Ethical Issues in Patient Ethical Issues in Patient CounselingCounseling

Sample Questions: We will come back to these Sample Questions: We will come back to these later.later.

Your patient presents a prescription for 30 lisinopril 10mg, Your patient presents a prescription for 30 lisinopril 10mg, with 12 refills. The patient asks you to fill it for 90 tablets at a with 12 refills. The patient asks you to fill it for 90 tablets at a time so they will have a reduced co-pay. The insurance time so they will have a reduced co-pay. The insurance company allows a 90 day supply, but only if the original company allows a 90 day supply, but only if the original prescription is written for a quantity of 90 tablets. What prescription is written for a quantity of 90 tablets. What would be the best approach to making this patient happy?would be the best approach to making this patient happy?

A close friend who is having a prescription for Adderall filled A close friend who is having a prescription for Adderall filled at your pharmacy confides she had to lie to the physician to at your pharmacy confides she had to lie to the physician to get her to write her daughters prescription for the drug. get her to write her daughters prescription for the drug.

During a review of the insurance log, you notice that a During a review of the insurance log, you notice that a customer who picked up 7 prescriptions for his mother failed customer who picked up 7 prescriptions for his mother failed to sign the log book. If you get audited it will be a problem. to sign the log book. If you get audited it will be a problem.

Your district manager has just sent out a memo that the chain Your district manager has just sent out a memo that the chain has purchased a large supply of Vitamin D with “short dating” has purchased a large supply of Vitamin D with “short dating” and he wants all pharmacists to recommend this product to and he wants all pharmacists to recommend this product to customers to avoid the risk of it expiring on the shelves.customers to avoid the risk of it expiring on the shelves.

Principles of EthicsPrinciples of Ethics

BeneficenceBeneficence AutonomyAutonomy HonestyHonesty Informed ConsentInformed Consent ConfidentialityConfidentiality FidelityFidelity

Ethical PrinciplesEthical Principles

BeneficenceBeneficence Acting in the patients best interestActing in the patients best interest

Past models doctor made decisionPast models doctor made decision Current thinking is to involve patient letting the Current thinking is to involve patient letting the

patient determine what is in their best interestpatient determine what is in their best interest

AutonomyAutonomy Letting the patient have the final decision, even Letting the patient have the final decision, even

if it is not in their best interest – i.e. refusing if it is not in their best interest – i.e. refusing treatment, surgery, etc.treatment, surgery, etc.

Ethical PrinciplesEthical Principles

HonestyHonesty The patient has the right to the truthThe patient has the right to the truth

Medical condition, course of the diseaseMedical condition, course of the disease TreatmentsTreatments

Code of ethics states:Code of ethics states: A pharmacist: “has the duty to tell the truth A pharmacist: “has the duty to tell the truth

and to act with conviction of conscience”and to act with conviction of conscience” Rapport is built on trust, which is based Rapport is built on trust, which is based

on honestyon honesty

Ethical PrinciplesEthical Principles

Informed consentInformed consent Requires honesty and autonomy to existRequires honesty and autonomy to exist Patients have the right to full Patients have the right to full

information of all relevant facts and information of all relevant facts and must give explicit consent before must give explicit consent before treatmenttreatment

Ethical PrinciplesEthical Principles

Informed consent exists when:Informed consent exists when: All relevant information has been providedAll relevant information has been provided The patient understands the informationThe patient understands the information Consent is freely given and there is no coercionConsent is freely given and there is no coercion The patient is capable of understanding the The patient is capable of understanding the

informationinformation

Note: Often, practitioners rely only on the disclosure Note: Often, practitioners rely only on the disclosure part of this list!part of this list!

Ethical PrinciplesEthical Principles

ConfidentialityConfidentiality From the patients perspective this is From the patients perspective this is

“self-disclosure” and they should be the “self-disclosure” and they should be the ones making this decision.ones making this decision.

