The role of patients and carers in medicines management

Chapter 7 The role of patients and carers in medicines management



CHAPTER CONTENTS


Introduction 107

Benefits and costs of modern medicines 107

Public, personal and professional perceptions 108

The Bristol Inquiry 109

Compliance of the patient 110

Non-compliance of the patient 110

Measurement of non-compliance 112

Significance of non-compliance 112

Factors in non-compliance 112

patients’ responses to problems with their medicines 112

Methods for improving patient compliance 113

Self-administration of medicines 116

Financial incentives 117

The role of social work home carers in the administration of medicines 117

Complementary and alternative medicine 118

Medicines in schools 118

Case study 119

Self-assessment questions 120


KEY OBJECTIVES


After reading this chapter, you should be able to:


• give reasons why demand for drugs is always rising

• discuss methods used nationally and locally to contain expenditure on drugs

• discuss what is meant by ‘postcode prescribing’

• identify sources of drug information available to the public

• discuss the ethical implications of drug testing on humans

• discuss how costs of drug therapy relate to patient outcomes

• define compliance in the context of drug therapy

• identify the factors that contribute to non-compliance

• distinguish between compliance and concordance

• discuss ways in which patient compliance may be improved

• discuss the precautions needed for and benefits to be gained from self-administration of medicines

• outline the role of home carers with regard to medicine administration

• discuss the issues concerning the giving of medicines in schools

• discuss the place of alternative and complementary medicines in society today.


INTRODUCTION



BENEFITS AND COSTS OF MODERN MEDICINES


Today, many patients are enjoying both a longer and better quality of life as a result of drug treatment. Perhaps the most dramatic example of this is the control of certain common infections that, 50 years ago, would almost certainly have had a fatal outcome. Drugs acting on the cardiovascular system, the newer insulins, oncolytics, improved anaesthetics, antiviral agents and psychotropic drugs have prolonged and improved life for many patients. In considering the advances made in drug therapy, the massive progress made in other aspects of health technology should not be overlooked (e.g. diagnostic and scanning equipment).


At a time when the resources available for healthcare are under great pressure, health service managers are required to examine carefully all competing demands. The drug bill is no exception to this process. There is a need for an informed public debate on this aspect of healthcare, especially when issues of rationing care and inequalities of provision may be involved. Patient pressure groups address such issues as inconsistent availability of anticancer drugs having a significant impact on the provision of care.


The National Institute for Health and Clinical Excellence covers England, and similar bodies have been established in Wales and Scotland. These bodies issue guidance on important new drugs, which is often reproduced in the British National Formulary.


Although most patients derive great benefit from their medicines, the search for the ‘magic bullet’ goes on, especially in oncology. All medicines have the potential to cause harm to the patient, even when used in standard doses. Many patients, especially older patients, suffer from more than one condition, resulting in multiple-drug therapy (polypharmacy). The risk of drug interactions therefore increases, but the risk of harm to the patient is low in well-managed situations because the professionals involved in the management of medicines take steps to protect the patient from such eventualities. Chapter 3 describes the vital contribution made by the nurse in helping to ensure that the patient derives benefit from the prescribed treatment.


Abuse of substances is of growing concern throughout the world, a particular concern being the use of so-called recreational and lifestyle drugs. Much drug abuse is based on the use of illegal substances, but medicines can be abused, with potentially devastating outcomes for misusers and their families. Dependency on drugs may arise as the result of prescribed medical treatment, but this is rare. Legislation is in place designed to reduce the likelihood of drugs being diverted for abuse (see Ch. 2).



PUBLIC, PERSONAL AND PROFESSIONAL PERCEPTIONS


Health promotion resources are targeted at prevention strategies such as a healthy lifestyle, but the belief that health can be achieved or maintained by the use of medicines is still widely held. All health professionals must seek to ensure that patients (and their carers) have realistic expectations of their drug therapy and know when and why drug therapy is needed. Surveys of public opinion clearly show that people want to be involved in decisions about treatment (Kelham et al. 2005).


