Ethical Behavior when Communicating with Patients

Ethical Behavior when Communicating with Patients

Ethical Patient Care The following cases illustrate several principles of ethical behavior discussed in this chapter. As you read the following three cases, make notes about what you would do in each situation. At the end of the chapter you will find an analysis of each case. Before reading the analyses, re-read the cases, and see if you would solve them any differently than you initially did. Then compare your analyses with those provided.

Each of these patient cases presents decisions that must be made on the basis of legal and ethical principles. Your ability to choose a proper course of action in these situations depends on your understanding of the ethical principles involved. The legal aspects of these cases are covered under state and federal law. However, many elements are not specifically addressed in laws and regulations but do involve underlying ethical principles of patient–health professional interaction. Principles related to ethical decision making in patient care include beneficence, autonomy, and honesty. This is by no means a complete list, but the principles seem to be most relevant to the communication responsibilities of pharmacists. Other issues that are derived from these principles and are particularly important in patient counseling are informed consent, confidentiality, and fidelity. These important concepts will be discussed in later sections of this chapter. A Pharmacy Code of Conduct for a Modern World Over the last few decades rapid advancements in health care and adoption of new technologies have changed the environment in which medical care is given. Despite its rapid change, the health care environment remains an exciting and complex arena offering rich opportunities for growth, professional satisfaction, and interesting intellectual challenges that affect all professionals—including pharmacists. The emerging role of pharmacists as medication therapy managers requires you to be more effective and efficient when engaging in all forms of communication as it relates to medications (Dhillon et al, 2001). As the practice of comprehensive pharmaceutical care grows, you will find yourself in the midst of a vast array of ethical and legal considerations that need resolution if you are to be guided into the more cognitive service role of “helping people get the best use of their medicine.” This phrase was adopted by the Joint Commission of Pharmacy Practitioners following their Pharmacy in the 21st Century Conference (Zellmer, 2001; Tindall and Millonig, 2003) and attempts to convey one important factor involving contemporary pharmacy practice: Pharmacists serve as repositories of sensitive and protected health information about their patients. Pharmacists are also being challenged by contemporary social issues such as being asked to dispense medications that end life (see Case Study 14.5), in physician-assisted suicide situations, or in situations that involve terminating pregnancies (see Case Study 14.4). Pharmacists can be proud of the fact that the World Health Organization (WHO) has praised their importance as communicators and health care givers (Zellmer, 2001). Thus, you must be prepared to carefully recognize and resolve ethical issues by understanding general and specific ethical principles and by applying these principles to pharmaceutical care and medication therapy management. 

THE PHARMACISTS CODE OF ETHICS

 The APhA adopted a revised Code of Ethics for Pharmacists in 1994; the American Society of Health-System Pharmacists (ASHP) endorsed the same code in 1996. This code was founded using a patient-centered approach and its eight principles are based on moral obligations and virtues intended to guide pharmacists in their professional relationships with patients and other health care professionals (APhA, 1994). This pharmacist-specific Code of Ethics addresses only ethical behavior and does not address any of the state and federal statutes and regulations governing pharmacy practice although both state and federal statutes and regulations address how pharmacists are to conduct themselves in relationships designed to respect and protect the well-being of the public. The eight principles described in the APhA Code of Ethics for Pharmacists are as follows: Principle I: A pharmacist respects the covenantal relationship between the patient and pharmacist. Principle II: A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. Principle III: A pharmacist respects the autonomy and dignity of each patient. Principle IV: A pharmacist acts with honesty and integrity in professional relationships. Principle V: A pharmacist maintains professional competence. Principle VI: A pharmacist respects the values and abilities of colleagues and other health professionals. Principle VII: A pharmacist serves individual community and societal needs. Principle VIII: A pharmacist seeks justice in the distribution of health resources. While these principles outline the professional obligation of pharmacists to use their knowledge and skills for the benefit of others, they reflect general and ethical principles held in high esteem by all health care professionals. More importantly, the APhA Code was built on a contemporary interpretation of underlying ethical principles that address nonmaleficence, beneficence, paternalism, autonomy, honesty and truth telling, informed consent, confidentiality, and fidelity. These underlying principles are something that every pharmacist should understand. Seven Key Principles Guiding Ethical Conduct  • Nonmaleficence • Beneficence • Autonomy versus paternalism • Honesty and truth telling • Informed consent • Confidentiality • Fidelity Underlying Ethical Principles Beardsley 

1. THE PRINCIPLE OF NONMALEFICENCE

 The “principle of nonmaleficence” is commonly stated as the principle of “above all else do no harm.” This is probably the most quoted principle of all moral maxims and has been used for 3,500 years, gaining prominence in the Oath of Hippocrates. The principle of nonmaleficence requires a health care provider to not act in any way that intentionally inflicts needless harm or injury to a patient, either through acts of commission or omission (Munson, 2000). The principle of nonmaleficence can be violated in two distinct ways. First, pharmacists can violate this principle if they knowingly and intentionally cause a patient harm. For example, knowingly filling a prescription to which a patient has an allergy or filling a prescription in defiance of the published literature that states it may have a drug–food interaction without telling the patient about the drug–food interaction may be seen as malfeasance. The principle of nonmaleficence may also be violated when no malice or intent to do harm is involved. For example, a pharmacist by honest mistake misreads a prescription for Zyrtec and fills it with Zyprexa. Should that patient come to harm through this error, the pharmacist may be found negligent in his or her actions even though the pharmacist had no intention to cause harm. The pharmacist may be considered as having failed to exercise due care in discharging his or her responsibilities as a professional. Thus, the pharmacist failed to meet his or her obligation of nonmaleficence and may be held accountable by the court system for his or her actions. The obligation of care imposed by the principle of nonmaleficence is not to demand that pharmacists or any health professional accomplish the impossible or to be perfect in any way. Rather, pharmacists must provide a standard of care that any reasonable professional would have done under the same circumstances and also at a level that is higher than an “ordinary” person. In essence, this expectation is reasonable because perfection in medicine is not possible since it is not a perfect or exact science. Thus, pharmacists and other health care professionals are held to “standards of due care.” It is by these standards, set by the profession, that their actions are evaluated and judged harmful or appropriate. To further protect the members of society from “malfeasance,” some dueprocess standards are met by using licensing statutes and regulations, educational requirements, standards for practical learning, and credentialing committees to set up entry barriers to a profession. This way society has some assurance that individuals trained as pharmacists have obtained and continue to maintain an acceptable level of knowledge and skills needed to take on the responsibility of providing care. Thus, the APhA Code of Ethics for Pharmacists addresses this ethical principle of nonmaleficence when it states that pharmacists must maintain professional competence and that they “have a duty to maintain knowledge and abilities as new medication, devices, and technologies become available and health information advances.” 

