The purpose of this article is to explore some of the processes involved in prescribing, from awareness of the patients pathophysiology, through appointment and decision-making to the provision of treatment. The author's rationale for choosing anticoagulation as the topic for discussion, is that but the author's field of practice is mainly with patients who've ischaemic cardiovascular disease, upon researching the practice log it became apparent that advancements within the author's role were leading the writer to take part more in the attention of patients with atrial fibrillation.
To highlight dialogue and hyperlink theory to apply the author use four case studies of patients accepted to a district general clinic, who subsequently were diagnosed with atrial fibrillation and due to the nature of the problem, were offered anticoagulation for the prevention of future thromboembolic events. The above processes will be reviewed under the headings of the training results below.
Evaluate effective record taking, analysis and appointment skills with patients/ clients, parents and carers to inform working/differential diagnoses.
Integrate a distributed approach to decision making taking bank account of patients/carers wishes, values,
Religion or culture.
Traditionally patient consultations have been performed with the doctors taking the more dominating role (Lloyd & Bor 2009). These consultations have been doctor-centred, building a examination and treatment plan without involving the patient in the decision making process. At the moment this was accepted by the patient because 'the doctor is aware of best' and the individual handed over responsibility for his well-being to the clinician. However this has now transformed and patients tend to be more considering their illnesses, curious about more and be involved in their treatment ideas. Increasing evidence shows that a far more patient-centred style of consultation results more happy patients who will stick to their treatment plans (Stewart et al 2003).
The author was able to observe her specified physician (DMP) in a number of patient connections but mainly during the process of discussion, for the purpose of establishing medical diagnosis and treatment ideas, (see appendix for case studies). Consultations are made up of a number of elements such as establishing a rapport, gathering and interpreting information and physical assessment, nevertheless the cornerstone of most patient interactions is effective communication.
Prior to each consultation, the DMP prepared by studying the medical information to acquire information about the patient's previous and present record, medications and allergies. At this stage consideration was presented with to potential treatment strategies or required checks. The patients in case studies 1-4 were all admitted to hospital anticipated to either new onset of symptoms or deteriorating specialized medical condition, thus each discussion was held at the bedside. Hastings (2006) outlined the value of recognising the different settings within which a consultation can occur and exactly how these settings can affect the individual and practitioner. That is a view shared by White (2002) who thought that the surroundings can greatly affect the discussion process.
Upon researching the literature the writer has found that there are many different approaches that can be adopted and various consultation models that can be utilised, to be able to produce the most effective consultation. The author sensed that the DMP's methods of consultation spanned several models. It incorporated elements of the biomedical model described by Byrne & Long (1976), where they express six phases which made a logical composition, but have a very doctor-centred way (see appendix). Charlton (2007) argues however, that whilst this model is simplistic and logical it offers difficulty accommodating the thoughts, values and psychosocial issues which color the meaning of health and condition. The consultations also included elements of a lot more patient-centred models as defined by Pendleton et al (2003) and Calgary-Cambridge (1996), see appendix *&*. These models aim to achieve a collaborative knowledge of the patient's problems. The author's DMP blended traditional ways of history taking with organized physical enquiry and examination, to elicit information about the patient's medical, social and family histories, together with medicine and allergy information, and the patient's point of view regarding their record and presentation of symptoms. After the history was obtained the physical assessment was performed to complement the diagnostic process. In each case the examination was cardiovascular, paying particular focus on the auscultation of center may seem, because in atrial fibrillation the exclusion of a valvular element is necessary prior to commencing anticoagulation.
In accordance with the models used, prognosis was founded and mentioned with the individual. The DMP used simple terminology to ensure understanding. The use of non-verbal communication was apparent throughout each discussion, from the outset where introductions and shaking hands took place, to the utilization of empathy and touch when the patient showed anxiety and stress. The history taking process may have involved a doctor-centred procedure but the discourse surrounding treatment options was certainly patient-centred. In each assessment the plan between your patient and the DMP was negotiated, with the DMP detailing the risks associated with atrial fibrillation, and being honest with the patient about the risks versus advantages of anticoagulation. Charlton (2007) thinks that it's important to elicit a patient's concerns and targets in order to ensure that both patient and the doctor's agendas are the same. This is reinforced by Neighbour (2005) who explained that, "Patients vary generally in their factual knowledge, in their values, their attitudes, their habits, their ideas, their values, their self-images, their common myths, taboos and traditions. Some of these are relatively labile and easy to change on a day to day basis, others will be more firmly organised and difficult to improve".
