How to approach challenging scenarios in primary care pharmacy

As healthcare becomes increasingly complex, the pharmacy profession must develop additional skills and competencies in line with its growing responsibilities.

Working with patient’s who are in crisis or at risk of harm is a reality of practice and these situtaions require an ability to appraise the available information, evidence and guidance, alongside a skilled reading of the specific situational context.

This article introduces three typical scenarios from primary care requiring professional judgement. In each case, the intention is not to provide definitive answers but to consider the questions raised by each scenario and how you might approach them if faced with a similar situation. The purpose of sharing these examples is to encourage reflection and initiate conversation, considering all possible approaches and why individual practice may be different. Each example is based on real cases with details changed to protect the identity of the individuals. The scenarios discuss topics of suicide, addiction and sexual violence.

Scenario 1: Depression, addiction and suicide ideation

A man aged 27 years comes in for a depression review follow-up. He has been diagnosed with moderate-to-severe depression and started antidepressants about eight weeks ago. During his appointment, he tells you the following information:

• He is a gambling addict with approximately £30,000 of debt and is unable to stop using gambling sites;
• He is actively suicidal: he thinks about suicide daily and is unsure what stops him from following through. He has a plan to overdose on tablets at home;
• He uses drugs recreationally, most commonly marijuana, but will “try anything he can get his hands on” as intoxication makes him feel less depressed. Quite often, when he takes recreational drugs, he accesses gambling sites.

What would you do if you saw this patient in a consultation?

With a patient disclosure such as this, one of the first challenges is to react appropriately. How can you ensure your response comes across in a non-judgmental way? It is difficult for anyone to admit that things are going wrong, and feeling judged will deter them from telling the truth.

It is important to learn more about the patient’s support network. This will provide additional context into the risk of suicide and their ability to access help. You could start by asking if they have shared what they have told you with anyone else or if they have people (e.g. friends or family) in their life with whom they can talk. Consider also signposting the patient to organisations, such as the Samaritans, regardless of what support network he might have.

What are the most significant risks for this patient?

• Suicidality — when a patient expresses suicidal ideation, an immediate appraisal of risk is required. There are some effective screening questions that can be asked to help establish this. For example, are you having suicidal thoughts right now? Do you have a plan in place? Do you think you will go ahead with a suicide attempt? The way a patient answers these questions can help guide what you decide to do next;
• Financial risk — accumulating levels of debt could spiral further, worsening their levels of depression and increasing their vulnerability;
• Use of recreational drugs — the patient’s use of recreational drugs potentially increases the risk of harmful behaviours and altered perception of reality.

What are the management options?

There are two things to consider here: depression and addiction. For depression, prescribers could increase the dose of the current antidepressant — this may be appropriate if the patient is not experiencing side effects or has tolerable side effects, and the patient’s dose is within a licensed range. You could also try switching to an alternative antidepressant: this may be warranted if the patient is experiencing intolerable side effects, if increasing the dose of the original antidepressant would take them to an unlicensed dose, or if the patient has not seen any therapeutic effects. Non-pharmacological management routes could also be investigated, such as cognitive behavioural therapy (CBT); however, this requires engagement from the patient to be effective so would require further investigation to establish if talking therapy is a viable strategy at this stage.

You could also alert the mental health crisis team and arrange follow-ups at shorter frequency, dependent on your assessment of the level of risk.

For gambling addiction, the patient could speak to banks or other institutes to obtain support for debt and help with debt recovery. He could also contact gambling sites and ask them to block his account. As with depression, the patient is likely to benefit from long-term counselling to tackle their addiction.

He may also benefit from being signposted to an organisation that can help him manage his use of recreational drugs.

Discussion

This case is complex owing to gambling addiction, severe depression, suicidal ideation and use of recreational drugs.