2. THE PRINCIPLE OF BENEFICENCE

 “As to disease, make a habit of two things—to help or at least to do no harm.” This directive from Hippocratic writings focuses on two moral principles:  nonmaleficence, as discussed above, and beneficence. Both principles require the health care provider to evaluate the potential benefits of an intervention in relation to the risk of harm to the patient. To be more specific, beneficence is the principle that health professionals should behave in the best interest of their patients. The principle of beneficence is also addressed in the APhA Code of Ethics for Pharmacists (APhA, 1994) when it states, “a pharmacist places concern for the well-being of the patient at the center of professional practice.” When considering a medical or pharmaceutical intervention that best benefits the patient, that intervention should answer some or all of the following seven questions: Does it promote health and prevent disease? Does it relieve symptoms, pain, and suffering? Does it cure the disease? Will it prevent untimely death? Will it improve functional status or maintain a compromised health state? Will its educational content and counseling help better a patient’s condition and prognosis? Will the intervention help avoid harm to the patient in the course of care? Although there are times when all or most of these questions can be answered, there are times in every professional’s life when it is really difficult to accomplish a desired therapeutic outcome due to a conflict between patient and provider expectations (i.e., what a patient wants versus what a professional wants for them) (Jonsen et al, 2002). For example, the use of combined antiretroviral therapy in the treatment of HIV infection comes with many benefits as well as risks. While the use of these drugs improves the patient’s quality of life and prolongs his survival, the side effect profiles of these drugs are extensive and the cost for such drugs is unduly burdensome. Thus, the use of these drugs for preventive purposes produces a risk-to-benefit relationship that must be carefully considered by both patient and practitioner. 

3. THE PRINCIPLE OF AUTONOMY VERSUS PATERNALISM 

Another ethical issue in health care is based on finding a balance between autonomy and paternalism in order to provide the best help to the patient. Paternalism refers to those health professionals or pharmacists who see their relationships with patients as “paternalistic.” That is, they see themselves in a parental role knowing what is best for the “child” (patient). In essence, paternalism is a poor practice as it fails to take into consideration the preferences, beliefs, and practices of the patient, especially those that could be of most benefit to them. Conversely, the principle of autonomy establishes a patient’s rights to self-determination; that is, the patient’s moral right to choose one’s own life plan and action (Jonsen et al, 2002; Munson, 2000). This right is considered paramount even if health professionals judge patient decisions as being damaging to their health. According to the “Harm Principle,” constraints on an individual’s free choices are morally permissible only when an individual’s preference infringes on the rights and welfare of others (Munson, 2000). When pharmacists desire to assess situations of ethical dilemmas, they find it helpful to do this in light of a patient autonomy–paternalistic continuum. If they assess some actions as being more authoritarian than others, they would place their actions toward the “paternalistic” end of this continuum. Actions that encourage patient involvement in decision making would be placed toward the “patient autonomy” end of this continuum. In daily practice, however, there may be many forces that limit or even obstruct the appreciation of patient autonomy, such as the compromised competence of patients, the disparity between provider and patient knowledge, the psychodynamics of the patient–provider relationships, and the stress of illness (Jonsen et al, 2002). Medical ethicists often state that the danger of paternalism is that it threatens individual rights and personal liberties. Yet, in past times, medicine has used the beneficence principle as justification for “paternalistic” relationships with patients. For example, physicians made decisions by themselves (without necessarily informing patients and without patient consent) and then did what was necessary because they saw it in the patient’s best interest. Put another way, they made certain decisions based on their perceptions of what was needed, and they did not include the patient in their decision making. Similarly, pharmacists say they are using “professional judgment” when they adjust a dose or refill a certain medication while rationalizing that the patient has no need to know what has happened. Although most health care professionals embrace and find value in the principle of patient autonomy, in some situations patient autonomy may be unintentionally compromised. For example, some patients who are naturally shy, nonassertive, uneducated, or illiterate may be intimidated in the presence of anyone wearing a white coat. Thus, although the pharmacist is not deliberately attempting to infringe on the patient’s autonomy, social and psychosocial factors may be so overpowering that the patient feels he or she is powerless to make a decision. It is easy to see how autonomy is critically linked to information. Information is vital to protecting and preserving patient autonomy. In an era of consumer-driven health care, it is hard to deny well-informed patients active partnership roles in their health care. Likewise, to become well informed, patients need to be informed in language they understand, and to have explained in unbiased terms the possible treatment options as well as their risks and benefits. In today’s hurried medical environment, patient education and even informed consent are many times pushed aside. Thus, patients often feel rushed and unprepared to make important decisions about their health care and thus relinquish their right to autonomy to their provider. 

4. THE PRINCIPLE OF HONESTY AND TRUTH TELLING

 On principle, all communications between patients and their health professionals should be truthful under all instances. But what should be done when full disclosure of every detail could prove to be harmful? With the increased prominence of the principle of autonomy and with the patient’s right to informed consent in these modern times, full disclosure and truthfulness have become the more accepted ethical courses of action (Da Silva et al, 2003; Jonsen et al, 2002).  The principle of honesty states that patients have the right to truthful communication regarding their medical condition, the course of their disease, the treatments recommended, and alternative treatments available. The APhA Code of Ethics for Pharmacists (1994) states that a pharmacist “has a duty to tell the truth and to act with conviction of conscience.” A certain level of trust must develop between patients and pharmacists to strengthen these relationships. This trust is developed because pharmacists adhere to the principle of honesty. Some health care providers, when withholding information, will claim “therapeutic privilege” as their reason for doing this. This is because they perceive that full disclosure or divulging all medical information would be harmful or upsetting to the patient. In addition, “privilege makes sense in an ethics based on paternalistic patient benefit, but it is contrary to an ethic giving important place to the principle of autonomy” (Veatch, 2000, p. 69). Further, therapeutic privilege, as a paternalistic attitude, has also been criticized because “displaying such behavior is not seen as providing a service but as guarding special knowledge and who would be in control as to when and who to reveal the truth to” (Da Silva et al, 2003, p. 420). Pharmacists may find themselves in the middle of an ethical dilemma concerning truth telling and therapeutic privilege. For example, a patient who claims to have allergies and/or hypersensitivities to some medications previously taken may be prescribed a similar medication but not told of the potential for an allergy or hypersensitivity by a prescribing provider who believes the information about it is purely psychological and has no basis in pathology. In some cases, the patient’s pharmacist may be asked to withhold a patient drug information sheet. The prescribing provider may claim “professional privilege,” stating that telling the patient of possible side effects or adverse reactions may actually cause the patient undue distress or even lead to the patient not taking the medication at all. This leaves the pharmacist in a position to make his or her decision not only within the confines of the statutes and regulations, but also under his or her own interpretation of what is ethically acceptable. 