Patients are expected to divulge Patients are expected to divulge information to practitioners, the only information to practitioners, the only choice is which onechoice is which one

Trust in confidentiality becomes very Trust in confidentiality becomes very important important

Ethical PrinciplesEthical Principles

FidelityFidelity The right of patients to have The right of patients to have

practitioners provide services that are in practitioners provide services that are in the patients best interestthe patients best interest

Infidelity from an Rx’er could be:Infidelity from an Rx’er could be: Recommending vitamins patients don’t needRecommending vitamins patients don’t need Failing to confront a doctor with an Failing to confront a doctor with an

inappropriate prescription out of fear that the inappropriate prescription out of fear that the doctor will direct his/her patients elsewheredoctor will direct his/her patients elsewhere

Principles of EthicsPrinciples of Ethics

BeneficenceBeneficence AutonomyAutonomy HonestyHonesty Informed ConsentInformed Consent ConfidentialityConfidentiality FidelityFidelity

Return to the Sample Questions: Return to the Sample Questions:

Your patient presents a prescription for 30 lisinopril 10mg, Your patient presents a prescription for 30 lisinopril 10mg, with 12 refills. The patient asks you to fill it for 90 tablets at a with 12 refills. The patient asks you to fill it for 90 tablets at a time so they will have a reduced co-pay. The insurance time so they will have a reduced co-pay. The insurance company allows a 90 day supply, but only if the original company allows a 90 day supply, but only if the original prescription is written for a quantity of 90 tablets. What prescription is written for a quantity of 90 tablets. What would be the best approach to making this patient happy?would be the best approach to making this patient happy?

A close friend who is having a prescription for Adderall filled A close friend who is having a prescription for Adderall filled at your pharmacy confides she had to lie to the physician to at your pharmacy confides she had to lie to the physician to get her to write her daughters prescription for the drug. get her to write her daughters prescription for the drug.

During a review of the insurance log, you notice that a During a review of the insurance log, you notice that a customer who picked up 7 prescriptions for his mother failed customer who picked up 7 prescriptions for his mother failed to sign the log book. If you get audited it will be a problem. to sign the log book. If you get audited it will be a problem.

Your district manager has just sent out a memo that the chain Your district manager has just sent out a memo that the chain has purchased a large supply of Vitamin D with “short dating” has purchased a large supply of Vitamin D with “short dating” and he wants all pharmacists to recommend this product to and he wants all pharmacists to recommend this product to customers to avoid the risk of it expiring on the shelves.customers to avoid the risk of it expiring on the shelves.

Case 1Case 1 Ms. Edwards, a 67yo female, is starting on a Ms. Edwards, a 67yo female, is starting on a

new medication for schizophrenia (Zyprexa by new medication for schizophrenia (Zyprexa by Lilly). The drug has a number of side effects, Lilly). The drug has a number of side effects, some of which are serious. She asks you some of which are serious. She asks you several questions about the purpose of the several questions about the purpose of the medication and possible side effects. When medication and possible side effects. When you ask her what the physician told her about you ask her what the physician told her about the medication, she reports that he said “I’ve the medication, she reports that he said “I’ve got a lot of patients on this medication and got a lot of patients on this medication and they are doing fine.” It is obvious to you that they are doing fine.” It is obvious to you that she is unclear about the purpose of this drug she is unclear about the purpose of this drug or any possible problems. Your concern is that or any possible problems. Your concern is that Ms. Edwards may be noncompliant if told Ms. Edwards may be noncompliant if told about possible side effects. What will you do?about possible side effects. What will you do?

Points for Case 1:Points for Case 1: Ms. Edwards does not understand the purpose / Ms. Edwards does not understand the purpose /

side effects.side effects. No informed consent can exist under these No informed consent can exist under these

circumstances.circumstances. If she knew, she might not take the medication. If she knew, she might not take the medication.

(beneficence)(beneficence) May see it as the doctors duty to inform her about May see it as the doctors duty to inform her about

the disease and treatmentthe disease and treatment Fear about doctor getting mad at you if you tell Fear about doctor getting mad at you if you tell

the patient things s/he didn’t.the patient things s/he didn’t. Autonomy would require you to tell her because Autonomy would require you to tell her because

she has a right to choose what happens to her she has a right to choose what happens to her body.body.