Hearing a patient disclose suicidal intentions can be an overwhelming experience, particularly if it is the first time encountering this during your practice. It can be difficult to know what type of language and tone of voice to adopt. Being clear and direct when asking follow-up questions can encourage patients to talk openly about how they are feeling. Displaying empathy is important but the priority is the patient’s safety and wellbeing; if hard questions are avoided, it may affect the patient’s capacity to speak openly and honestly about suicide. In addition, knowing what to do if the patient is high risk can be difficult. If you are unsure of what action to take, there is usually a colleague you can call upon to help you work through your decision making.

Treating patients with these conditions can be complex for healthcare professionals. Finding the right balance of empathy while staying within professional boundaries can take some practice. Debriefing about these scenarios with other healthcare professionals can provide valuable opportunities for reflection and acknowledgement of any emotional toll it may have taken.

For more on how to deal with suicide disclosure, see ‘Suicide: how to recognise the warning signs and deal with disclosure‘.

Scenario 2: Sexual assault and safeguarding

A patient aged 15 years has booked an appointment for emergency hormonal contraception. It is her first time requesting contraception. She appears to be worried and dishevelled. During the consultation, it emerges that:

• This was her first time having sexual intercourse;
• She does not have a regular partner;
• She has bruises on her wrists. When asked, she says she was attacked.

What should you do next in this consultation?

Be as empathetic as possible. Although only basic facts are known at this stage, it is clear that the patient has been through a distressing and traumatic experience. Build trust by showing that you recognise this and allow her to talk further. You can better judge what to do next as you gather more information.

What else should you ask the patient?

The immediate priority is establishing risk and you can start by asking whether the patient would be safe once they leave the appointment. You could provide reassurance that she would not get into trouble by talking to you. It will be necessary to explore who the perpetrator is; for example, if it was someone known to her, she may still be at risk.

It will be helpful to ask about her support network by asking questions, such as whether she has told anyone else or reported the incident to the police. There may also be opportunities to signpost her to further sources of support and explain the options available to her.

The next priority is preventing pregnancy and the patient’s request for emergency hormonal contraception. You will need to ask questions sensitively to ensure the safe supply of a suitable emergency contraceptive, making sure to explain the purpose of the questions.

Should you notify anyone? If so, who?              

With the agreement of the patient, a referral to the nearest NHS Sexual Assault Referral Centre (SARC) can be made. These centres specialise in providing support to victims of sexual assault, which includes access to specially trained police officers, as well as arranging to safeguard referrals where appropriate, including for children. You could provide the patient with details of the nearest centre, ensure she has the ability to access it and encourage her to invite a friend or family member to go with her.

At this stage, details are limited, but if you judge that the general public may be at risk, it may be necessary to notify the police.

If this is the first time that you have managed a situation such as this, it may be appropriate to seek advice from a colleague. It is also helpful to run through your rationale with a third party to sense-check your actions and see whether they can identify anything you have not yet considered.

What are the management options?

With scenarios such as this, it is important to be clear about the legal and professional obligations and the patient’s rights. A doctor or other healthcare professional can provide contraceptive advice and treatment to those aged under 16 years without parental consent​[1]​. The Care Quality Commission has a useful summary page of things to consider when treating anyone aged under 18 years, including a summary of when there may be safeguarding concerns. It is aimed at primary care but the principles can be transferred to other care sectors. 

As long as the emergency hormonal contraception was not contraindicated, and the patient has been judged to have the required level of competence to give informed consent, a prescription may be a viable option in this situation.

What other support might the patient require?

The patient is likely to benefit from the support of a friend or family member and it may be appropriate to encourage them to seek this out if they have not done so already.

If emergency hormonal contraception is chosen, patient education will be required, including a verbal explanation of how this might affect the patient’s menstrual cycle, as well as written information to read once she has processed the event.

The patient could also be signposted to other support services (see Useful resources section for examples).