5. THE PRINCIPLE OF INFORMED CONSENT

 “Informed consent is a critical element of any theory that gives weight to autonomy” (Veatch, 2000). Thus, “informed consent” is the way in which patient preferences become expressed and are applied out of respect for that patient’s autonomy (Jonsen et al, 2002). Both honesty and autonomy serve as foundations to the right of the patient to give informed consent to treatment. The informed consent principle states that patients have the right to full disclosure of all relevant aspects of care and must give deliberate consent to treatment based on “usable” information and a clear understanding of that information (Munson, 2000; Quallich, 2005). In general, consent is not required when a procedure is simple and the risks are commonly understood (Cady, 2000). However, any provider who recommends treatment for a patient, especially if it is invasive, must obtain informed consent. Informed consent forms the ethical basis for the patient–provider relationship as it “consists of an encounter characterized by mutual participation, good communication, mutual respect, and shared decision  making” (Jonsen et al, 2002). For informed consent to successfully take place, it requires a dialogue between patient and provider that consists of five distinct components (Quallich, 2005): • Diagnosis or nature of the specific condition that requires treatment(s), • The purpose and distinct nature of the treatment(s), • Risks and potential complications associated with the proposed treatment(s), • All reasonable alternative treatment(s) or procedures and a discussion of their relative risks and benefits including the option of taking no action, and • The probability of success of the proposed treatment(s). Thus, it is understood that informed consent has occurred and treatment can be implemented if all relevant information is provided, if consent is freely given and is without coercion, and if the patient is capable of understanding the salient information provided. Even under the very best of circumstances it is not always easy to determine who is competent to consent to treatment and who is not (Munson, 2000; Wingfield, 2003). Health care providers must consider how “vulnerable populations,” such as children, the mentally retarded, and those suffering from psychiatric illnesses, are to be considered with respect to consent. The law often uses the terms “competence” and “incompetence” to indicate whether individuals have the legal authority to make health care decisions for themselves. Judges alone have the authority to rule that an individual is legally incompetent. However, medical providers may encounter legally competent patients who appear to have their mental capacity compromised by illness, anxiety, pain, or even hospitalization (Jonsen et al, 2002; Wingfield, 2003). This clinical situation is referred to as “decisional capacity” rather than the legal term of “determination of competency.” Many times in actual practice, health care professionals focus more on “disclosure” than on patient understanding of information. This point can be summarized by the phrase, “the central problem about informed consent are issues of communication rather than the disembodied and abstract issues about proper legal standards of disclosure” (Beauchamp, 1989). Thus, the message that is implicitly being given is that a pharmacist’s success in interpersonal communication is related to his or her willingness to invite patients to engage in open and honest dialogue based on questioning and the exchange of information and full disclosure of it. The pharmacist must create an atmosphere that encourages patients to seek answers to questions. Unfortunately, this style of dialogue is often inhibited by limitations in communication skills and styles, patient comprehension, the inability of pharmacists to listen carefully to their patient’s words and the emotions underlying them, and the time constraints imposed by reimbursement policies that reward procedures rather than education (Jonsen et al, 2002). A meaningful dialogue or consent process is unlikely to be initiated by patients themselves for a variety of reasons. This is true in part because of patient reticence to question providers. In addition, patients often do not know when there is important information about treatment that they have not yet acquired. The burden is on providers to make sure that patients understand all they need to know both to make a reasoned decision about therapy and to implement therapeutic plans appropriately. While drug therapy is the most common type of therapy in health care, informed consent issues surrounding drug therapy are largely ignored compared with issues involving other types of treatment, such as surgery. In addition, patients have much more control over adhering to their medication therapy. Earlier assumptions by society that risks associated with drug therapy are minimal have been challenged by recent research and government reports, such as the Institute of Medicine’s Crossing the Quality Chasm (IOM, 2001). The estimated number of deaths and adverse health events caused by inappropriate therapy is staggering. In the future, pharmacists will be expected to assume their share of responsibility in ensuring that informed consent has occurred before drug treatment is initiated. What are the roles of pharmacists in informed consent? Many pharmacists assume that when patients bring in prescriptions, (a) their physicians have provided all relevant information, (b) patients understand the information, and (c) they have consented to treatment. In fact, many patients lack information on crucial aspects of drug treatment. In addition, physicians frequently do not explicitly discuss key aspects of drug therapy and often fail to obtain meaningful consent from patients. In certain situations, it may become clear that informed consent has really not occurred. Patients may not fully understand important aspects of treatment, may have unanswered questions, or may not be aware of significant side effects. In addition, patients may indicate reluctance to begin taking medications but feel that they have no choice but to follow their physicians’ directions. Many may feel coerced into their decision based on the hierarchical relationship between patient and provider, where power is largely vested in the health professionals on whom patients feel dependent. It is difficult to determine whether consent to treatment has been freely given. When patients express reservations about initiating drug treatment, pharmacists may need to consult not only with patients but also with prescribing physicians to inform them of the lack of freely given consent to treatment. 

6. THE PRINCIPLE OF CONFIDENTIALITY 

The Hippocratic Oath states, “what I may see or hear in or outside the course of treatment . . . which on no account must be spread abroad, I will keep to myself, holding such things shameful to speak about.” The principle of confidentiality serves to ensure that health care providers are obligated to refrain from divulging information that is obtained from patients during the course of medical treatment and to take reasonable precautions to protect that information. In another approach to confidentiality “modern medical ethics bases this duty on respect for the autonomy of the patient, on the loyalty owed by the physician, and on the possibility that disregard of confidentiality would discourage patients from revealing useful diagnostic information and encourage others to use medical information to exploit patients” (Jonsen et al, 2002). As pharmacists become more involved with direct patient care, they gain access to a wide range of sensitive and private patient information, which is necessary for appropriately managing therapy. With the advent of the new regulations set by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), pharmacists must know the working of this statute and be able to address the issues relating to its principles of confidentiality and consent, and the regulations concerning “protected health information.” This new layer of professional responsibility is made all the more important because the greatest challenges today to confidentiality result from technological developments in information storage, retrieval, and access (Jonsen et al, 2002; Wingfield and Foster, 2002). While computerization of pharmacy and medical records enhances patient care, it also enhances statistical information and administrative tasks allowing the availability of such records to third parties such as employers, government agencies, payers, and family members. This increased availability threatens patient and professional control over sensitive information. HIPAA took effect on April 14, 2003, and is one of the most significant pieces of federal legislation to affect pharmacy practice since the Omnibus Budget Reconciliation Act of 1990 (OBRA) (Spies and Van Dusen, 2003). HIPAA is also considered to be the first comprehensive federal regulation designed to safeguard the privacy and security of protected health information. Thus, every pharmacy that conducts certain financial and administrative transactions electronically, such as billing, must be in compliance with its regulations. HIPAA prescribes a framework for the use and disclosure of health information for treatment, payment, and health care operations at all health care institutions, including pharmacies (Giacalone and Cacciatore, 2003; Spies and Van Dusen, 2003). HIPAA was written to “enhance the efficiency and effectiveness of data exchange for administrative and financial transactions while improving the security and privacy of healthcare information” (Mackowiak, 2003). Confidentiality has always played a key role in pharmacy practice and therefore the new HIPAA guidelines do not necessarily replace state pharmacy statutes and regulations. However, HIPAA provides strict guidelines as to what a pharmacy can do with patient health information. It also provides important rights to patients, such as “the right to access the information, the right to seek details of the disclosure of the information, and the right to view the pharmacy’s policies and procedures regarding the confidential information” (Spies and Van Dusen, 2003). Compliance with HIPAA is mandatory. The Privacy Rule (the Rule) of HIPAA provides pharmacies some flexibility to create their own privacy rules and procedures. “The Privacy Rule requires each pharmacy to take reasonable steps to limit the use or disclosure of, and requests for, protected health information (PHI) . . . defined as individually identifiable health information transmitted or maintained in any form and via any medium” (Spies and Van Dusen, 2003). Examples of PHI include prescriptions and patient record systems. To accomplish this, pharmacies must employ reasonable policies and procedures that limit how PHI is used, disclosed, and requested. Further, pharmacies must also post their complete Notice of Privacy Practices within the facility as well as on their website, if one exists. It has been stated that “although privacy is an important issue, efforts to protect it may conflict with social needs, including the ability of health professionals  to exchange information when caring for a patient, the right of parents to sensitive health information concerning their children, and the use of data for research, public health, or audit purposes” (Jonsen et al, 2002). Therefore, it is the responsibility of the health care provider to become an advocate for the patient by being familiar with the regulations and policies and being an advocate for better control of information and for improved policies and laws to safeguard it. 

