Recently I was approached by a nurse to review a patient with Parkinson’s disease. The nurse was concerned because the patient was acutely unwell with severe pneumonia. As such, the patient had fluctuating levels of consciousness and was struggling to take his medicines. The nurse had performed an assessment to gauge the patient’s ability to swallow and determined that it was not safe for him to take medicines orally. I was contacted to review the patient and consider a plan for managing the problem at hand. I reviewed the patient’s history, including the list of current medicines. The treatment I wanted to get sorted immediately was his Parkinson’s medicines. He was being reviewed regularly by the Parkinson’s specialist team and was on a complex drug regimen.
My first thoughts were to consider either rotigotine patches or a nasogastric tube dependent on his swallowing ability resuming. We would then re-establish oral therapy once he was recovering from the pneumonia and his swallowing reflexes had improved further. I spotted an annotation of allergy to rotigotine patches in the drug chart and, upon further investigation, I discovered that a rash had developed on the patient after about three months of rotigotine patch treatment a few years ago. Was this significant and, if so, do I need to talk to the doctors about a nasogastric tube more urgently?
It is important to consider the patient’s own views and gain consent, if possible. Unfortunately on this occasion it was not possible because he was confused and unresponsive.
To my relief, however, the patient’s daughter, and main carer, was in the room. She expressed the opinion that the patient would prefer to trial the rotigotine patch and risk a reappearance of the rash. This insight into the patient’s views helped me make a decision about the best course of action. Within minutes the patient had a rotigotine patch in place, the Parkinson’s nurse had a referral to review the patient urgently and the doctors were aware of the need to consider a nasogastric tube if the patient’s level of consciousness was not improving later in the day.
In an ideal world I would have been able to obtain consent for the treatment plan from this patient. Because this patient was temporarily unable to provide consent I acted in his best interests in an urgent situation. I used my clinical judgement combined with the views of family members, and aimed to help the patient make an informed decision when he had regained the capacity to do so. This situation demonstrated the multitude of grey areas there are in providing care to patients.
David Gibson, MSc, MRPharmS, is lead clinical pharmacist at Darlington Memorial Hospital, County Durham and Darlington NHS Foundation Trust.