Discussion

There are many things to consider in this scenario. The immediate physical elements, as mentioned previously, include the patient’s safety and preventing pregnancy. There is also the likelihood that a serious crime has been committed against a child and consideration needs to be given to the viability of collecting physical evidence for a potential prosecution. The sooner this is gathered, the better the chances of collecting reliable samples, so encouraging the patient to visit a SARC would be a priority. Referring to a SARC would also ensure the most appropriate channels for safeguarding referrals were made.

The patient could react in a number of ways and it may be that you can emphasise to the patient that visiting a SARC would not necessarily mean she must report the incident to the police, and that what happens next is her choice.

The psychological effects of sexual assault will have the most extended impact. The patient is likely to benefit from specialist support and advice, and should ideally access these as soon as possible. The best things to do in this situation are to remain empathetic and non-judgemental, reinforce to the patient that the assault was not their fault, and ensure they understand the different options available and are able to access the best available support services.

Scenario 3: Health beliefs, adherence and patient preference

A male aged 43 years presents for an asthma medicines use review. He knows one of his asthma triggers is his cat but he has a strong bond with his pet and is not willing to relinquish ownership. He considers himself an expert patient and has researched asthma extensively. His previous medical notes are sparse, but include that he is prescribed Relvar Ellipta (fluticasone furoate, vilanterol trifenatate; GSK) every 3–4 months. He has also had four exacerbations in the past 12 months where antimicrobials and oral prednisolone have been prescribed. During the consultation, it emerges that:

• The patient considers their asthma to be well controlled as they do not need their inhaler daily;
• They do not allow the cat into certain rooms of the house to minimise symptoms.

What would you do if you were the consulting pharmacist?

A good initial step may be to further explore the patient’s perception that their asthma is well controlled and build up your understanding of how it affects him day to day. You could ask questions from the asthma control test to establish this.

Other questions could focus on his inhaler use, including frequency of use, and what stops him from using them daily.

It could also be helpful to explore how he felt during an exacerbation and see if he can make connections between his asthma control, the frequency of exacerbations and inhaler use.

Spending some time getting to know what is most important for this patient will help you to frame your advice and relate this to his asthma/breathing. We know his pet is important to him, and that he is unwilling to give up ownership despite the health impacts, but it is important to establish what other changes he may be willing to make.

What are the most significant risks for this patient?

The most considerable risk for this patient could be that his perception of disease control is leading to continued exacerbations and long-term lung and airway damage. His control is unlikely to improve (and may worsen) if he continues to believe his asthma is well managed despite experiencing regular exacerbations.

What are the management options?

The patient has formed fixed beliefs about his asthma, which means he may be reluctant to adopt a new treatment plan. Although he has already stated he will not relinquish ownership of his cat, it is worth checking whether he would temporarily trial living without it to see if he notices a difference in his breathing. This may allow him to explore the option in the future.

There may also be other things the patient can do to minimise symptoms if he would like to keep his cat. For example, removing any carpets to prevent the accumulation of allergens, the use of air purifiers, vacuuming more frequently and, depending on the type of cat, grooming may also help to reduce allergens.

The patient’s inhaler technique should be checked at every opportunity​[2]​. Finding out more about the patient’s inhaler preferences could provide further insight and the benefits of adherence could be discussed with the patient, with connections made as to how this will help improve his lung health and prevent exacerbations.

Asthma UK has an extensive range of asthma plan templates that can be used and tailored to patients​[3]​. These templates could be used as the basis of an agreement with the patient over how to manage his asthma going forward, including acute exacerbations.

What other support might he require?

Since the patient has shown capacity to learn about his condition, you could direct him to resources that will further improve his understanding of asthma. It may be possible to jointly explore what the evidence says about the harmful effects of uncontrolled asthma and regular exacerbations.

Discussion

Asthma is a condition commonly treated or managed by pharmacists. One of the largest components of managing asthma is successful adherence to treatment,[5] making the profession ideally placed to improve outcomes for patients. This means effective inhaler prescribing — prescribing the right product at the right frequency.