7. THE PRINCIPLE OF FIDELITY AND THE PATIENT–PROVIDER RELATIONSHIP 

The principle of fidelity, as it relates to the patient–provider relationship, is based on the concept of loyalty. It is understood that a special type of relationship is created between patient and provider, one that is based on all the ethical principles previously discussed. The ethics of medicine have traditionally directed providers to attend exclusively to the needs of the patient and to act in ways that best benefit the patient. However, it is also recognized that providers, in some sense, have certain responsibilities beyond their patients. Thus, ethical problems brought on by multiple responsibilities can arise when it is unclear which responsibilities have priority or when it appears that duty to one’s patient is in direct conflict with other duties (Jonsen et al, 2002). Fidelity or loyalty is then even more clearly defined as “a sustained commitment to the welfare of persons or to the success of an endeavor, requiring an investment of effort and sometimes even a subordination of self-interest” (Jonsen et al, 2002). Pharmacists, like other health care providers, have multiple loyalties—to family, to friends, to a religious faith, to a community, and to other personal, professional, and financial obligations. Thus, pharmacists, at times, may experience differing loyalties that will pull them in opposing directions, which is difficult when one choice must be made. For example, pharmacists who promote the use of vitamins by patients who do not need them may be enhancing their financial well-being at the expense of their patients. Pharmacists who refuse to confront physicians about inappropriate prescribing because they want to ensure that physicians will continue to direct patients to their pharmacies are displaying a misplaced sense of their professional responsibility. Pharmacists who are more attentive to the desires of the parties signing their paychecks than to the health care needs of their patients are in a conflict-of-interest situation. Ethically, the responsibilities of pharmacists should be directed toward the welfare of patients. The focus on the rights of patients and the obligations of providers can make the relationships between them seem mechanistic and legalistic. It would be easy to create a list of dos and don’ts for each party to follow. However, the situations encountered within patient–provider relationships are often complicated. Thus, the principles discussed above must be considered when working with patients. In addition, the ability to effectively work through sensitive issues depends on trusting, caring relationships between patients and providers. Each patient is a unique individual and, in an illness situation, is particularly vulnerable. Thus, patients have the right to be treated with compassion. Patients need humane, sensitive care from providers, care that will assist them in making the best decisions they are able to make. This is the essence of the “helping” role of the  health care professional. There is a caveat to this helping role: it is influenced by the vulnerability of the patient, especially the status accorded to physicians and other helping professionals that sets up a power difference between the patient and provider. In fact, “if one shares power with the person having the greatest danger of being victimized, the potential for self-correction of

error seems greatest” (Brody, 1992). So, once again, the need for mutual participation through an active patient role in health care decision-making becomes essential if one wants to reduce health care errors and mishaps. Empowering patients to be active participants in treatment decisions, with decisions being made in the context of a respectful, trusting relationship then becomes a large part of the work pharmacists must take on as part of their professional responsibility to patients. 

special situation communication

Strategies to Meet Specific Needs

Introduction 

Older Adults Communication Impairments Patients with Disabilities Terminally Ill Patients Patients with HIV or AIDS Patients with Mental Health Problems Suicidal Patients Patients with Low Health Literacy Cultural Competence Caregivers Beardsley_CH10_148-168.qxd 11/14/06 10:00 AM Page 148 Before discussing the unique communication challenges of these special patient groups, one caveat that applies to most situations must be offered: if you sense that a person has a unique problem, you should check your perception of that problem (see Chapter 3). An example is how we often treat the elderly. Although some elderly patients may appear to be frail, they may not be forgetful or hearing impaired. However, we make certain assumptions based on our perceptions of the elderly as a group of patients. Thus, we may start shouting at them or talking slower. The key is to assess how they are responding to our educational efforts. We should watch for nonverbal clues to see whether they are leaning toward us or whether they have a confused look. Asking open-ended questions can also provide feedback about the patient’s ability to communicate. Not checking initial impressions could lead to some potentially embarrassing situations for both patients and us. We should try to avoid stereotyping individuals and make sure to check our perceptions. Older Adults Several factors make it imperative for you to be sensitive to interactions involving older adults. The number of elderly in our society is increasing, and the elderly consume a disproportionate amount of prescription and nonprescription medications compared with other age groups. Elderly men and women present special opportunities for pharmacists because they account for 30% of all prescription medication taken in the United States and 40% of all over-the-counter (OTC) medication. As a group, two out of three elderly people take at least one medication daily. Thus, this growing segment of the population is in need of our patient counseling services. Unfortunately, the aging process sometimes affects certain elements of the communication process in some older adults. These potential communication problems are discussed below.

LEARNING

 In certain individuals, the aging process affects the learning process, but not the ability to learn. Some older adults learn at a slower rate than younger persons. They have the ability to learn, but they process information at a different rate. Thus, the rate of speech and the amount of information presented at one time must meet the individual’s ability to comprehend the material. In addition, shortterm memory, recall, and attention span may be diminished in some elderly patients. The ability to process new and innovative solutions to problems might also be slower in some older adults. Thus, attempts to change behaviors should be structured gradually and should build on past experiences. A good approach with some older adults is to set reasonable short-term goals, approach long-term goals in stages, and break down learning tasks into smaller components. Another important step is to encourage feedback from patients as to whether they received your intended message by tactfully asking them to repeat instructions and other information and by watching their nonverbal responses. When given the opportunity to learn at their own speed, most elderly people can learn as well as younger adults.

