Patient involvement in therapeutic decision process

Sri Suryawati Department of Clinical Pharmacology

Objectives of the session

After attending this lecture, students are expected to be able to:
1. 2. 3. 4. Explain the importance of patient involvement Explain the patient rights on therapeutic decision Explain the steps in therapeutic decision process Explain techniques to involve patients in therapeutic decision process

A case study
A 60-year old woman with atrial fibrillation, heart failure, hypertension, diabetes mellitus, osteo-arthritis, depression and insomnia, who has an acute urinary infection received the following prescription: Propranolol 80 mg 3xday Bendrofluazide 10 mg 1xday Digoxin 0.25 mg 1xday Ibuprofen 400 mg 3xday Chlorpropamide 250 mg 1xday Cotrimoxazole 2 tabs 2xday Amitryptiline 25 mg 3xday Nitrazepam 5 mg night only

How will she organize the medication..???

Patients adherence to treatment

Studies shown that about 50% of what doctors prescribe for chronic illness does not get taken About the same percentage was found for each indication studied, e.g., hypertension, glaucoma, hypercholesterolaemia, etc.

Factors affecting patients adherence to treatment

Why do I have to take this drug? I doubt this is a good drug

She is nice, but her prescription is too simple..

..too expensive, I cant afford..

too complicated..
Drugs wont help, this is a curse

To minimise non-adherence.

Simplify dosage regimen Involve patients in therapeutic decision process

Patients rights
Patients have a right to determine what happens to their own bodies (WHA 47) Patients have a right to be given information about medicines they are prescribed, and patients should have access to appropriate and understandable information about medicines and their side effects (WHA 47) Patients have a right to be fully informed about the potential benefits and risks of the medicinal products before they are prescribed (WHO, 1994) Patients have a right to be fully informed about the proposed medical procedures, together with the potential risks and benefits of each procedure, about alternatives to the proposed procedure, including the effect of non-treatment (1994).

Your patients are not illiterate.

Town
Clinics 2% Hospital 1% Neighborhood Store 40% Doctor 7% Drugstore 35%

MEDICINES (n=1324)
Neighbors and Relative 5% Household Stocks and Free Clinics 8%

80%..!

10%..!

Neighborhood
Anita Hardon, 1991

Problems in communication
Gaps between doctor-patients in social level or language Doctor fails in providing enough consultation time Lack of skills in retrieving information from the patient Mis-interpretation of information Patient does not agree with the treatment Patient forgets the information/instruction Patient is not capable to do the instruction Information/instruction is too complicated Information/instruction is incomplete Patient has inconvenient experience with the doctor Etc.

Doctors bias

about the patients

Doctors think that patients have the same concepts about illness and disease etiology Doctors think that patients have the same concepts about cure Doctors think that patients understand the doctors language Doctors think that when patients say yes (or nod), it means they agreed or understood Etc..

Different concepts

about illness/disease etiology

Different people have different concepts of disease
Evil eye, bewitching. . Faith, immorality..

Bacteria, viruses..
Cold, heat, wind..

Differen t foods..

Different concepts of cure

Destroy bacteria? Remove symptoms? Take away visible lesions? Control measured signs, e.g., blood pressure? Etc?

Different concepts

about the value of medicines

Colors: blue, red, green, yellow? Forms: tablet, capsule, injection, suppository? Taste: sweet, Pain relief score after taking different colors of placebo bitter, sour, tasteless? Price? Source? Packaging? Provider? Time (hours) Huskisson, BMJ 1974 Etc..?
2 1.5 1 0.5 0 0 1 2 3 4 5 6

Effect of

promotion and marketing

Direct promotion to consumer of even prescription drugs is common Advertisements usually promote brand names, may be inaccurate or misleading Consumers are very sensitive to some advertising messages

Six steps of

therapeutic decision process

(WHO, 1994)

Step 1: Define the patients problem Step 2: Specify the treatment objective Step 3: Select medicine Step 4: Start the treatment Step 5: Give information to the patient Step 6: Monitor (or stop?) treatment If you start talking to patients at step 5, it is too late..!!!!

Discuss with your patients.

Nature of the disease Treatment objective(s) Choice of treatment, including non-drug treatment Benefits and risks of treatment, including those of no-treatment Dosage regimen Treatment cost How, when to monitor the result of treatment

Unlimited

techniques to involve patients

1.
2. 3. 4.

Share with the patients what is in your mind

(Yati Sunarto, Senior Pediatrician)

Ask the patients opinion when you have options

(Inu Wicaksono, Popular Psychiatrist)

Make encouraging statements, e.g.,

You are absolutely right, could you tell her not to ..

Use open-ended questions to check understanding

Correct: Incorrect: Correct: Incorrect: could you tell me how would you take this suppository? you know how to take this suppository, dont you? when will you see me again? come again next week, OK

5.

Etc?

Techniques to check adherence

Counting pills Monitoring therapeutic effect Simple technique to monitoring drug concentration:
Color of urine Smell of urine