important to document any decisions made as a result. It's also important to remember that a decision to do nothing is still a decision.
Additionally, pharmacists have the autonomy to make decisions and to collaborate when necessary. For example, if a pharmacist identifies a serious drug interaction and then sends a fax to the prescribing physician who confirms the prescription, the pharmacist now needs to make a decision about how to proceed (e.g. putting in
place additional monitoring, providing more patient education, researching additional options, suggesting alternatives, refusing to fill). It is not acceptable in this situation for the pharmacist to say that they have no decisions to make because the “doctor said so.”
It is imperative that when collaborating with prescribers or other healthcare professionals, pharmacists should put thought into how they are communicating and how they decide what to include in their communication. Is the information provided complete? Is it clear? Has the pharmacist made a recommendation that reflects their skills and knowledge?
It is the College’s expectation that pharmacists are making decisions that optimize patient outcomes, that they are implementing those decisions and that they are monitoring the outcome of them to ensure they continue to be the best option for the patient.
AN EXAMPLE PATIENT SCENARIO
In the Pharmacy Connection Spring article, "The Importance of Patient Assessment," a patient scenario was shared of a 59-year-old male who had been filling his prescriptions at the pharmacy for about one year. His patient profile showed that he has Type 2 Diabetes, dyslipidemia, osteoarthritis and is a smoker. He was currently on Atorvastatin 10mg once daily, Metformin 1000mg twice daily, Gliclazide MR 30mg daily and Venlafaxine 150mg once daily and was looking to pick up his new refills.
In looking at this patient case, what decisions may be made during the course of the interaction?
Consider the following:
- What do you need to know to make an appropriate decision regarding whether and how to fill this prescription?
- Do you need to speak with the patient to gather enough information?
- What questions do you need to ask the patient?
- Do you need to adjust the therapy?
- Do you need to make a recommendation to the prescriber or otherwise communicate or collaborate with them?
- Do you need to advise the patient on any related health issues (e.g. smoking cessation)?
- Do you need to put in place monitoring of the patient?
- Is there an opportunity for a more comprehensive medication review?
- What needs to be documented and what needs to be followed-up on?
- What needs to be communicated to the patient and is any additional education needed?
All of the above considerations represent actions that could be explored further and each one individually will result in a decision. Even the order in which these actions are triaged is a decision. In this case, all of these smaller decisions will add up to a larger one, which is deciding the appropriate action to take regarding this patient and their prescription.
In the previous article, the Chat, Check, Chart IESU (indicated, effective, safe and patient use) model was referenced in the context of patient assessment. However, it is also relevant for decision making actions, especially since patient assessment and decision making are intertwined. During a patient assessment, you are asking yourself questions such as whether you have enough information or if you are making assumptions about effectiveness and indication.
Asking these questions then requires you to make decisions about how to proceed, such as deciding to confirm the prescription or gather more information (for example through patient dialogue). Ultimately, your ethical obligations to do no harm and to benefit the patient mean that if you believe that there is a more appropriate medication therapy to optimize a patient’s health outcome, you need to take appropriate action.
HERE’S WHAT THIS SCENARIO COULD LOOK LIKE IN PRACTICE
You’ve determined that is it necessary for you to speak with the patient to gather more information before deciding whether the prescription as written is appropriate (a decision).
You ask the patient whether he has been experiencing any side effects and what his latest blood work looks like, keeping in mind that the patient may not know what side effects he should be monitoring for (ask specifically about common side effects like dizziness). The patient says that his blood sugar numbers have been a little high lately and the medication doesn’t seem to be helping. He also says he has a doctor’s appointment in a couple of weeks. You decide to make a recommendation to the prescriber to alter the dosage (a decision) and engage in more proactive monitoring (a decision).
You see there is a note on the patient’s profile to check back in with him on how his attempt to quit smoking is going (a decision made by the previous pharmacist involved in this patient’s care). The patient says that he is having difficulty quitting “cold turkey.” You talk to him about his options for smoking cessation (a decision).
Ultimately, you decide to fill the prescription as written with patient-directed monitoring until his next appointment. You obtain the patient’s informed consent to initiate smoking cessation therapy. You discuss with the patient that it is important for him to discuss his blood sugar issues with his physician at the next appointment and that you have made a recommendation to the physician to adjust the dose. You provide appropriate guidance on the smoking cessation therapy and ask the patient to check back in with you next month. You make a note on the patient record to follow up with both the physician and the patient.
As a pharmacist, you are frequently making decisions in every aspect of patient care you provide. Making appropriate decisions is not just a component of your scope of practice; it is fundamental to putting the patient’s interest and wellbeing first.