STRATEGIES TO MEET SPECIFIC NEEDS 

149 Beardsley_CH10_148-168.qxd 11/14/06 10:00 AM Page 149 VALUE AND PERCEPTUAL DIFFERENCES Potential communication barriers between you and older patients may be attributable to the generation gap. Some older adults may perceive things differently from those in different age groups since people typically adhere to values learned and accepted in their younger years. Thus, some older adults may have different beliefs and perceptions about health care in general and about drugs and pharmacists specifically. Some behaviors, such as hoarding and sharing medication, may seem inappropriate to you, but such actions may make sense to someone who grew up in the 1930s during the Depression. You should be aware of situations in which you may be reacting to their different values and belief systems rather than to the patients themselves. The image of the pharmacist and the pharmacy profession is also important. Older patients may expect a well-groomed, clean-shaven, professional-looking male practitioner to serve them. If you do not meet these expectations, they may be somewhat reluctant to interact with you initially. Their perception of authority may also influence how they interact with you. Some older adults grew up respecting the authority of physicians and pharmacists and prefer a more directed approach to receiving health care. Thus, they may be receptive to being told what to do. On the other hand, many patients want to be more independent and may feel the need to assert themselves. They may be somewhat more demanding, may want additional information, or may want more input into the medication decision-making process. Thus, it is important to assess which approach seems to work for each patient.

PSYCHOSOCIAL FACTORS

 Several psychosocial factors may influence your relationship with older adults. First, some older adults may be experiencing a significant amount of loss compared with people of other age groups. For example, their friends may be dying at an increased rate, they may have retired from their jobs, or they may have had to slow down or cease certain activities due to the aging process. All these situations involve loss and subsequent grieving. Thus, their reaction to certain medical situations, such as ignoring your directions or complaining about the price of their medications, may be responses to fear of their diseases, of becoming even less active, or of dying. They may deny the situation or become angry at you or other health care providers. They may also turn to self-diagnosis and self-treatment or to the use of other people’s medications. Communication Impairments 150

VISION

Pharmacists and their staffs work with patients with visual impairments in a variety of practice settings. Be prepared to offer alternative forms of patient counseling to deal with these impairments. If you work with elderly patients, you need to realize that the aging process may affect the visual process. Written messages for persons with visual deficiencies should be in large print and on pastel-colored paper rather than on white paper. Many times visual acuity is not as sharp, and sensitivity to color is decreased. In some older patients, more light is needed to stimulate the receptors in the eye. Thus, when using written information, make sure you have enough light.

HEARING

 Three general types of physical hearing impairment (conductive, sensorineural, and central) can occur singly or in combination with one another. Conductive hearing impairment results when something blocks the conduction of sound into the ear’s sensory nerve centers. Sensorineural impairment occurs when the problem is situated in the sensory center of the inner ear. Central hearing impairment occurs when the nerve centers within the brain are affected. A hearing aid is helpful for people with conductive hearing problems, less effective for those with sensorineural impairment, and ineffective for those with central loss. Because the hearing aid only makes the sound louder, it is not as helpful in patients who cannot distinguish sounds easily and may actually make some situations worse. Hearing deficiencies can also be caused by a variety of factors, including birth defects, injuries, and chronic exposure to loud noises. Aging may also affect the hearing process. Auditory loss in various degrees of severity is seen in more than 50% of all older adults. The hearing loss associated with the aging process is called presbycusis. Unfortunately, this condition may lead individuals to withdraw socially and psychologically or, in extreme cases, may lead others to label them as senile or forgetful. Many older adults describe their hearing impairment as being able to hear what others are saying, but not being able to understand what is being said. They can hear words, but they cannot put them together clearly. Other types of hearing loss seen in some older adults are related to diminished response to high-frequency sounds. In some older adults, sensitivity to sound is decreased, and the volume must be increased to stimulate the receptors. Many individuals with hearing deficiencies, including some older adults, rely on speech reading (watching the lips, facial expressions, and gestures) to enhance their communication ability. Speech-reading is more than just lip-reading. It involves receiving visual cues from facial expressions, body postures, and gestures as well as lip movements. Research has shown that everyone develops some speech-reading skill and that the hearing-impaired typically develop that skill much further. Development of this skill is hindered if sight is impaired as well, as in some older adults. For speech-reading to be most effective, you should position patients directly in front of you and have a light shining on your lips and face when communicating. To improve communication with hearing-impaired patients, try to position yourself about 3 to 6 feet away; never speak directly into the patient’s ear because this may distort the message. Wait until the patient can see you before speaking; position yourself on the side of the patient’s strongest ear; if necessary, touch the patient on the arm. If your message does not appear to be getting through, you should not keep repeating the same statement, but rephrase it into shorter, simpler sentences. Many pharmacists and their staffs have learned sign language to assist hearing-impaired patients. Other types of hearing loss seen in some older adults are related to the actual hearing process. Response to high-frequency sounds is usually diminished before the response to lower-frequency sounds. Thus, using a lower tone of voice may help some older adults. In some older persons, sensitivity to sound is decreased, and increased volume can assist in hearing. It is also important to slow your rate of speech somewhat so that the person can differentiate the words. Remember not to shout when speaking, since shouting may offend some people. Talking in a somewhat higher volume may be necessary, but more likely a slower rate of speech will help most individuals. Finally, be aware of environmental barriers, such as loud background noises or dimly lit counseling areas, which make communication difficult for the hearing impaired.

SPEECH

 In pharmacy practice, you may need to interact with people who have some type of speech impairment. Speech deficiencies can be caused by a variety of factors, such as birth defects, injuries, or illnesses. A common speech deficiency is dysarthria, or interference with normal control of the speech mechanism. Diseases such as Parkinson’s disease, multiple sclerosis, and bulbar palsy, as well as strokes and accidents, can cause dysarthria. In dysarthria, speech may be slurred or otherwise difficult to understand because of lack of ability to produce speech sounds correctly, maintain good breath control, or coordinate the movements of the lips, tongue, palate, and larynx. Many of these patients can be helped by certain medications or by therapy from a trained speech pathologist. Another common speech problem results from the removal of the larynx secondary to throat cancer or other conditions. Such individuals can usually learn to speak again either by learning esophageal speech or by using an electronic device. However, you must be sensitive to these patients, since they sound “different.” Many people realize they sound different and that they may make other people feel uncomfortable. Thus, they may shy away from interacting with others. To overcome speech barriers, many patients write notes to their pharmacist or use sign language as a means of communicating. Some pharmacists have responded to this need by providing writing pads for patients and even by learning how to sign along with the patient.