Each patient we encounter will have come from another type of background and some from different social systems whereby their principles, values and behaviours may not be exactly like the professionals (Lloyd & Bor 2009). Each patient within the sphere of these culture or religious beliefs will have a different view about what treatments or care and attention is appropriate (Helman 2000). This is the case in respect of patient * who was a Jehovah's See. Patients who reveal this religion do not acknowledge blood transfusions or blood vessels related products established upon their interpretation of Serves, a publication in the New Testament Bible (Wikipedia 2012).
Although the author's DMP and the patient were from different ethnical and religious backgrounds, effective communication was still maintained. The DMP had taken time with the patient to explore the implications that the patient's beliefs would have upon the form of treatment that was suggested. In cases like this it was not taking the medication that posed the challenge however the increased threat of bleeding that can occur, which probably may necessitate a blood vessels transfusion if the bleeding were to be severe. In the case of patient * they at first were not keen to start out warfarin. When it was first mentioned the patient grimaced and said "oh, isn't that rat poison". Indeed the individual was right, Warfarin has previously been used to get rid of rodents but its safeness and efficiency as a medication in addition has shown. Patients often have myths about medication which can effect their decision making. Their decisions regarding treatments are based after their understandings and these could by affected by external factors including the media. However, in regards to to the consultations observed by the writer, it seems that the intrinsic factors were more influencial. Patient * and * were both concerned about potential changes in lifestyle. "How often would i need to come for testing? What about going on holiday? Will I bruise easily? What happens if I lower myself? Does it have an effect on my other medicines". For patient * the answers were satisfactory and warfarin was approved. However patient * felt that the change would be too much and dropped. Respecting a patient's to refuse treatment is part of the consultation and prescribing process. In its help with consent, the GMC (2008) discusses the value of accepting a competent patient gets the right to make decisions about their professional medical and that doctors must value these decisions, even if they do not agree with them. This view is reinforced by NICE (2009) who state that patient's if they chose to, should be involved in your choice making process, and so long as they have mental capacity, as described in the Mental Capacity Function (2005), to have the ability to make informed alternatives, as professionals we should recognize that patients have different views to us about dangers and benefits and we should accept their right to refuse.
For patient's ***and *, the recommended treatment was anticoagulation. Patient * and * once their initials concerns were dealt with, were happy to proceed with the procedure. Patient's * and * weren't. The author observed that this didn't change the DMP's treatment of the patient, who well known their decision and agreed an alternative solution plan.
Although each discussion was different in the individual specifics, there have been still common elements. Each discussion was organized and was systematic in establishing the mandatory elements. An excellent rapport was established with each patient, leading to effective communication. Communication problems between your doctor and patient can result in dissatisfaction (Simpson et al 1991), leading to misunderstandings and lack of arrangement or concordance with treatment plans (Barry et al 2000). This is false yet, in patient * and *. Each patient was presented with a full justification of the procedure options and each made an informed choice regarding their treatment, choosing to go after a course not suggested by the author's DMP. A review by Cox (2004) summarised that patients and healthcare professionals need to have a two way debate in order to share their views and concerns regarding treatment.
6. Integrate and apply understanding of drug actions in relation to pathophysiology of the condition being cared for.
With the arrival of impartial and supplementary prescribing, and the ever changing role of the nurse, it is considered crucial that nurses have a larger knowledge and knowledge of medicine pharmacology (Thomas & Young 2008). Pharmacokinetics studies how our bodies process drugs and Pharmacodynamics studies how these drugs exert their result (Greenstein & Gould 2009).
When the center beats normally, a regular electrical impulse triggers the muscular heart walls to long term contract and force blood vessels out and around your body. This impulse originates in the top chambers of the heart (atria) and is also conducted to the bottom chambers (ventricles). In atrial fibrillation this impulse is initiated and conducted in a arbitrary uncoordinated manner causing the heart to function less efficiently. The chance of your 'pooling' or 'stasis' of blood vessels remaining in the center, increases the risk for a thromboembolic event. Atrial fibrillation is the most commonly sustained cardiac arrhythmia affecting 10% of men over 75 years (NHS Alternatives 2013) of course, if remaining untreated is a substantial risk factor for stroke (NICE 2006).