Economic and other pressures have led to campaigns designed to encourage people to take more responsibility for their own health. One outcome of this is the increasing sales of proprietary medicines, both traditional and less orthodox. There can be no doubt of the importance of self-medication in healthcare. The NHS would collapse if all the demands for medicines had to be met from NHS resources alone. There are dangers in assuming that proprietary over-the-counter medicines are completely safe and can be treated as placebos. As more medicines are made available for sale without prescription, the possibility of drug interactions must be borne in mind.


The use of complementary and alternative medicine (CAM) appears to be increasing. Issues relating to CAM are discussed on page 118.


One key objective of the NHS is to provide patients with comprehensive information about all aspects of their treatment. Linked with this is the need to ensure that patients and their carers have all the necessary information to enable courses of drug treatment to be completed successfully. A coordinated approach between professionals is called for on the provision of relevant non-conflicting information. The recognition of the need for a wider range of information on treat-ment is a product of both consumer pressures and changing attitudes within the professions. Care is needed to ensure that the information needs and views of ethnic minorities are recognised and responded to. In all situations, it is important to avoid information overload.


As yet, prescription-only medicines cannot be advertised to the public in the UK. In the USA, such advertisements are allowed and free telephone numbers offer callers a detailed information service. Website addresses are given where detailed information can be accessed. The use of Internet search engines can yield much detailed information on current drug treatments. There can be no doubt that patients and their carers are much better informed today than they were in the early years of the NHS.



PERSONAL FACTORS


The realisation that patients and their families hold, and are entitled to hold, their own beliefs about treatment was recognised by the Patient’s Charter (Scottish Office Home and Health Department 1991). Patients (and their families) can formulate views on a proposed treatment only if they are in possession of relevant information about the condition, nature and effects of the treatment, alternatives available and consequences of not accepting treatment. The right of the patient or client follows the principle of informed consent, which is based on the individual having the necessary knowledge to make a decision (Nursing and Midwifery Council 2004). There may be situations, however, when it is in patients’ best interests not to provide full information on their drug therapy.


From time to time, it may be necessary to change a patient’s drug therapy, the reasons for which must be clearly explained to the patient by the prescriber. A medicine that has proved to be highly successful in treating a particular condition plays an important part in the patient’s life. There may be an understandable reluctance on the part of the patient to accept the change. Nurses can play an important part in providing the patient with any necessary reassurance when drug treatment is changed for whatever reason. It should be remembered, too, that the patient has the right to refuse to take the medication. Were this to happen, details of the refusal must be documented. Major problems could arise if insulin or high-dose corticosteroids, for example, were refused.


Ethnic minority groups may have special needs and concerns that must be recognised and met. Cultural barriers may inhibit access to mainstream healthcare. In order to overcome these barriers, novel approaches may be needed. Moberly (2005) describes a service for the review of medicines within a mosque.



SOCIAL FACTORS


The ethical issues relating to medicines with which society is confronted raise many questions. For example, should the pharmaceutical industry be making profits out of illness? Some argue that profits from innovation and high levels of capital investment must be rewarded. Dependence, addiction and over-reliance on drugs raise doubts in the minds of many health professionals. Nurses will enter the debate on the ethical aspects of the use of medicines as part of their professional role. Local ethics committees provide guidance on specific matters, particularly on clinical trials. There may be situations in which, on religious grounds, a nurse cannot be involved in a particular form of treatment. This stance has to be respected and accepted by colleagues without any form of sanction being applied. Nurses in such situations will receive the support they need but, as always, the best interests of the patient must be served.



PROFESSIONAL FACTORS


Nurses want to be able to help their patients get better. There are factors, however, that must be considered before deciding which is the best treatment (or indeed whether or not to treat the patient at all). For example, the decision may be influenced by the likely side effects, the risk of dependence on the drug, the age of the patient and the patient’s prognosis.


Downwards pressure on prescribing costs must not be allowed to compromise patient care. Well-researched, evidence-based prescribing policies must take into account cost factors, but all healthcare professionals have a duty to provide the best for their patients in the light of the current state of knowledge. When to withhold treatment may be a more difficult decision than when to initiate treatment.


Medical misadventures may also have a profound and long-term effect on all those unfortunate enough to be involved. Even with more enlightened policies on such matters as drug errors, health professionals may suffer from a lack of confidence that may need expert professionals’ help to overcome (see Ch. 6).