APHASIA

A group of patients with related speech difficulties are those who suffer from aphasia after a stroke or another adverse event. Aphasia is a complex problem that may result, to varying degrees, in the reduced ability to understand what others are saying and to express oneself. Some patients may have no speech,  whereas others may have only mild difficulties in recalling names or words. Others may have problems putting words in their proper order in a sentence. Speech may be limited to short phrases or single words, or smaller words are left out so that the sentence reads like a telegram. The ability to understand oral directions, to read, to write, and to deal with numbers may also be disturbed. Fortunately for some patients, their communication ability can be improved after extensive therapy. However, improvements are often seen in small increments. Aphasic patients usually have normal hearing acuity; shouting at them will not help. Their problems are due to lack of comprehension; they are not hard of hearing, stubborn, or inattentive. Until you are aware of the extent of language impairment, avoid complex conversations. You need to be patient with these individuals when discussing their medications. Many times, they get frustrated with their situation because they know what they want to say but cannot say it. Also, it takes longer to communicate with them, since they may hear the word but may not immediately recall the meaning of it. Patience is also needed, since you may be tempted to fill in the word or phrase for aphasic patients. It is best to let them try to communicate. If they are unsuccessful after a few attempts, help them by supplying a few words in multiple-choice fashion and let them select the word they desire. Aphasic patients often feel isolated and may withdraw from social interactions. Thus, they should be encouraged to interact with other people. Most appreciate being included in a conversation even if only to listen. Some aphasic patients have difficulty reading. The difficulty is not one of visual acuity but rather of comprehending written language. Some have severe dyslexia and cannot read at all; others can read single words with comprehension but cannot read sentences. Patients with dyslexia may not be able to write notes to you. Dyslexia is not a physical disability but rather the inability to recall or form conventional written symbols. Many aphasic patients retain certain automatic responses and may appear to be able to communicate very well. They may be able to count to 10 but not to count 4 items placed in front of them. They can name the days of the week, but cannot tell you that Tuesday comes before Thursday. They may be able to function effectively only in repetitive situations. Usually, their automatic speech skills are within socially acceptable limits, but sometimes patients utter profanities that may embarrass both listeners and patients themselves. Patients are not displaying anger or other displeasures when they curse, but rather are using automatic speech and are unable to inhibit these responses. You will probably be challenged when counseling aphasic patients and getting feedback may be difficult, but you should at least make an attempt, since they may benefit from the experience. Many times it is best to counsel other people who are caring for aphasic patients, but do not exclude patients from this experience. Patients with Disabilities One cannot anticipate all the various types of patients you will be interacting with during your career, but many will have disabilities that must be considered. In addition, there is a wide spectrum of how patients are able to cope with  their disabilities. On one end of the spectrum, patients may be coping so well that their disability is hardly noticeable, while on the other end, their disability may severely affect their ability to access care and communicate with you. The key is to be sensitive to their unique needs. As many disabled individuals would say, “don’t treat me as a disability, treat me as an individual with a disability; in other words, treat me as an individual first.” Using common sense and being sensitive to individual needs would be good practices to follow. Due to some disabilities, you may need to interact with the patient’s caregiver rather than the patient. As discussed later in the chapter, this necessary approach presents a variety of communication issues.

WHEEL CHAIR BOUND PATIENTS

 Access issues are paramount when caring for wheel chair bound patients. The Americans with Disabilities Act (ADA) has specific guidelines regarding access to health care environments that would be applicable to pharmacies. Unfortunately, many pharmacy practice settings, including hospital, clinic, and community sites, are not readily accessible to these individuals. Entrances and aisles are often not wide enough, counters are too high, and pharmacists may not be visible to wheel chair bound patients. When talking with patients in wheelchairs, it is important to realize that you may be talking down to them. Although they may be used to having people hovering over them, it is best to talk on the same eye level, if it is not too awkward. Patients appreciate any efforts to minimize the distance between you and them without causing increased attention to the fact that they are in a wheel chair. You should watch patient nonverbal messages to monitor whether they are comfortable during the communication process. You may need to adjust your location or approach if they appear to be straining to hear or do not seem satisfied with the communication environment.

LEARNING DISABLED PATIENTS

 Patients with learning disabilities are especially challenging since you do not want to treat them differently, but at the same time you want to make sure that they can comprehend the critical information that you provide, including how to take the medicine, proper storage requirements, or what side effects to monitor. You must develop tact in approaching these patient education situations. You may have to repeat key information or use a variety of analogies to make your point. In addition, you should not get frustrated if the patient does not seem to get the main points. Some pharmacists have developed effective written information that is written at the appropriate level to share with their patients. Unfortunately, most available literature is written on the tenth to twelfth grade level, which is too complex for some patients. For many patients, you may also have to work with the patient’s caregiver to make sure that information is transmitted correctly and used appropriately. If the patient and caregiver are both present, make sure that you speak to the patient, not just to the caregiver, to get them involved with the situation as much as possible.