The patients recognized in the event studies were all given a prognosis of non-valvular atrial fibrillation. Their specific risk for thromboembolic event was evaluated using the CHAD credit scoring systems and the results was that all patient required treatment with anticoagulation.
Anticoagulants were found out in the 1920's with a Canadian veterinary who discovered that cattle eating mouldy silage made from great clover were dying of haemorrhagic disease, and it wasn't before 1950's that anticoagulants were found to be effective for preventing thrombosis and emboli by reducing clot creation, and were finally licenced for use as medicines. (Wikipedia 2012). Warfarin is the anticoagulant most commonly used in the treatment of atrial fibrillation. To understand the pharmacodynamics of warfarin, one must first understand the basic clotting cascade.
Blood contains clotting factors (inactive protein) which switch on sequentially pursuing vascular destruction. These factors form two pathways (Intrinsic and Extrinsic) which lead to the forming of a fibrin clot. The extrinsic pathway is activated by injury from outside of the blood vessel. It works to clot bloodstream that has escaped from the vessel in to the tissues. Damage to the tissue activates 'tissue thromboplastin' which is an enzyme that activates 'Factor X'. The intrinsic pathway is brought about by elements that lie within the bloodstream itself. Harm to the vessel wall membrane stimulates the cascade of individual clotting factors which also trigger Factor X. Once triggered Factor X turns Prothrombin to Thrombin which changes Fibrinogen to Fibrin. Fibrin fibres then form a meshwork which traps red blood skin cells and platelets therefore stems the blood circulation (Doohan 1999). Vitamin K is essential for the maturation of clotting factors such as Factor X and prothrombin which is on Vitamin supplements K that anticoagulants such as Warfarin take effect. Warfarin reduces coagulation by inhibiting the processing of Vitamin supplements K. This reduces the quantity of matured clotting factors designed for the clotting cascade, creating clotting time for you to be prolonged (Melnikova 2009). This time around structure can be assessed by examining a patient's INR (International Normalised Ratio), which is simply a taking of the amount of time it requires for a blood vessels test to clot.
Using Warfarin in the treating Atrial Fibrillation, reduces the risk of clot formation and the chance of potential clots being ejected from the heart into the standard circulation. This technique however would depend upon the way the body initially functions the medicine (pharmacokinetics). Warfarin is immediately ingested from the GI tract, however this can be affected by age group related changes such as reduced gastric emptying and slowed motility influencing intestinal transit time. This phase can determine a drug's bioavailability. The extent of drug distribution depends on the quantity of plasma protein and whether a drug is 'destined' or 'unbound'. Warfarin is 99% bound to plasma proteins and therefore can take longer to reach the site of action, thus the syndication phase lasts about 6-12 hours (Holford 1986). The patient in case * was noted to be on aspirin. Patients on drugs which bind at the same site can cause problems when implemented together, as you displaces the other causing elevated degrees of the medication to be circulating, leading to toxicity (Sunalim 2011).
Whilst the great things about warfarin are evident the side results and precautions for use are numbered. Warfarin has a slim therapeutic screen making control difficult and increases the risk of hemorrhage and haemorrhage. It interacts with other approved, over the counter and herbal supplements which is contraindicated in motherhood. Despite its utilization in scientific practice for over 50 years, the MHRA still receive a substantial volume of adverse reaction circumstance accounts through the 'Yellow Card' system. Nearly all these reviews were consequently of over anticoagulation with nearly all fatal circumstances being related to haemorrhage. It had been concluded that occasionally connection with other medications was the reason (MHRA 2009). Hence, it is essential that a full drug background including allergy symptoms is taken prior to commencing any new medication.
Critically appraise sources of information/advice and decision support systems in prescribing practice and apply the principles of evidence based mostly practice to decision making.
9. Demonstrate an expert knowledge of prescribing decisions made in a ethical framework with
due consideration for equality and variety.
The decision to prescribe an anticoagulant such as warfarin is not a decision taken lightly. Due to the potential side effects, mainly the increased threat of bleeding, the risks versus benefits debate must be explored. The advantage of warfarin is the reduction in risk of thromboembolic events like a heart stroke or pulmonary embolism, the risks arehowever before this conversation may take place, it must first be founded whether anticoagulation with warfarin is necessary or whether an alternative treatment can be done.