THE BRISTOL INQUIRY


The Bristol Inquiry, which examined many failures on the part of cardiac surgeons and others, made numerous recommendations regarding the importance of health professionals treating all patients as partners by regarding them as ‘equals with different expertise’ (Coulter 2002). Key recommendations in the report of the inquiry are given in box 7.1.



Box 7.1 Bristol Inquiry report recommendations


(From Anonymous 2001, with permission.)



• Involve patients (or their parents) in decisions.

• Keep patients (or their parents) informed.

• Improve communications with patients (or their parents).

• Provide patients (or their parents) with counselling and support.

• Gain informed consent for all procedures and processes.

• Elicit feedback from patients (or their parents) and listen to their views.

• Be open and candid when adverse events occur.

Although these recommendations were made following major failures in the provision of paediatric cardiac surgery services, the principles involved can be used to encourage greater responsiveness to the needs of patients by all those involved in the provision of drug therapy. Healthcare professionals carry out many functions that help to ensure a good outcome of a patient’s drug therapy. However, without the active participation of the patient (and parents or carers), optimal results of the treatment may not be achieved.


The recommendations in box 7.1 provide the necessary broad guidance for health professionals that, if followed, will help to ensure the achievement of an effective partnership with patients’ concordance. Involving patients more in decision making has many benefits, not least in improving patient safety. Prescribing errors could be reduced by actively involving patients in their own care (Coulter 2002). It is recognised that, to achieve this, resource implications will have to be met and cultural and technical barriers overcome (Coulter 2002). Electronic access by patients to a range of relevant information may be the way forward (Coulter 2002). Patients may also become involved in the training of those involved in the provision of healthcare. The concept of the expert patient is being developed. Selected patients suffering from a chronic disease are given short training programmes in anatomy, physiology and the disease process. Drawing on this training and, above all, their own experiences, patients are then able to provide inputs on a range of matters into the training of medical students, doctors and other healthcare professionals.


The key recommendations of the Bristol Inquiry and the implications of these should be kept in mind when reading this chapter.



COMPLIANCE OF THE PATIENT


An essential component for the successful outcome of any treatment plan, drug or otherwise, is the patient’s compliance with the prescriber’s advice and directions. The compliance of a patient can be defined as the ‘extent to which the patient’s behaviour coincides with medical or health advice’ (Sackett 1976). The term patient compliance is often considered to be unsatisfactory, because it has overtones of coercion or compulsion and does not include any reference to treatment outcome. Alternative, less-threatening terms that have been proposed include therapeutic alliance and treatment adherence (Blackwell 1976). At no time will the term compliance be used here with any implications of coercion of the patient. Increasingly, an approach (concordance) based on a partnership in medicine taking is advocated as a framework for improving patient care.


The key aspects of concordance are:


• there is an understanding of and respect for the patient’s view on his or her medicines

• healthcare professional explores/understands the patient’s view

• an equal partnership is formed, i.e. patient/healthcare professional

• an agreed plan that incorporates the above is formulated

• in the event of no agreement on the way forwards, the healthcare professional should offer further discussions

• the patient’s decision on whether or not to take the medicine/use the therapy is respected

• differences between patient and healthcare professional are recognised

• the whole process depends on consultation – it is a two-way process

• the whole process is patient-centred.

Nurses in both community and hospital practice are well placed to help patients comply with the medical advice and instructions they are given regarding drug treatment. Often, the nurse is the only health professional who has continuing contact with the patient over long periods. As a result, the nurse is able to gain an understanding of the patient’s difficulties, offer advice and monitor compliance.



NON-COMPLIANCE OF THE PATIENT


A very crude indication of the extent of non-compliance may be obtained when surveys are undertaken on the vast quantities of prescription medicines returned to pharmacies by patients.