HOMEBOUND PATIENTS 

The key to communicating with homebound patients is to work with patients’ caregivers when they visit the pharmacy to verify that information is transmitted correctly and used appropriately. Clear, concise written information is essential in these situations. It is critical to review this information with the caregiver to make sure that key points are highlighted and are eventually discussed with the patient. Communication over the phone or Internet may also be possible (see Chapter 7 for advice on how to conduct an effective telephone interview). Many homebound patients can use the Internet and thus you may be able to communicate with them via e-mail. You can also recommend links to appropriate websites for relevant information for the patient. It is very rare that pharmacists visit homebound patients, but patients and their caregivers certainly appreciate these visits. In addition, some health insurance companies will pay for pharmacy home visits, especially if they are linked to providing delivery and monitoring of special medication (home infusion, for example). Terminally Ill Patients Most individuals, including pharmacists, find it somewhat difficult to interact with terminally ill patients. People typically feel uncomfortable discussing the topic of death and are uncertain about what to say; they do not want to say the “wrong” thing or upset patients. Yet most terminally ill patients need supportive relationships from family members, friends, and pharmacists. Pharmacists are becoming increasingly important in the care of terminally ill patients owing to the complex nature of cancer therapy and pain management and to their increased involvement on oncology teams in hospitals and other institutions. By the same token, more community-based pharmacists and their staffs are getting involved because of the de-institutionalization of cancer treatment and the evolution of home health care as a popular option for many patients. More important, pharmacists may be the only health professionals in their community who are readily accessible to patients and families. In addition, more patients are receiving palliative care at home. Palliative care seeks to comfort patients and to keep them pain free which addresses physical, as well as the psychological, emotional, and spiritual needs of the patient. A key component of palliative care is effective communication between the patient, the pharmacist, and other health care providers. Managing these unique needs requires strong communication skills; thus, you should be ready, professionally and emotionally, to interact with these patients. The following communication strategies should be used when working with terminally ill patients. Many of these approaches are too complex to be discussed in detail here but are listed in the suggested reading at the end of this chapter (Beardsley et al, 1977; Feifel, 1977; Kubler-Ross, 1969). Most strategies require “meeting the patients where they are” in relation to their understanding of their condition and their stage of adjustment. For example, a patient may be denying the existence of his illness, or he may be angry or depressed about his situation. You would approach these two situations differently. The key is to ask open-ended questions, such as “How are you doing today?” or “How are things going?” to determine patient willingness to discuss the situation with you. You should not assume that patients do not want to talk about it. Even if patients do not respond initially, they at least realize that you are willing to talk and may open up at a later time. In addition, you should not “push” patients who are in denial or are angry to change their perceptions or feelings. Acceptance of whatever patients feel regardless of the coping strategies they use is an important aspect of caring. Before interacting with terminally ill patients, be aware of your own feelings about death and about interacting with terminally ill patients. Do you typically avoid conversations with these patients? Do they remind you of someone close to you who struggles with a terminal illness? Being aware of your feelings will help you assist these patients. You should realize that you can handle some situations yourself, whereas other cases should be referred to others for assistance. Many pharmacists have found that just being honest about their feelings improves their interaction with terminally ill patients. Just by saying “I don’t know what to say right now. Tell me how I can help you?” or “I feel so helpless. Is there anything I can do for you?” seems to communicate concern for patients and gives them a chance to share their concerns as well. As in any type of patient interaction, the degree of involvement depends on your relationship with the patient. You will be more open with some patients than with others. It is also important to implicitly or explicitly set limits on what you can do for the patient. You must communicate your concern without raising the patient’s expectations that you can assist in all areas of the patient’s life, such as providing financial advice or preparing a will. Many terminally ill patients realize they make other people feel uncomfortable. Thus, they tend to avoid certain interactions. However, if you can express your uneasiness or your frustration about not knowing how to help them at the same time that you express your concern for them, patients will typically feel more at ease and more willing to express their own feelings. You may also come in contact with family members who will probably have special needs themselves. Research has shown that family members go through the same types of stages (denial, bargaining, anger, depression, and acceptance) that dying patients go through, and need support and often drug therapy (Kubler-Ross, 1969). Thus, you should be prepared to deal with the various emotions that are associated with each stage. In addition, Kubler-Ross and others have found that many individuals do not enter all stages and often move back and forth between various levels of denial and acceptance. Therefore, you need to listen closely to family members to determine their specific needs. In summary, communicating with terminally ill patients and their families is extremely important. You should not avoid talking with them unless you sense that they do not want to talk about their illness. Not interacting with them only contributes further to their isolation and may reaffirm the idea that talking about death is uncomfortable.  Patients with HIV or AIDS As a pharmacist, you will probably be working with patients who have a variety of health issues around human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS). Not only are these patients dealing with potentially life-threatening diseases, they are also dealing with the social stigmas that often accompany their condition. The key is not to treat them as being “different” from your other patients. Typically, they do have a unique set of needs that should be recognized and addressed. Many of the issues discussed in the terminally ill section apply to AIDS patients, since AIDS can still be a terminal disease. However, many patients are living much longer life spans with the advent of highly active antiretroviral therapy. Therefore, health professionals must adjust their thinking and come to perceive HIV infection as a chronic condition rather than a terminal disease. In any case, you should use some of the strategies outlined in the previous text, such as using open-ended questions to determine patient receptivity to interaction. Patients with HIV or AIDS have special needs that should be considered. For example, many patients do not have an adequate support system, since relationships with family and friends may be strained because of the social stigma. You may be asked to be part of the patient’s support system or called on to refer the patient to an appropriate source of support. You may need to supply additional triage or problem-solving support when others are not providing it. Many patients have trouble dealing with their own identity as the disease progresses. In many cases, dealing with HIV or AIDS has a physical component (i.e., weight loss, lack of energy), but also psychological and sociological aspects (i.e., becoming more dependent on others, fear of dying, fear of pain). Patients are wrestling with a lot of issues and may need some assistance sorting things out. Patients must also deal with misinformation and inaccurate perceptions about HIV and AIDS. People around them may not understand the various aspects of the disease or its treatment. It is hoped that pharmacists are not included in this misinformed group. We must keep up with the latest literature, since we know that many patients monitor what is being researched. You must determine what your role should be in assisting these patients. You may or may not feel comfortable becoming a close member of a patient support network or taking an active role in ensuring that patient needs are met beyond your professional responsibility to provide pharmaceutical care services. The key is to identify what the patient’s needs are and what services you can provide or referrals you can make to best meet these needs. Patients with Mental Health Problems Many pharmacists admit that they have difficulty in communicating with patients with mental health disorders. By the same token, many mental health patients may be reluctant to interact with other individuals. Some pharmacists feel that they do not know what to say to mental health patients. They are afraid to say the wrong thing or something that might cause an emotional outburst by the patient  in the pharmacy. Some pharmacists are also unsure of how much information to provide to such patients about their condition and treatment. Many times it is unclear what patients already understand about their condition and what their physicians have told them. Once again, open-ended questions are good tools to use to determine the level of patient understanding before you counsel them about their medications. Examples include “What has the doctor told you about this medication?” or “This drug can be used for different things. What has your physician said?” Asking open-ended questions also helps you determine patient cognitive functioning. That is, are they able to comprehend what you are saying, and can they articulate their concerns to you? If not, you may have to communicate through a caregiver. Some pharmacists may also be reluctant to distribute written information to patients receiving psychotropic medications for fear that patients may misinterpret the information. Another related concern is that many psychotropic medications are used for nonmental health disorders, such as imipramine for bed-wetting or diazepam for muscle spasms. Thus, the written material may not be relevant to the patient’s condition and may only cause alarm. It is important that you carefully screen all materials for their relevance to the individual patient before distribution and that you make an attempt to verbally reinforce the information to ensure a better understanding by the patient. Pharmacists interacting with patients with mental disorders must address a more fundamental ethical issue: should patients with mental disorders be allowed the same level of information regarding their drug treatment and the same type of informed consent as patients with nonpsychiatric disorders? Does the uniqueness of having a mental illness versus a physical illness preclude these patients from knowing more about the effects (both positive and negative) of their drugs? Do we withhold certain information that would be given to a nonpsychiatric patient? Obviously, each situation must be evaluated individually, and many times in consultation with the patient’s physician and caregiver. However, the issue is raised here because the way you deal with these questions affects how you communicate with mental health patients. In many situations, trusting relationships develop among patients, mental health practitioners, and pharmacists. In these cases, pharmacists can be key members of the patient’s care management team. Regardless, the pharmacist should be aware that the ethical responsibility is to provide patients with accurate information in a way that meets their needs to understand their treatments. Only with compelling reasons can a health professional ignore the principle that patients have the right to information about their treatment (a compelling reason may be that the patient is not competent to understand information and is dependent on caregivers to make decisions regarding their care). Unfortunately, certain stereotypes about mental illness and patients with these disorders tend to inhibit communication. People in general, as well as many pharmacists, have certain misconceptions about mental illness. We tend to categorize people based on images from the media or from beliefs we have formed about how “crazy” people act. Our reluctance is also reinforced by the fact that some patients indeed act “different.” They may have awkward body and facial movements (possibly due to their medications). Some are chronic cigarette smokers and have poor hygienic habits. They may make what we consider to be bizarre statements. They may not establish good eye contact, which may make us even more uncomfortable. Patients with mental illness may be reluctant to interact with pharmacists for a variety of reasons. First, they may have a poor self-concept and may be insecure about interacting with others. They may also realize that they have a condition that makes other people uncomfortable. Thus, this societal stigma about mental illness makes them avoid social interactions. In some cases, patients may be paranoid about dealing with other people, especially health care professionals. Thus, your attempts to communicate may find initial patient resistance. Patients with mental illness typically need multiple contacts to establish trusting relationships. However, you should realize that this may never happen and that your interactions may always be “different” compared with your relationships with other patients. These differences should be handled the same way that you deal with other unique individuals discussed in previous sections. Differences should not stop you from trying to interact with these special patients. However, the potential communication problems may require you to be innovative in developing strategies to overcome them. Suicidal Patients A patient who is being treated with hydrocodone for chronic back pain resulting from a previous injury asks you “What would be the fatal dose of this stuff?” What would go through your mind? What would you say? Undoubtedly, you would consider the possibility that the patient is suicidal. Yet you may not feel confident in your ability to communicate effectively with someone who could be suicidal. How can you tell whether the patient’s question represents a cry for help? Before discussing how you may respond in this situation, it would first be helpful to identify various myths surrounding suicide that may prevent people from offering help to a suicidal person when help is needed. Further information on the myths surrounding suicide is available at the American Association of Suicidology (www.suicidology.org), the National Institute of Mental Health (www.nimh.nih.gov/suicideprevention/suicidefaq.cfm), and the National Library of Medicine (www.nlm.nih.gov/medlineplus/suicide.html). Myth: “People who talk about committing suicide just want attention and do not actually kill themselves.” In fact, the majority of individuals who commit suicide have given warnings about their intent. Their clear statements or more subtle hints about wanting to end it all or feelings that others would be better off if they disappeared should be seen as a “cry for help.” They want someone to recognize their need and respond. Myth: “People who have actually attempted or committed suicide wanted to die.” Evidence is that individuals in a suicidal crisis are motivated by a desire to escape extreme psychological pain and feelings of despair. Their thinking has become so distorted that they believe the only way to escape the pain is to die. The cognitive constriction also leads them to lose hope that relief from their suffering is possible in the future or that effective treatment is possible. 

