Martine Kruijtbosch

35 Mo ra l d i l emmas o f commun i t y pha rmac i s t s PHARM-54: A cardiologist deviated from the guideline for combining antiplatelet drugs. When the pharmacist requested clarification, the cardiologist replied: ‘ Do you mind if I continue with my patients now? ’ The pharmacist could not properly inform the patient about his doubts about the therapy. ‘ I had strong doubts about the safety of this combination. Informing the patient about the risks, however, might worry the patient and undermine his confidence in the cardiologist .’ Disruptive behaviour of a colleague Pharmacists reported disruptive behaviour of colleagues, such as gossip, lying or suspected fraud. Both neglecting and addressing such behaviour could influence the work climate in the pharmacy. PHARM-1084: A pharmacy is reimbursed for every patient who receives instructions about a new inhaler. The senior pharmacist asked a junior pharmacist to send a list of all patients who had received a new inhaler with instructions to the insurance company for reimbursement. The junior pharmacist was reluctant to do this, struggling with going against his senior colleague’s request as well as his responsibility to society. ‘ I was uncertain whether the instructions had always been given. Technicians didn’t always document this and patients sometimes refused the instructions or had already received them elsewhere .’ Pharmacist and physician have a different opinion about appropriate pharmacotherapy In these dilemmas physicians ‘overruled’ pharmacists’ proposals, although not necessarily in a brusque manner. Pharmacists had the idea that the physician did not really consider their suggestions and doubted the suboptimal or unsafe pharmacotherapy. Pharmacists felt at a disadvantage because they lacked sufficient knowledge about the patient’s condition. Moreover pharmacists did not want to further disrupt their professional relationship with the physician. PHARM-22: The pharmacist had suggestions about alternative therapy options for a patient with serious pain complaints. However, the physician said that he had tried everything and that nothing more could be done and did not want to change the medication. ‘ In the end, it is the physician who prescribes. I wanted to help the patient but suggesting these options directly to the patient also did not feel appropriate. ’ Deviating from a prescription or missing relevant data with the physician absent Pharmacists had a moral dilemma when they wanted to deviate from a prescription because of potential drug related problems such as interactions or allergy warnings, or to discuss the treatment because of lack of relevant clinical data, but could not contact prescribers. Both situations impeded their judgement on the appropriateness of pharmacotherapy.