May need to call doctor to discuss – how to May need to call doctor to discuss – how to approach this – assertiveness?approach this – assertiveness?

Case 2Case 2 Your district manager requires techs to say: “It Your district manager requires techs to say: “It

may be a while before you can talk with the may be a while before you can talk with the pharmacist, do you really want to talk to the pharmacist, do you really want to talk to the pharmacist about the medicine?” You’ve argued pharmacist about the medicine?” You’ve argued with the DM saying this approach is not with the DM saying this approach is not appropriate. You want to talk to patients appropriate. You want to talk to patients personally to verify what they know about their personally to verify what they know about their medications. The DM’s position is clear: his medications. The DM’s position is clear: his method meets the legal requirements, your store method meets the legal requirements, your store is too busy to do more and financially he can’t is too busy to do more and financially he can’t afford any more staff to solve the problem. The afford any more staff to solve the problem. The store is in danger of being closed due to store is in danger of being closed due to competition in the area. But, he encourages you competition in the area. But, he encourages you to counsel, in depth, anytime you have time and to counsel, in depth, anytime you have time and no other patients are waiting.no other patients are waiting.

Points for Case 2:Points for Case 2:

Conflict of interestConflict of interest Your self interest (pleasing your boss) Your self interest (pleasing your boss)

and the patient’s need for information.and the patient’s need for information. Should hold the patients interest as Should hold the patients interest as

paramount.paramount. Decision to counsel should be based on Decision to counsel should be based on

patient need, not time, waiting lines, patient need, not time, waiting lines, managers preferences, etc.managers preferences, etc.

Case 3Case 3 James Bently, a 17 year old patient was James Bently, a 17 year old patient was

diagnosed with epilepsy and prescribed phenytoin diagnosed with epilepsy and prescribed phenytoin 6 months ago. You understand that he is 6 months ago. You understand that he is embarrassed by his disease and is not convinced embarrassed by his disease and is not convinced the doctor is right about the diagnosis. He thinks the doctor is right about the diagnosis. He thinks he does not need the drug. You have tried to he does not need the drug. You have tried to educate him on the med and the importance of educate him on the med and the importance of taking it properly but it has not worked – he still taking it properly but it has not worked – he still omits doses frequently. He also continues to omits doses frequently. He also continues to drive, and was recently in a non-injury accident. drive, and was recently in a non-injury accident. His father sometimes picks up his meds, but does His father sometimes picks up his meds, but does not seem to have knowledge of his son’s denial of not seem to have knowledge of his son’s denial of the disease or his non-compliance. Should you the disease or his non-compliance. Should you disclose to the father, physician, or the police that disclose to the father, physician, or the police that the patient is not taking the medication? the patient is not taking the medication?

Points for Case 3:Points for Case 3: ConfidentialityConfidentiality

Should be up to James on whether or not the Should be up to James on whether or not the information is shared with his parents or information is shared with his parents or doctor. (self-determination)doctor. (self-determination)

Beneficence (acting in patients best interest) Beneficence (acting in patients best interest) could justify breaking confidence in this case – could justify breaking confidence in this case – to protect the patient.to protect the patient.

Also have a duty to protect the innocent Also have a duty to protect the innocent people he could harm if his behavior people he could harm if his behavior continues.continues.

May want to press James to give you May want to press James to give you permission to tell his doctor. You could do this permission to tell his doctor. You could do this without his permission and without breaking without his permission and without breaking confidentiality, but you would break trust.confidentiality, but you would break trust.

Case 4Case 4 You are a pharmacist who works for a You are a pharmacist who works for a

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

Supplemental InformationSupplemental Information

Propranolol is a beta-blocker and Propranolol is a beta-blocker and should be tapered before should be tapered before discontinuation.discontinuation.

Coumadin is a potent anticoagulation Coumadin is a potent anticoagulation medication.medication.

Your friend’s father was not Your friend’s father was not prescribed Coumadin.prescribed Coumadin.