Patients today have access to vast amounts of information about their condition and are likely to have formed fixed beliefs about it, some of which may be inaccurate or potentially harmful. Tailoring your communication approach is important here. Consider how a patient may react if they are bluntly told that they are wrong. Spending some time getting to know the patient, understanding what is important to them, and using this to help convey how certain changes can benefit them, will likely have a better impact. Look to use the knowledge they have gained as a starting point and explore together the consequences and impact of different approaches to the management of their condition.

Patients have the right to choose how to live their lives. They will have priorities outside of their condition, which, as in this case, can negatively affect disease control. Pets are often viewed as part of the family and some patients can become offended if it is suggested that they give them away. This discussion should be approached sensitively so the patient does not feel dismissed.

Using the ICE (Ideas, concerns, expectations) consultation model can be beneficial in scenarios such as this. There are specific models and techniques, such as motivational interviewing, that have been developed to promote positive health behaviour changes, which could be used to help this patient. The article ‘Motivational interviewing to improve medicines adherence’ explores this topic in more depth.

Tips for improving your ability to deal with complex situations

Knowledge and experience are two critical components of effectively managing challenging situations, but there are several guiding principles that you can draw from to help you improve your ability to identify options and make good decisions. 

Be person-centred

Whatever consultation model you follow, ensure you can tailor it to the patient. Thinking back to Scenario 3, if looked at from a purely medical perspective, the best solution for the patient’s asthma control would be to give up owning a cat. A person-centred approach, however, allows us to consider the full consequences of decisions and work with patients to identify the option that is best for them. Being person-centred also helps the practitioner to be responsive to unusual patient circumstances. If you are considering patients individually and avoiding assumptions, you are less likely to be thrown off balance when patients tell you something unexpected or that you have not come across before.

It can be helpful to develop a hierarchy of elements to focus on when faced with a professional dilemma. For instance, ensuring the immediate safety of the patient is the first priority. From there, you can take a triage approach to the different components of the scenario and work with the patient to plan next steps.

The more information you have, the better your judgement is likely to be and it is important to allow the patient to tell you as much as possible. Avoid interrupting them prematurely (e.g. employ the ‘golden minute’ at the start of a consultation) and probe into details as necessary.

Use reflection to build your competence

Understanding the clinical rationale for a decision is incredibly important when it comes to increasing your scope of practice safely. Decision making and clinical judgment are something that practitioners should continuously look to improve. The ability to gather information and work logically through a clinical problem in a patient-centred way requires skills that can be improved over time. A significant amount of learning comes from reflecting on decisions and speaking to other healthcare professionals about what they would do and why.

Be clear on your rationale and produce effective documentation

With complex cases, you may be required to explain the course of action taken and justify specific decisions. For instance, in Scenario 1, the pharmacist may need to provide evidence that they assessed the patient to be ‘Gillick competent’ before prescribing emergency hormonal contraceptives. Written notes can act as an audit trail for decision making. Always document the reason for a decision, especially if it involves taking action outside of standard operating procedures. This advice applies regardless of the sector in which you practice.

Be prepared

Although it is impossible to predict every clinical situation, there is value in using your experience and judgment to anticipate queries and challenges and prepare for certain situations. Developing your digital literacy is also important: being able to quickly search for required information in real time during a consultation can improve effectiveness and lead to better decisions and outcomes.

Become comfortable dealing with uncertainty

With healthcare becoming increasingly complex, challenging situations are to be expected. Pharmacists must develop the ability to deal with uncertainty and risk effectively. Working through dilemmas and emotionally-charged situations provides an opportunity to grow professionally and can be highly rewarding. If it does become necessary to refer to another clinician, review their notes after the patient has been seen and, if possible, discuss the case with the other clinician. Reflect on the experience and consider making the topic a continuing professional development priority so that you feel more prepared for similar future cases.