Martine Kruijtbosch

37 Mo ra l d i l emmas o f commun i t y pha rmac i s t s PHARM-278: A nursing home requested multidose drug dispensing systems for every patient. This would include anticoagulant medication, the dosing of which often has to be adjusted. The pharmacy did not have the capacity to change the multidose drug dispensing systems manually each week. ‘ I realise the importance of this request, but it would almost take an extra technician without getting any reimbursement .’ Risk of harm to (unborn) children Pharmacists confronted with off-label prescriptions for children and adolescents felt they could not appropriately assess the risk-benefit ratio or the correct dosing of drugs. Another dilemma was when children collected medication. Pharmacists worried about the possibility of the child misusing the medication, but also did not want the patient to be left without medication. Even more complicated moral dilemmas arose when medication was prescribed to pregnant women. In these cases, pharmacists had to weigh the benefits for the mother against the potential risks for the unborn child. PHARM-1202: ‘ A psychiatrist told me he did not want to tell a pregnant woman with a major depressive disorder about the teratogenic risks of paroxetine because he was afraid that she would not take the drug. The psychiatrist considered that the mother not taking paroxetine would potentially be riskier for the unborn child than the small teratogenic risk. I struggled with appropriate counselling .’ End-of-life pharmaceutical care These dilemmas concern euthanasia or palliative sedation. Dutch Pharmacists’ and Physicians’ Associations have a joint guideline on providing euthanasia. 48 Sometimes physicians did not adhere to the guideline recommendations; e.g. a physician requested euthanasia drugs without timely communication with the pharmacist. Pharmacists were then reluctant to cooperate. However not dispensing felt wrong because the patient was suffering. The dilemmas that dealt with palliative sedation concerned both disagreement about the dose of palliative sedation and the expectations of physicians that pharmacists would have the necessary drugs readily available. PHARM-57: This pharmacist did not dispense drugs for euthanasia because of religious objections. Surrounding physicians knew about this. A physician from another area, unaware of the objections, requested these drugs too late in the day to find another pharmacist. ‘ Should I remain faithful to my personal values but then trouble both the patient and physician, or should I dispense the drugs this one time? ’