Table 7 Management of ethical scenarios

Palliative care patient and high dose of opioid

Scenario of hospital pharmacist reviewing a patient’s medicine prescribed for end-stage metastatic cancer. The patients’ husband does not want her to take any sedating pain medicines, even though the patient suffers from severe abdominal pain. The doctors prescribed regular opioids for the pain but the nurses have to withhold it when her husband is there. However, when he is not there at night, she requests the opioid and appears to be much more comfortable.

When you talk to the patient during your inpatient unit review one morning, (the husband is not there, he has left to get a coffee), the patient tells you that her pain is intolerable, but she wants to ‘please’ her husband. You have another discussion with the nurse who tells you she has been ‘sneaking in’ when the husband is not there to administer some medicines as the patient is competent to make decisions.

Please indicate your level of agreement with the following hypothetical options you could undertake

You:

Mean pre (95% CI)

Mean post

(95% CI)

p-value

… agree with the nurse and would suggest she keeps doing the same thing with no need to inform the husband

2.74 (2.42-3.06)

2.86 (2.40-3.31)

0.628

… agree with the nurse and would suggest she keeps doing the same thing but insist the nurse informs the husband about this

2.76 (2.41-3.12)

2.73 (2.28-3.18)

0.885

… disagree with the nurse’s behaviour but do not interfere with the process as it is not your role

2.17 (1.96-2.38)

2.07 (1.77-3.27)

0.563

… inform the husband of the situation as he has legal say as the next of kin, do not report the incident

1.85 (1.60-2.10)

1.66 (1.30-2.03)

0.392

… inform the husband of the situation as he has legal say as the next of kin, report the incident

2.20 (1.81-2.58)

2.31 (1.74-2.88)

0.739

… do not discuss the situation with the patient or husband and Riskman or report an incident

1.74 (1.48-2.01)

2.20 (1.82-2.56)

0.024

…discuss your concerns with the patient but not the husband

3.69 (3.31-4.06)

4.02 (3.50-4.53)

0.228

… discuss your concerns with the patient and her husband

3.13 (2.75-3.51)

3.85 (3.29-4.41)

0.028*

… discuss the situation with a senior medical officer

4.43 (4.14-4.71)

4.52 (4.11-4.93)

0.698

… discuss the situation with another pharmacist

4.36 (4.05-4.67)

4.37 (3.91-4.82)

0.986

Disagreeing with doctor’s decision

A patient has been given a discharge prescription for an antibiotic. The patient has not started the antibiotic in hospital. When you check his notes, you read that he previously had nausea and vomiting from an antibiotic in the same class resulting in non-compliance.

You contact the discharge doctor, and she informs you that she was aware of the elderly gentleman’s previous experience, but she considered other possibilities and is content with her choice of medication. The doctor informs you she has met the patient on previous admissions, and in her opinion his adverse reaction is “not real, it’s all in his mind”.

Please rate your level of agreement with the following statements: after reading the case above:

You continue with discharge preparation:

Mean pre

(95% CI)

Mean post

(95% CI)

p-value

… without saying anything to the patient because you do not want to discredit the doctor

1.73 (1.47-1.99)

1.68 (1.29-2.06)

0.837

… without saying anything to the patient because you accept the doctor’s explanation of the adverse reaction being all in the patient’s mind

1.70 (1.43-1.96)

1.62 (1.23-2.00)

0.720

… without saying anything to the patient as his previous adverse reaction was not serious

1.66 (1.47-1.84)

1.70 (1.45-1.96)

0.746

… without saying anything to the patient as it is more important for the patient to be compliant with his medication and telling him of the side effects may result in him being non-compliant

1.75 (1.49-2.01)

1.86 (1.49-2.24)

0.584

… and inform the patient that both medications are similar and therefore he may experience the same response as previously

4.03 (3.81-4.26)

4.00 (3.66-4.33)

0.878

… and you inform the patient that the medications are not similar and therefore it is unlikely for him to experience the same response as previously

1.49 (1.24-1.73)

1.73 (1.37-2.09)

0.246

… but discuss the situation with another pharmacist 

3.54 (3.17-3.91)

4.00 (3.45-4.54)

0.188

… but discuss the situation with another medical officer 

3.25 (2.86-3.63)

3.51 (2.94-4.08)

0.446

… but document your concerns and actions 

3.57 (3.17-3.97)

4.15 (3.57-4.72)

0.076