Many studies have been published that demonstrate in detail the extent of non-compliance with directions regarding drug treatment. In long-term therapy, compliance is often inadequate. Patients taking antiepileptics achieved a 76% compliance level, which fell to 39% when the dosage schedule was changed from 8-hourly to 6-hourly (Cramer 1989). With short-term therapy, the position may generally be better. Studies by Donabedian and Rosenfeld (1984) and Mushlin (1972) showed that up to 75% of patients complied with their directions. Few studies relate the extent of non-compliance to the failure to achieve the desired therapeutic outcome. Nevertheless, non-compliance should always be considered as a possible reason for the failure of treatment.


Some patients may need extra help in managing their medicines, because of a disability. The Disability Discrimination Act 1995 applies to many aspects of everyday life, including the supply of medicines. Disabled people have a right to be treated no less favourably than other people. Pharmacists are required to provide the extra help a disabled person may need, for example by providing an aid to the use of medicines (see Table 7.1).


Table 7.1 Factors contributing to non-compliance





































































Factor Comment(s)
Personal factors
Patient’s belief as to value of therapy Patients from all groups of society may have particular views which are influenced by many factors.
Ethnic aspects May conflict with mainstream western medicine.
Relationship with health personnel involved Patient’s faith in prescriber, especially, often influences outcome.
Ageing process Loss of recent memory, physical disability, etc. may contribute to non-compliance.
Some psychiatric illnesses Schizophrenia, for example, may bring particular problems.
Pressures of a busy life Especially hard to comply when several daily dosage intervals are involved.
Poor understanding of regimen Increasingly, patients may be receiving multiple therapy and may lack the ability to manage a complex regime.
Limited knowledge of condition This may arise due to poor explanations by health professionals or denial.
Social factors
Isolation May arise from a breakdown in the family structure.
Deprivation Some patients have to contend with a difficult journey to the surgery or pharmacy.
  Older people often have to contend with multiple deprivation and are more vulnerable when things do go wrong with their medicine taking.
Poverty Patients who cannot afford prescription charges will probably need help and guidance not only with use of medicines but with the social security system also.
Factors directly related to medicines
Tablets Large tablets may be difficult to swallow; very small tablets may be difficult for a patient with stiff fingers to pick up.
Liquid medicines Liquid medicines may have an unpleasant taste, colour or “feel” in the month. Many liquid medicines that are used by older patients are formulated for children. Highly coloured, sweet, sickly flavours are generally not very acceptable to older patients, even if children find them acceptable, which often they do not. Measuring liquid medicines will be difficult for many patients, as will handling a 500-mL glass bottle of liquid medicine that may weigh almost 1 kg.
Topical preparations Stiff ointments may be difficult to use, or there may be difficulty squeezing creams or ointments out of a tube. Products that stain the the patient’s linen,shower or bath may prove unacceptable.
Packaging Child-resistant packaging is difficult for many people, although its use has reduced accidental poisoning of children significantly.
Labelling Labelling systems have been improved with the introduction of machine-printed labels for all dispensed medicines, but the small print on some labels may be impossible for some patients to read.
Prophylactic medicines Medicines prescribed for prophylaxis may not always be taken as prescribed, because the patient does not feel the benefit directly, e.g. malarial prophylaxis.
Unpleasant side effects Unpleasant side effects such as headache and nausea may, undoubtedly, be a cause of non-compliance.


MEASUREMENT OF NON-COMPLIANCE


Many difficulties are presented when measuring or assessing patient compliance. The methods available vary from the basic tablet count to the use of electronic monitoring devices (Punchak et al. 1992) and the measurement of the drug (or metabolite) in body fluids. The methods available are listed under two headings: first, methods that are normally available to the nurse, and second, those methods that require considerable technical back-up and are applicable only in structured investigations into patient compliance.



METHODS OF COMPLIANCE ASSESSMENT AVAILABLE TO THE NURSE



• General impressions of the patient’s understanding of the drug regimen.

• Tablet counts at suitable intervals.

• Physiological markers (e.g. pulse rate in digoxin therapy).

• Visible presence of drug or metabolites in urine or faeces (e.g. rifampicin produces a reddish discoloration of the urine).


METHODS OF COMPLIANCE DETERMINATION



• Chemical methods of determination of metabolites in body fluids.

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May 13, 2017 | Posted by in NURSING | Comments Off on The role of patients and carers in medicines management

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