In 1994 the Atrial Fibrillation Researchers (AFL), conducted randomised specialized medical trials whose individuals got untreated atrial fibrillation. Data from these trials showed that patients with previous heart stroke, hypertension or diabetes were at increased risk of stroke. This data was established by the Heart stroke Avoidance & Atrial Fibrillation Investigators (SPAF 1995) who looked at thromboembolic risk for AF patients on aspirin. The amalgamation of the two systems in 2001 resulted in the introduction of the CHAD2 system (see appendix), which really is a specialized medical prediction tool used for estimating the chance of stroke in patients with AF also to determine whether or not treatment is necessary with anticoagulant or antiplatelet therapy. Risk stratification techniques that accurately and reliably stratify stroke risk could affect the management of those who have AF and spare those low-risk patients the risks, inconvenience and costs associated with anticoagulation remedy (Gage et al 2004). The use of the CHAD2 and CHAD2VASc rating is advocated in the European Contemporary society of Cardiology (ESC) recommendations (2010), which suggests that if the patient has a CHAD score of 2 or above anticoagulation therapy such as warfarin or one of the newer drugs, such as dabigatran, should be recommended. This view is reinforced by NICE assistance (2006) which analysed individual trials and concluded that warfarin significantly reduced the incidence of heart stroke and other vascular incidents in people with AF. NICE also discusses stroke risk stratification models, which the CHAD2 credit score is one. It generally does not however make suggestions as to the most suitable choice of tool. Patient * was the only one from the circumstance studies that acquired their heart stroke risk calculated using the CHAD credit scoring system and had it recorded in the records. The reasons for this are unknown however the writer hypothesises that perhaps as the other patients experienced greater apparent risk because of the existing co-morbidities, it was deemed unnecessary to really perform the calculation as anticoagulation would finally be indicated. The author could dispute here that if this is the truth this generalisation should go against the idea of diversity.
Warfarin has been extensively accepted as the drug of choice for oral anticoagulant remedy, however newer drugs on the marketplace such as dabigatran and rivaroxban are also suggested as alternatives to warfarin, yet it is the author's experience that these are very hardly ever reviewed with patients as different treatment in support of seem to be prescribed when warfarin is not an option. The writer believes the reason for this can be partly due to economic and physical inequalities in health, a view shared by Abraham & Marcy (2012) & Wartak & Bartholomew (2011). They figured compared to warfarin dabigatran was disadvantaged by the lack of knowledge about its use, its poor gastrointestinal tolerability and in the end the cost which resulted in its limited use.
Treatment decisions made for these patients were in keeping with National and Euro guidelines promoting access to treatment for those. Local rules however are under current review and were not designed for scrutiny. As prescribers we should use all available information to ensure that people make the best research based prescribing decisions with this patients. Guidelines facilitate best practice but resources such as the British National Formulary (BNF) and the Electronic Medicines Compendium (EMC) are very helpful research tools in facilitating best prescribing practice.
In day-to-day practice healthcare professionals are expected to make judgements about what is best for his or her patients. The NMC (nnn) advocate that to apply in an ethically sensible manner it's important to balance moral things to consider with professional values and relevant legislation. The honest theory of principlism detailed by Beauchamp & Childress (2008) considers the ideas of beneficence, non-maleficence, autonomy and justice as the components of honest theory that will be the most appropriate in promoting decision-making within the medical system. Making ethical prescribing decisions is not really a solitary activity, in particular when your choice will impact after another person. The ethos of quality patient care and attention relies upon a team procedure that supports your choice making of the individual, together with the professionals, making certain the worth and beliefs of the individual have been well known and acknowledged.
5. Demonstrate critical awareness of the roles and romantic relationships of others involved in prescribing, supplying and administering medicines.
Earlier discussion outlined the importance of communication in expanding the doctor-patient romance and how consultations are either doctor or patient-centred. This is also true in regards to to other 'professional connections' the patient may have with people of the multidisciplinary team, who are also involved in prescribing, delivering and administering their medications. An assessment of the source, prescribing and administration of medicines by the DOH (1999), advised that there must be two types of prescriber; unbiased and supplementary. An unbiased prescriber is "responsible and accountable for the evaluation of patients with undiagnosed or diagnosed conditions and for decisions about the specialized medical management required. supplementary prescribing is a voluntary relationship between a doctor or dental professional and a supplementary prescriber to suggest in a agreed patient specific specialized medical management plan, with the patient's contract" NPC (2012).
