In this work, the following case is analyzed using the Case Resolution Model (CRM). CASE 2: THE OBSERVANr PHARMACIST You are a pharmacist in the drugstore where Mr. Ramirez (age eixty- seven) is a regular customer. You know Mr. Ramirez because he usually comes in during your shift for his refills. From the prescriptions you have filled, you know that Mr. Ramirez suffers from congestive heart failure, and rather badly at that, given the dosages the physician has ordered. The past few times Mr. Ramirez has been in the store, you have noticed that he buys several different packages of salted nuts. This time is no exception. When you fill the prescription, you review the records and note that the physician has an open refill (may be refilled as often as needed) and that Mr. Ramirez has been filling it more and more fre- quently. You wonder if the extra salt intake due to the nuts leads to the need for higher doses of the medicine. As Mr. Ramirez is picking up the medicine, you ask him whether he has been back to the doctor recently and had his medication dosage increased. He replies that he has been increasing it himself because he does not think it has been working as well as it used to-he needs more to feel better. Since increasing the dosages has helped, he sees no need to go to the doctor.
¶ … pharmacist."In this case, the pharmacist is faced with a moral and ethical dilemma of informing one Mr. Ramirez's (a congestive heart failure patient) doctor, the risks that he might be exposing himself to by his tendency/trend of increasing dosage of his medication while also consuming several packages of salted nuts. Such an increase of medication and ingestion of salt predisposes him patient to a cardiac arrest. The pharmacist could also attempt to explain to Mr. Ramirez the dangers he predisposes himself to.
A review of the case indicates that Mr. Ramirez is an octogenarian who suffers from congestive heart failure. He is however taking a lethal combination of prescription pills (on an increasing scale) and salted peanuts under the watchful eye of a concerned pharmacist. This realization came to be after a rather moral and ethical concern from the pharmacists who noticed the worrying trend in his refill intervals coupled with the salted nuts intake. Of course the initial response from the pharmacist was rather natural.He asked Mr. Ramirez if he had been back to the doctor recently and had his medication dosage adjusted upwards. Mr. Ramirez replied that he had been increasing the dosage himself since he did not think it had been working as well as it used. He noted that he -he needed more to feel better. Because increasing the dosages actually worked, he saw no need to go to his doctor for the dosage adjustment.
Relevant facts, identification of the main issues as well as moral situation
Alteration of drug dosage is dangerous and constitutes irrational drug use
Rational drug use (RDU) is noted by Sankaravadivu et al. (2011) as the use of efficacious, appropriate, cost-effective and safe drug as indicated in the right direction in the right formulation and dosage and at the appropriate time interval. Well, from our case study we see that Mr. Ramirez had been using his drug irrationally since his usage was not in any way efficacious, appropriate, cost-effective and safe in regard to the actual dosage that he took. He continuously adjusted the dosage upwards without his doctor's approval.
Irrational drug use is noted by Sankaravadivu et al. (2011) to lead to an unsafe and ineffective drug treatment, adverse drug reaction as well as prolonging of the illness. The promotion of a safe and rational drug use usually entails a wide range of activities like the adaptation of the essential concepts of drugs, continuous training of doctors, nurses and pharmacists as well as the development of evidence-based clinical guidelines. Other moves that can promote a rational use of drugs include the provision of an unbiased and yet independent drug information, educating the consumer as well as the use of regulatory strategies (U.S.F.D.A,2006).
The drug related problems are numerous. Some of these include errors made during the prescription, dispensing as well as administration processes. Others include adverse drug reactions as well as drug interactions (Van Dan Bemt et al., 2000). The results of drug related problems are varied and numerous and may lead to a reduced quality of life as well as increased morbidity as well as mortality rates (Viktil & Blix,2008).
Adverse drug interaction can cause death in the elderly population
The work of Routledge, O'Mahony and Woodhouse (2004) affirmed that several studies indicates a correlation between the increasing age and the rate of drug reaction (commonly called drug reaction rate-ADR) in some medical conditions such as heart complications (Which Mr. Ramirez was suffering from). Routledge, O'Mahony and Woodhouse (2004) further noted that more than eighty percent of adverse drug reaction (ADR) rate that cause admission are dose related in nature are therefore predictable from the popular/known drug pharmacology of the given drug. This makes it potentially possible to avoid the drug over dose cases. Frail elderly persons/patients appear to be very vulnerable to the adverse drug reaction (ADR) rate associated risks. The toxicity of certain drug combinations may be synergetic and even be far much greater than the total sums of the risks of the toxicity the constituent agents when used alone. Routledge, O'Mahony and Woodhouse (2004) advised that good communication is crucial between the patients and prescribers. There is therefore a need for the development of an effective therapeutic partnership between the patients and the healthcare professionals.
Pharmacists have a role to play in the rational use of drugs
Drugs are noted by Passmore and Kailis (2004) to be a great technology in the fight against diseases at the individual as well as community levels. The management of drugs for the benefit of the general public health is therefore paramount. Pharmacists are therefore recognized by the World health organization (WHO) and other major players to play a key role in the promotion of rational drug use as well as in the strengthening of the effectiveness of drug management practices.
The practitioners are however noted to be answerable to their role in the effective communication of the relevant information to the patients as part of their clinical roles.The good things is that there is evidence of the ever expanding role of pharmacy in the global health sector. This is however coupled with a challenge of its role in the strengthening of the global public health care.
Their efforts in educating the public on the optimal drug use as well as compliance with the generally recognized drug dosages must be encouraged. In order for the overdose cases such as the one of the elderly Mr. Ramirez to end, there is a need the pharmacists to work together with the government and other stakeholders in the development of effective legislation and policies for the entire pharmaceutical sector.
Moral situation
It is a fact that pharmacists can only survive economically via the sale of their products. This however should never be their principal focus. The product selection or rate of consumption and sale should be appropriate to the exact need as well as circumstances of the patient. This must also be based on a sound and informed judgment. In addition to these, the patient should be referred by or to a licensed physician (WHO,2001).
Assessment of the rightness as well as wrongness of the various outcomes
Generally speaking, an evaluation of the case reveals that the pharmacists did the right thing. The rightness of the outcome is supported by the fact that the pharmacist took it upon himself to ask the patient (Mr.Ramirez) if his action of increasing his drug dosage was sanctioned by his doctor. This was the first step in ensuring the good communication was put into action. After this initial assessment, Mr. .Ramirez would be taught on the best way forward to self-manage his heart condition.
Decision as well as reaching of a solution
As noted earlier, Generally speaking, an evaluation of the case reveals that the pharmacists did the right thing. The rightness of the outcome is supported by the fact that the pharmacist took it upon himself to ask the patient (Mr.Ramirez) if his action of increasing his drug dosage was sanctioned by his doctor. This was the first step in ensuring the good communication was put into action. After this initial assessment, Mr. .Ramirez would be taught on the best way forward to self-manage his heart condition. The solution would therefore be the fostering of good communication between Mr. Ramirez and his doctor as well as educating him on the dangers of taking salty substance with his heart condition.
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