Points for Case 4:Points for Case 4:

BeneficenceBeneficence AutonomyAutonomy HonestyHonesty Informed consentInformed consent ConfidentialityConfidentiality FidelityFidelity

Case 5Case 5 Mary is a school teacher at a local public Mary is a school teacher at a local public

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

Case 5Case 5

Today she presents a prescription for Today she presents a prescription for phentermine 15mg capsules.  The tech took phentermine 15mg capsules.  The tech took the prescription in while you were on the the prescription in while you were on the phone.  You become aware of the phone.  You become aware of the prescription when the tech can't find the prescription when the tech can't find the medication on the shelf.  You immediately medication on the shelf.  You immediately react and think to yourself, "What is she react and think to yourself, "What is she getting this for?"  You know her profile well getting this for?"  You know her profile well and are concerned that the phentermine is and are concerned that the phentermine is not going to be compatible with her thyroid not going to be compatible with her thyroid or BP medications, even though there are or BP medications, even though there are not outright contraindications or not outright contraindications or interactions.interactions.

Case 5Case 5 Questions:Questions: Should you tell the patient you don't think she Should you tell the patient you don't think she

needs the medication or not?needs the medication or not? Will you be able to communicate without Will you be able to communicate without

being judgmental?being judgmental? How do you approach communication with How do you approach communication with

the patient since you already know her well?the patient since you already know her well? What do you say to the patient - to get the What do you say to the patient - to get the

message to her that you don't think she message to her that you don't think she needs this medication?needs this medication?

How will you handle the problem of the How will you handle the problem of the doctor's view on all of this?  Will you call her doctor's view on all of this?  Will you call her MD?MD?

Case 6Case 6 A good friend of yours stops by the A good friend of yours stops by the

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

Case 6Case 6

Questions:Questions: What do you do?  If you choose not What do you do?  If you choose not

to give the medication how will you to give the medication how will you tell your friend no?  If you do give the tell your friend no?  If you do give the pills, how do you justify this?pills, how do you justify this?

What if the request was for What if the request was for antibiotics for your friend’s child with antibiotics for your friend’s child with an obvious ear infection?  Would this an obvious ear infection?  Would this make a difference?make a difference?

Case 7Case 7 Mr. Heyward is one of your favorite customers. He Mr. Heyward is one of your favorite customers. He

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

Case 8Case 8 Mrs. Sheen been using your pharmacy for a Mrs. Sheen been using your pharmacy for a

couple of years. During this time she has been on couple of years. During this time she has been on antidepressants, tranquilizers and occasional pain antidepressants, tranquilizers and occasional pain medications . You have noticed that she seems to medications . You have noticed that she seems to be very accident prone. She has reportedly been be very accident prone. She has reportedly been in at least two traffic accidents where she was in at least two traffic accidents where she was injured and she has fallen at least a time or two. injured and she has fallen at least a time or two. It's been a while since she has been in, but today It's been a while since she has been in, but today she presents with bruises on her face. While she presents with bruises on her face. While writing the check to pay for her prescriptions you writing the check to pay for her prescriptions you notice that she has significant bruising on her notice that she has significant bruising on her wrists. You ask if she is OK and she just looks at wrists. You ask if she is OK and she just looks at you and says, "I'll be fine". She takes her you and says, "I'll be fine". She takes her prescriptions and leaves quickly. Your technician prescriptions and leaves quickly. Your technician leans over and says - you need to report this! leans over and says - you need to report this!

Case 9Case 9 A 16 year old make customer comes by to pick up A 16 year old make customer comes by to pick up

