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.