Ethical Challenges Pharmacists Face When Managing Noncompliant Patients

Adverse effects of medications can irrefutably steer a patient away from taking their medication. This can threaten the patient’s beliefs about the effectiveness of their medication; consequently, having a negative influence on the patient’s autonomous decision and adherence to their medication. This paper will investigate the ethical challenges pharmacists combat when a patient refuses to take their maintenance medication due the adverse events and will establish the best course of action that coincides with the Code of Ethics for Pharmacists.

Poor compliance in patients due to medication adverse events is remarkably prevalent, ranking in as one of the most common reasons for noncompliance. Patient noncompliance is also derived from a multitude of different factors including the depth of patient knowledge, health literacy, and the patient-healthcare provider relationship.¹ This brings light to the healthcare providers who must support and encourage the dignity and autonomy of the patient and who must also be committed to the welfare of the patient. However, healthcare providers generally assume patient’s compliance, overlook patient autonomy, and blame the patient for their poor health outcomes.² Thus, it is necessary to regard the ethical issues stemming from patient’s beliefs about their medication and health as well as the healthcare provider’s stance on compliance barriers. This paper will explore the ethical challenges surrounding healthcare providers, particularly pharmacists, when managing a noncompliant patient and how pharmacists can apply the Pharmacist’s Code of Ethics to resolve an ethical issue concerning a patient who is refusing to take their maintenance medication due to the adverse events.

A male patient with late-onset type 2 diabetes has been admitted to the hospital due to hyperglycemia and diabetic foot ulcer as a result of not taking his metformin. This patient has a long history of being noncompliant with his medications due to the side effects. According to the patient, the metformin made him use the bathroom excessively throughout the day, which decreased his overall quality of life; therefore, he has discontinued his metformin several weeks ago, and he does not feel comfortable with continuing his medication any further. The pharmacist involved in the patient’s care was unaware that the patient discontinued his maintenance medication. The patient mentioned that he did not feel the need to raise his concerns about his abrupt discontinuation of the medication to anyone.

When a patient refuses to take his or her maintenance medication that is used to treat their chronic illness due to experiencing the common adverse effects, it is undeniably a large ethical problem for everyone involved in the patient’s healthcare. Accordingly, it is critical to identify who all is involved and affected in the ethical issue. In this situation, the patient is largely involved because the patient made an independent choice that valued self-direction to abruptly discontinue his maintenance medication, which undesirably led to a very serious and detrimental health outcome. Hence, patient autonomy, otherwise recognized as the right to self-determination, is fundamental in this case. The healthcare professionals, predominantly with focus to the pharmacist, involved in this patient’s healthcare are also affected since they could have appropriately informed the patient at the start of his drug therapy and helped him achieve optimum benefit from his metformin and reach his peak health. Fortunately, there are no illegal acts committed by the individuals involved in this case. Nonetheless, because there were no clear therapeutic alliance established between the patient and the pharmacist from their first encounter, the pharmacist in this case has failed to uphold their moral obligations to help shape the patient’s autonomous decision and to preserve and enhance the welfare of the patient. This therefore signifies that the pharmacist did not value benevolence, rapport, dependability, or guidance that must all be respected within a professional code of ethics.

There are two viable plans of action that the pharmacist can partake in this scenario. One course of action is to engage in a consultation with the patient regarding his medication, to evaluate the patient’s awareness about the complications that accompanies his chronic illness, and to discuss the importance of taking his maintenance medication.

Buerki and Votter (2002) encourage pharmacists to conduct patient consultation in a private setting in order for the pharmacists to be entirely attentive to the patient during the patient encounter.³ This can unquestionably be implemented in this plan of action to create a patient-centered environment and to nurture the good of all patients in a confidential manner as according to the Code of Ethics for Pharmacists.⁴ The pharmacist can concurrently apply the code of ethics to establish a connection with the patient by providing information in a manner that is understandable to the patient and by expressing their empathy to recognize the patient’s needs. By being empathetic, the pharmacist will be able to confirm their understanding of the patient’s circumstances and make an effort to remedy the patient’s concerns. The pharmacist can also assess the depth of the patient’s knowledge regarding his chronic illness and his medication. The patient would hopefully be able to make an informed decision about their health by the end of the consultation as specified in medical ethics. According to Mitchell and Selmes (2007), recognizing the patient’s preferences and concerns, forming trust, and clarifying the benefits and risks of medication therapy to the patients greatly improves compliance.⁵ Thus, approaches such as having an open discussion with this patient could truly improve his adherence to his medication.

Another plan of action can be for the pharmacist to provide the patient with the option for an alternative drug therapy that has the potential for fewer side effects. The pharmacist can achieve this by first contacting the patient’s prescriber. The pharmacist can either directly propose an alternative drug to the prescriber or consult another colleague about an alternative medicine that is appropriate for this patient and subsequently suggest the new recommendation to the patient’s prescriber. The pharmacist must do so with respect to the other healthcare professional’s values and skills as per the Code of Ethics for Pharmacists. ⁴ In this plan of action, the pharmacist altruistically recognizes that it is urgent to put forth the patient’s best interests by resolving the patient’s primary concern about the side effects of his metformin.

In agreement with Keszthelyi and Blasszauer (2003), it is important not to provide the patient with unreliable information and false hopes, as it is crucial to earn the patient’s trust in order for the patient to ultimately comply with the pharmacist’s recommendations. ⁶ Therefore, the pharmacist must act with veracity and provide honest, but sufficient information about the new drug and its potential for side effects to the patient. The pharmacist in this case is more accepting of the patient’s resistance to their therapy. They are protecting the patient’s dignity by allowing the patient to discover his own barriers in a supportive setting as well as pursuing the patient in an unaggressive manner about his noncompliance.