As a potential non-medical prescriber the author recognises the importance in understanding and applying the ideas of good prescribing practice, in order to become an impartial/supplementary prescriber. Doctors undertake trained in prescribing within their undergraduate programme and are required to illustrate this activity in order to obtain their registration. Their practice is guided and governed by the General Medical Council (GMC). In the same way nurses and midwives who are self-employed/supplementary prescribers, are governed by the Medical and Midwifery Council (NMC), whose regulatory specifications and legislation require practitioners to be experienced before they embark on such training and in safeguarding the needs of the patient, ensure that nurses and midwives remain up to date with the knowledge and skills that permit them to suggest and administer drugs safely and effectively (NMC 2004, NPC 2012). Pharmacist's whose governing body, the General Pharmaceutical Council (GPC 2010), allow a pharmacist indie prescriber may, after successful conclusion of an accredited course, suggest autonomously for just about any condition of their clinical competence. Current legislation however only allows other multidisciplinary users such as radiographers and physiotherapists to be supplementary prescribers.
During a patients stay static in hospital, it is most likely they will enter a medication consultation with at least a couple of of the multidisciplinary members mentioned above. All of the patients in the case studies had connection with a health care provider, nurse and pharmacist. The doctors performed the initial talk to at the patient's admission which is here that the original drug record was used. The nurse then implemented the medication recommended on the medication chart, giving the patient's information about the drugs they were taking and potential part effects. This information was limited to their specific knowledge base. In the event the medication was unavailable then it was requested from the pharmacy department. The author observed the practice that took place when an unavailable medication was requested. The original process was simple, the physician prescribed it and the ward nurse sent the drug graph and request slide to pharmacy. Once in pharmacy the procedure became more technical requiring the demand to pass through several 'channels' before being dispensed. Ahead of this course the writer had very little understanding concerning how important the role of the pharmacist was. Pharmacists play an important role in bettering a patient's medication management during admission and through transitions of good care from medical center to home. Weiss (2013) decided that patients are often discharged from hospital with changes from other previous medication regimes, causing discrepancies and lack of understanding, which lead to non-adherence and unfavorable drug effects. The pharmacists spoken with by the author decided that providing medication counselling in planning for release is a huge part of the role.
Patient * and * who were commenced on warfarin, received counselling prior to discharge. The author could observe this practice. The period occurred at the bedside which, upon reflection, was not conducive to the information exchange. Noises and interruptions from a perplexed patient in the next bed intended that the passing of information was often disrupted and needed to be repeated. The pharmacist provided the individual with an information load up and reviewed the drug, part results, anticoagulant monitoring and lifestyle changes such as travel, diet, outdoor recreation and dental goes to. NICE drugs adherence advice (2009) advocate the importance of providing patients with both written and verbal information in order to make the best choice. For patient * and *, verbal information was presented with previous to prescription, however the written information was only provided following the patient had agreed to treatment. Providing everything beforehand could increase patient consent to treatment (Elwyn et al 2006).
Considering the role of others within the prescribing team has led the writer to examine and reflect after her own role. The author entered this course with knowledge and competence in diagnosing a patient with an severe coronary syndrome and questioned why such a broad prescribing knowledge was necessary. It's the view of Lymn et al (2010) that non-medical prescribers in just a small specialist field often ask this question. Taylor & Field (2007) imagine the response to be because breakthroughs in remedies have meant that patients tend to be in a position to live with long-term disease and multiple co-morbidities. Learning to be a prescribing pupil has given the author understanding into what she did not know and what she never realised she had a need to know.
At the beginning the writer posed the question, "Anticoagulate or never to anticoagulate?" To be able to answer this, the author explored some of the processes involved in prescribing and through the use of case histories, linked theory to practice with analytical dialogue. The answer to the question is clear, you can find no-one true answer. It's the author's conclusion that all circumstance for anticoagulation must be viewed separately. Each patient differs, their understanding, their views and their pathophysiology all are unique. As professionals it is our obligation to provide our patients with the information and support they want to make informed choices. As prescribing professionals these tasks are increased. Using the procedure of responsible practice as referred to by Lymn et al (2010), it is essential that people analyse our obligations as accountable prescribers and in doing this consider each prescribing situation on its own merits.
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