Myth:

 “Suicidal risk is greatest when individuals are in the depths of a major depressive episode.” Surprisingly, suicides often follow a period when people seem to be coming out of their depressed states. Family and friends are thus shocked because they thought the worst was over. Myth: “Asking depressed individuals whether they are suicidal is dangerous because it may get them to consider suicide when they hadn’t been thinking of it before.” The fact is that you will not put suicidal thoughts into people’s minds who have not been considering suicide. Asking about suicide will likely provide a sense that you care about them. If the patient who asks about the lethal dose of hydrocodone is not suicidal, he will clarify the reason for his question. If he is depressed or in despair (which often accompanies chronic, severe pain), your question may provide an opening for him to tell you what he is feeling. You can then provide the empathy, support, and information on sources of help that he needs. Myth: “Once a person decides to commit suicide, there is nothing anyone can do to stop him.” The reality is that the acute crisis is short-lived. However, effective treatment of the underlying depression (as well as the psychic and physical pain) is necessary to prevent future crises. When faced with someone you think may be suicidal, you must have the courage to talk about your concerns. Say to the patient who asks about the lethal dose of hydrocodone “I’m concerned about the reason behind the question. Are you thinking about killing yourself?” If the question is a cry for help, you have provided the opening for the patient to admit to needing help. Stay calm. Listen with empathy. Express your caring for the patient and your desire to help. Avoid arguing with him or trying to get him to justify why he feels the despair he obviously feels. Don’t discuss your own values or moral objections to suicide. Have someone stay with the individual until he is under professional care. Be familiar with sources of help in your community. Make a note in the patient’s profile about their statements and your conversations with the patient in case another colleague deals with the patient during the next encounter. This is especially important when patients are taking medications that exacerbate depression. You and your colleagues need to monitor these situations and to respond appropriately. If you are not sure about what help is available, call the crisis intervention or suicide prevention help lines that are prominently listed in the front of most telephone books. Help and advice are also available through the National Suicide Prevention Lifeline at 1-800-273-8255. Various websites provide information on recognizing suicidal intent and advice on responding to someone in crisis. These include: • The National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (www.cdc.gov/ncipc) • The American Association of Suicidology (www.suicidology.org) • The American Foundation for Suicide Prevention (www.afsp.org), the National Strategy for Suicide Prevention (www.mentalhealth.samhsa.gov/ suicideprevention) • Suicide Awareness Voices of Education (www.save.org) • The Suicide Prevention Resource Center (www.sprc.org) Patients with Low Health Literacy Low health literacy is a pervasive problem that impedes the ability of many patients to understand information we provide them about their medications. Health literacy is the ability to “read, understand and act on healthcare information” (AMA, 1999). Studies have found that 90 million Americans have limited health literacy (Nielsen-Bohlman et al, 2004). About 34% of English-speaking and 54% of Spanish-speaking American adults have marginal literacy. The average reading level in these populations is eighth grade, while most health information is written at the twelfth grade level. About 15% of patients with literacy problems are foreign born and 5% are learning disabled, which means that 80% of the population with literacy issues were born in this country and do not have a documented learning disability. To illustrate the extent of the problem, one study found that 42% of patients could not read and comprehend directions for administering a medication on an empty stomach (Williams et al, 1995). At the same time, health care professionals are largely unaware of the extent of the problem in society and in their own population of patients. Persons with limited ability to read and comprehend information are frequently embarrassed and fail to disclose this fact to health care providers. Due to the strong stigma associated with reading problems, many patients will make excuses or try to conceal that fact that they have trouble reading. Many patients with literacy issues have average IQs and function well in daily life, so detection is difficult. Unfortunately, health care providers typically fail to assess patients’ understanding of written information provided to them. However, several instruments have recently been developed to assess literacy, including the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Test of Functional Health Literacy in Adults (TOFHLA). See Chapter 8 for additional information regarding reading level assessment. The key to this dilemma is that poor health literacy is directly linked to patient safety. If patients cannot understand the material, then they are in danger of therapeutic misadventures and medication errors. The issue is so important that the U.S. Congress has proclaimed October as Health Literacy Month. As far as strategies to deal with this issue, some research has found that providing pictures with accompanying simple written instructions can improve comprehension of key medication instructions (Morrow et al, 1998). The United States Pharmacopeia (USP) has developed 81 pictograms that illustrate common medication instructions and precautions. These graphic images can be downloaded from the USP website (www.usp.org) and can be used by health care professionals to supplement written instructions for low literate or nonEnglish-speaking patients. In addition, the American Medical Association Foundation has produced a Health Literacy Introductory Kit for health care providers describing the scope of the health literacy problem and suggesting ways to overcome barriers to communicating with low-literacy patients (www.ama-assn.org). Hardin (2005) suggests that, among other things, pharmacists should have their patients repeat back instructions to ensure accurate transmission of information. Cultural Competence As mentioned earlier, you may be working with patients who are different than yourself. Some of these differences relate to culture and ethnic background. Thus, you must have sensitivity to the cultural differences in your diverse patient environment. This will become even more critical in the future since, according to the projected demographic changes in the United States, our country will become even more diverse. It is beyond the scope of this chapter to describe all the various cultures within the United States and their related beliefs about health care and medication therapy, but a few general guidelines are offered to assist you in developing your cultural competence and enhancing your ability to work with patients from diverse backgrounds. First, you may want to examine the cultural make-up of your practice catchment area. What are the predominant ethnic groups in the neighborhoods surrounding your practice site? What are their overall feelings about the accessibility and quality of health care? What is their trust level regarding health care in general and medication management specifically? You may want to speak with community leaders to assess general community beliefs. Together you may be able to develop strategies for interacting with the various groups. Learning more about these various cultures is a challenging but necessary task.