Spring 2018

What Would You Do?

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A Patient’s Request for Renewal

In the Spring 2017 edition of Pharmacy Connection, the College published A Framework for Ethical Decision Making. The framework provided a process to guide decision making in practice that supports the commitment to serve and protect patients’ best interests. This “What Would You Do” explores a specific scenario in practice that presents an ethical issue or dilemma for the pharmacy professional. It does not provide a definitive answer to the dilemma but instead invites pharmacy professionals to make their own professional judgments in practice, while considering all appropriate guidelines and standards.

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A patient comes to your pharmacy on a Friday night

He is not a regular patient of your pharmacy but has his prescription vial and a list of his medications, which he filled at another pharmacy. The prescription vial indicates that he does not have any additional refills from his physician. Both the pharmacy that filled the original prescription and the physician’s office are now closed until Monday. You know this physician has a policy of not renewing prescriptions without an appointment. You work with this physician a lot and don’t want to undermine her policy or put a strain on your collaborative relationship. However, the patient could potentially experience side effects if they don’t have their medication (which is not a controlled substance).

What do you do?

It’s helpful to utilize the broad steps of the ethical decision making framework to consider the issue.

Identify the Issue

You can start by identifying the issues and examining the facts. The issue here is that the pharmacist believes that the physician who originally wrote the prescription would not want it to be renewed without an appointment with the patient. The pharmacist also believes that disregarding the physician’s intention could lead to interprofessional conflict with the physician.

However, the patient has expressed that he needs this medication and the pharmacist knows that it could cause uncomfortable side effects to be without for a few days. The medication is not a controlled substance and is unlikely to be used in an illicit manner. The prescription vial appears to be valid.

Apply Guidelines and Standards

The Code of Ethics, the Standards of Practice, applicable legislation and regulations, College policies, guidelines and other supporting resources can be reviewed and applied when exploring an ethical dilemma. Examples that could be considered with this scenario include:

  • Code of Ethics
    • Standard 1.1 Members ensure that their primary focus at all times is the well-being and best interests of the patient.
    • Standard 1.2 Members utilize their knowledge, skills and judgment to actively make decisions that provide patient-centred care and optimize health outcomes for patients.
    • Standard 2.5 Members challenge the judgment of their colleagues or other healthcare professionals if they have good reason to believe that their decisions or actions could adversely affect patient care.
    • Standard 4.8 Members understand that their trust in the care provided by colleagues and other healthcare professionals must be balanced with critical evaluation.
  • Standards of Practice – Expertise in Medications and Medication Use Standards 11 and 12, Collaboration Standard 1
  • Guideline – Initiating, Adapting and Renewing Prescriptions
  • Resources – Optimizing Patient Care Modules
    • A Difference of Opinion – Managing Issues Due to Expanded Scope
    • What Will the Doctor Think? Managing Relationships with Physicians

Evaluate Possible Resolutions

As a pharmacist, you must use your professional judgment to make decisions. It’s important to note that each situation and patient is unique. Evaluate the various factors to make the best decision for this particular scenario. Here are some things to consider when doing so:

  • What are your ethical obligations as a healthcare professional?
  • How could the patient benefit or be harmed through your decision? What is in the best interest of the patient?
  • What do you know about the condition and drug therapy in question? What was the original amount of the prescription?
  • Has the patient made an appointment with the physician?
  • What does your patient assessment tell you? For example, what is the indication for use? How has the patient been using the medication? How long? What has their experience with the therapy been? What other medications are they taking?
  • What would you advise your fellow pharmacist colleague to do in this situation if they asked you?
  • What could be the reasoning behind the physician’s decision making?
  • What is ultimately influencing your decision making – the patient’s need, the physician’s reaction and/or something else?

The actions you take should: put your patient first, bear public scrutiny, be considered acceptable as a precedent for future behaviour, and support the commitment to serve and protect the best interests of patients.

Document Your Decision Making

Once you have made your decision, you should document that decision, your rationale for it, what the expected result is and how it supports the patient. If you have communicated with the patient, the prescriber or any other healthcare professional, ensure you’ve made a notation to that effect. Having this information on hand will help you address any questions that may arise at a later date as well as support future patient care.

In this case, you may want to communicate the decision to the other pharmacy so that they are aware of any notes that should be made in their patient record.

You will need to notify the prescriber if you have renewed the prescription.

Remember: doing nothing is also a decision.

Review and Reflect

Following the decision, you have an opportunity to review and reflect. What did you learn? How can you be more prepared for these types of situations in the future?

Good relationships with the other healthcare professionals on a patient’s care team are important and both pharmacists and physicians have critical and complementary roles in patient care. Regardless of the decision made in this particular scenario, you may identify that there is an opportunity to connect with the physician to discuss with her what you, as a pharmacist, can do to help your mutual patients. A conversation could help identify why the physician feels there is a need for have a policy that requires appointments for renewals and whether there are any collaborative solutions to those issues.

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