his prescription for erythromycin which he uses to his prescription for erythromycin which he uses to fight acne. His mom, a long time friend of yours, fight acne. His mom, a long time friend of yours, usually comes in with him, but today he is alone. usually comes in with him, but today he is alone. Since he has been taking the erythromycin he has Since he has been taking the erythromycin he has been having stomach pains. He does not know that been having stomach pains. He does not know that the erythromycin can cause this, and he does not the erythromycin can cause this, and he does not mention the stomach pain to you. While counseling mention the stomach pain to you. While counseling him on the refill you ask if he has any other him on the refill you ask if he has any other questions or concerns. He hesitates, the asks questions or concerns. He hesitates, the asks "What will happen if I used any other drugs with "What will happen if I used any other drugs with this? Your response is that it would be very this? Your response is that it would be very important for him to check with you first - before important for him to check with you first - before using any other medication. He says OK then using any other medication. He says OK then leaves. A few minutes later he comes back in and leaves. A few minutes later he comes back in and very hesitantly asks if smoking pot with his very hesitantly asks if smoking pot with his prescription could be causing his stomach to hurt?prescription could be causing his stomach to hurt?

Case 10Case 10

You have a male patient at the community You have a male patient at the community pharmacy who has several prescriptions filled for pharmacy who has several prescriptions filled for HIV infection.  Your long time friend Susan is over HIV infection.  Your long time friend Susan is over for dinner one night and she tells you about this for dinner one night and she tells you about this great new guy she has met.  She's falling fast, great new guy she has met.  She's falling fast, and through the course of the conversation you and through the course of the conversation you realize that this new fellow is an HIV patient at realize that this new fellow is an HIV patient at your pharmacy.  From her comments, you are your pharmacy.  From her comments, you are able to discern Susan has no idea that he is HIV able to discern Susan has no idea that he is HIV positive.  What, if anything can or would you do?positive.  What, if anything can or would you do?

Case 11Case 11

You are a pharmacist for CVS.  A 15 year old high school student You are a pharmacist for CVS.  A 15 year old high school student presents her prescription for birth control pills to you at the presents her prescription for birth control pills to you at the pharmacy drop off window.  You fill it, counsel her and provide an pharmacy drop off window.  You fill it, counsel her and provide an information leaflet on the medication.  She pays the $25 information leaflet on the medication.  She pays the $25 medication co payment with a Visa card.  A few days later, the medication co payment with a Visa card.  A few days later, the young girls dad notices the Visa charge from CVS in the exact young girls dad notices the Visa charge from CVS in the exact amount of his co payment, while reviewing his monthly charges.  amount of his co payment, while reviewing his monthly charges.  He is confused and thinks a mistake has been made because he He is confused and thinks a mistake has been made because he uses another pharmacy for his prescriptions.  So, the Dad picks up uses another pharmacy for his prescriptions.  So, the Dad picks up the phone and calls CVS to ask about the charge.  The call is 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 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 up for him, then notice that it was for the daughter - and you apologize, but, refuse to provide any further information about the apologize, but, refuse to provide any further information about the situation.  The father insists, but, you hold your ground.  His last situation.  The father insists, but, you hold your ground.  His last words had something to do with getting you fired.words had something to do with getting you fired.

Case 12Case 12

A female patient presents you with a prescription for Plan B, the A female patient presents you with a prescription for Plan B, the morning after pill.  You have thought a lot about this, and even morning after pill.  You have thought a lot about this, and even talked to your colleagues, and your boss.  Your boss has told you talked to your colleagues, and your boss.  Your boss has told you company policy which is vague and could go either way - for or 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 against you.  Your good friend Tom at CVS has made it clear that he has no problem with the medication.  Having never been faced he has no problem with the medication.  Having never been faced with actually making a decision you've not really decided what with actually making a decision you've not really decided what you would do under these circumstances.  The pharmacy does you would do under these circumstances.  The pharmacy does carry Plan B.   You look at the prescription and then simply state carry Plan B.   You look at the prescription and then simply state that you can not fill the prescription because of your beliefs, and that you can not fill the prescription because of your beliefs, and direct the patient to Tom at CVS, and apologize for any direct the patient to Tom at CVS, and apologize for any inconvenience. The patient is furious.  She insists you have no inconvenience. The patient is furious.  She insists you have no right to refuse to fill her prescription and demands that you fill it.  right to refuse to fill her prescription and demands that you fill it.  You hold your ground.  She threatens to sue you and the You hold your ground.  She threatens to sue you and the pharmacy if you do not comply.pharmacy if you do not comply.