patient involvement in therapeutic

7/30/2019 Patient Involvement in Therapeutic

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Patient involvement in

therapeutic decision process

Sri SuryawatiDepartment of Clinical Pharmacology


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Objectives of the session

After attending this lecture, students are expected to be

able to:

1. Explain the importance of patient involvement2. Explain the patient rights on therapeutic decision3. Explain the steps in therapeutic decision process4. Explain techniques to involve patients in therapeutic

decision process


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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 1xdayDigoxin 0.25 mg 1xday

Ibuprofen 400 mg 3xday

Chlorpropamide 250 mg 1xday

Cotrimoxazole 2 tabs 2xday

Amitryptiline 25 mg 3xdayNitrazepam 5 mg night only

How will she organize the medication..???


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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.


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Factors affecting

patients adherence to treatment

Why do I have to

take this drug?

She is nice, buther prescriptionis too simple..

I doubt this isa good drug

Drugs wont help,this is a curse

..too expensive,I cant afford..

toocomplicated..


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To minimise non-adherence.

Simplify dosage regimen

Involve patients in therapeutic

decision process


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Patients rights

Patients have a right to determine what happens to their ownbodies (WHA 47)

Patients have a right to be given information about medicines theyare prescribed, and patients should have access to appropriate

and understandable information about medicines and their sideeffects (WHA 47)

Patients have a right to be fully informed about the potentialbenefits and risks of the medicinal products before they areprescribed (WHO, 1994)

Patients have a right to be fully informed about the proposedmedical procedures, together with the potential risks and benefitsof each procedure, about alternatives to the proposed procedure,including the effect of non-treatment (1994).


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Your patients are not illiterate.

Anita Hardo n, 1991

MEDICINES

(n=1324)

Town

Neighborhood

Hospital 1%

Doctor 7%

Clinics 2% Drugstore 35%

Neighborhood

Store 40%

Neighbors andRelative 5%

Household Stocks

and Free Clinics 8%

80%..!

10%..!


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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.


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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 conceptsabout cure

Doctors think that patients understandthe doctors

language

Doctors think that when patients say yes (or nod), itmeans they agreed or understood

Etc..


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Different concepts

about illness/disease etiology

Different people have different concepts ofdisease

Bacteria,viruses..

Cold,heat,wind..

Evil eye,bewitching.

.

Faith,immorality..

Different foods..


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Different concepts of cure

Destroy bacteria?

Remove symptoms? Take away visible lesions?

Control measured signs, e.g.,blood pressure?

Etc?


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Different concepts

about the value of medicines

Colors: blue, red, green, yellow?

Forms: tablet, capsule, injection, suppository?

Taste: sweet,

bitter, sour,

tasteless?

Price?

Source? Packaging?

Provider?

Etc..?

0

0.5

1

1.5

2

0 1 2 3 4 5 6

Pain relief score after taking differentcolors of placebo

Time (hours)Huskisson, BMJ 1974


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Effect ofpromotion 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


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Six steps of

therapeutic decision process

Step 1: Define the patients problem

Step 2: Specify the treatment objectiveStep 3: Select medicine

Step 4: Start the treatment

Step 5: Give information to the patient

Step 6: Monitor (or stop?) treatment

(WHO, 1994)

If you start talking to patients at step 5, it is too late..!!!!


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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


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Unlimited

techniques to involve patients

1. Share with the patients what is in your mind(Yati Sunarto, Senior Pediatr ician)

2. Ask the patients opinion when you have options(I nu Wicaksono, Popular Psychiatri st)

3. Make encouraging statements, e.g.,You are absolutely right, could you tell her not to ..

4. Use open-ended questions to check understanding

Correct: could you tell me how would you take this suppository?

Incorrect: you know how to take this suppository, dont you?

Correct: when will you see me again?Incorrect: come again next week, OK

5. Etc?


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Techniques to check adherence

Counting pills

Monitoring therapeutic effect

Simple technique to monitoring drug

concentration:

Color of urine

Smell of urine

patient involvement in therapeutic

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