The most optimal approach for resolving this ethical dilemma would be for the pharmacist to adhere to the Code of Ethics for Pharmacists, earn the trust and cooperation of the patient, and subsequently take the time to explain to the patient about his chronic illness along with the importance of taking his maintenance medication. By supporting patient autonomy and exploring patient ambivalence, the pharmacist can help in reducing defiance to treatment, give reassurance to the patient that it is completely up to him, and help the patient to reflect on the advantages and disadvantages of making a change to his health choices. According to Butterworth (2008), embracing a patient-centered approach is the most critical segment in improving the patient’s health and achieving patient compliance. ⁷ This approach will allow the patient to appreciate and believe in the pharmacist who genuinely wants to understand their illness and to help them explore their uncertainty to change. Thus, this plan is the key to building the ethical based pharmaceutical care in a covenantal relationship-based way that can positively impact the patient’s autonomous decision-making process.

The second plan of action could perhaps work for this situation only if the patient confirms that he has a problem with a certain side effect that is absent in an alternative medication. However, choosing a different medication will not rid of the potential for adverse effects since that all medications come with its own fair share of side effects. The main issue in this case is that the patient is noncompliant to his medication because of the adverse effects; thus, it is highly probable that the patient will fall back into his old habits and not take the alternative medication as well given his past medication history. Regardless of the patient having the last say in his autonomous decision, the patient only has a small fraction of liberty in his decisions about his medication if a pharmacist does not intervene. This is because the patient’s informed decision is initially molded for him by the pharmacist’s action, which depends heavily on whether the patient was educated about his medication or not. Clifford, Barber, Elliott, Hartley, and Horne (2006) all discovered that there are many benefits when a pharmacist fulfills the patients’ needs for advice and information on their medication.⁸ Their research findings demonstrated that non-adherence as well as the sum of patients reporting medicine-related issues was significantly lower in those who received these services from a pharmacist and that these patients had a much more positive outlook and belief about their medication than those who did not receive consultation from a pharmacist. Therefore, a patient-centered advice from a pharmacist would be the most effective in improving this patient’s compliance to his medicine.

In summary of how the action plan will be carried out, after the pharmacist assesses the patient’s knowledge about his metformin, the pharmacist can then educate the patient on the dangers of uncontrolled glucose levels and worsening foot ulcers. By providing this education, the pharmacist is increasing awareness and clarity about the chronic illness to the patient. The pharmacist can also advise the patient on the benefits of taking metformin with a meal and at the same times each day to decrease the gastrointestinal side effects, which should also subside after a couple of weeks of use. Once earning trust from the patient, the pharmacist can inform the patient that his refusal to take his metformin was the primary cause for the complications of his diabetes that lead to his hospital admission. With that in consideration, it would be important to also let the patient know that the mild gastrointestinal problem is far less harmful, and that the patient should continue his current therapy to prevent deterioration of his conditions. The pharmacist could additionally counsel the patient on the step-by-step details of diabetes self management education, as it is essential to maximize the effectiveness of his anti-diabetic drug. Eventually, the patient will be persuaded that the pharmacist really does want what is the best for him.

The pharmacist may also run into several objections during the encounter with the patient and must appreciate that not all patients will respond to the information provided to them the same way. It is essential for the pharmacist to routinely practice the ethical principles that can help circumvent any actions that can compromise their commitment to the best interest of their patient. It is also important for the pharmacist to act with conviction of conscience. As previously mentioned, it is imperative not to provide too much information as this can weaken the patient’s autonomy, which can then lead to poor compliance from the patient. Information provided to the patient regarding their drug therapy must be accurate and easy to understand as according to the Code of Ethics for Pharmacists⁴; however, it should not generate fear or panic as it can possibly further damage the patient’s beliefs about his healthcare.

The ethical challenges concerning a noncompliant patient who refuses to take their medication due to the adverse effects is multifaceted for pharmacists. Evidently, a pharmacist must always display empathy, encourage autonomy, and show compassion when connecting with the patient. The patient’s trust in their pharmacists is a vital element to the patient-pharmacist relationship. Given that the interest in the well-being of the patient is one of the fundamental qualities of a pharmacist, the pharmacist’s definitive objective is for this patient to achieve the maximum desired effects from his medication and to help relieve the patient’s concerns about their health. Nevertheless, despite all the best intention and efforts from the pharmacist, these desired effects are not always reachable if the patient chooses not to be compliant to his medication.¹ Therefore, it is critical for pharmacist to make a good professional judgment by upholding the ethical principles involved in healthcare and to deliver the deeds of beneficence to all patients by respecting the patient-pharmacist’s covenantal relationship.

References

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3. Buerki RA, Vottero LD. Ethical Responsibility in Pharmacy Practice. Madison, WI: American Institute of the History of Pharmacy; 2002.

4. Code of Ethics for Pharmacists. American Pharmacists Association. 1994;34(8):79. doi:10.1016/s0160-3450(15)30342-1.

5. Mitchell, A. J., & Selmes, T. Why don't patients take their medicine? Reasons and solutions in psychiatry. Advances in Psychiatric Treatment, 2007;13(5), 336-346. d

6. Keszthelyi S. Challenging non-compliance. Journal of Medical Ethics. 2003;29(4):257-259.

7. Butterworth SW. Influencing Patient Adherence to Treatment Guidelines. Journal of Managed Care Pharmacy. 2008;14(6 Supp B):21-25. doi:10.18553/jmcp.2008.14.s6-b.21.

8. Clifford S, Barber N, Elliott R, Hartley E, Horne R. Patient-centered advice is effective in improving adherence to medicines. Pharmacy World and Science. 2006;28(3):165-170.