LEARNING OUTCOMES
After completing this module, the paramedic will be able to:
- Understand the concept of patient autonomy, and why it is important
- Understand the principles of patient-centred prescribing
- Raise their awareness of the common reasons why a patient may have reduced medication concordance
- Implement strategies to increase patient concordance
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Patient-centred prescribing is putting the patient at the centre of everything we do. Simon et al (2020) advise that the fact a medication can be prescribed for a particular condition does not mean it necessarily should be prescribed. This means the paramedic prescriber must ask themselves (among other things) ‘what are the risks versus benefits’? Autonomy is one of the four ethical principles from Beauchamp and Childress' seminal work on medical ethics (1979) (the others being beneficence, non-maleficence and justice), and it means recognising and respecting a patient's ability to come to their own decisions about their care. Concordance is the accuracy with which the patient follows the prescribed treatment regimen; a high level of concordance means that the patient takes the prescribed medication correctly, at the correct times of day and for the correct length of time (Joint Formulary Committee (JFC) 2020). A high level of concordance is however rarely the case, which will be later discussed. These topics are important to all prescribers, but to paramedic prescribers in particular as the newest prescribers on the block. The Royal Pharmaceutical Society (RPS) (2016) prescribing framework advises that prescribing is not a right, but a responsibility. This means it is our duty as paramedics to prove we are equal to that responsibility. The Health and Care Professions Council (HCPC) (2019) have adopted the RPS (2016) framework for their own paramedic prescribing framework and expect all paramedic prescribers to adhere to it. Paramedic prescribers are fully capable of driving the paramedic profession forward and upward but—in the words of Spiderman's uncle—‘with great power comes great responsibility’.
Reflection 1
How patient-centred is your consultation style and in what ways?
The patient at the centre
The following patient example provides a framework for discussion. The patient's name has been changed to ensure confidentiality, and only the information relevant to this article is presented. The examples is therefore not meant to demonstrate a complete patient assessment. Mr Smith was a 48-year-old male with a 3-week history of increasing upper abdominal pains and heartburn. There were no red flags present, and the patient was not systemically unwell. He had suffered from the same symptoms intermittently since his late 20s, and an abdominal examination produced normal results. He had tried over-the-counter anti-acid treatment but with only minimal relief. He was previously successfully treated with omeprazole—a commonly used proton pump inhibitor effective for acid reflux (JFC, 2020)— from which this patient was diagnosed as suffering. A further course of omeprazole 20 mg daily was prescribed and the patient's symptoms settled after approximately 5 weeks of use. This demonstrates a relatively simple yet very common problem in primary care.
What does the literature say?
Knight (2013) stresses that patient-centred prescribing naturally follows a patient-centred consultation, which in turn goes together with the principle of autonomy. McWhinney et al's (1986) disease-illness model gives a framework where the practitioner goes back and forth between their own and the patient's agendas, taking both equally into account. This model seeks to explore the patient's ideas, concerns and expectations (ICE), as well as their feelings, by giving them time to express them. When merged with the medical model of history, signs and symptoms, investigations and pathology (Mehay and Chahal, 2012), this creates a balanced model, satisfying both the patient and the practitioner. While this model is intended for consultation, it is just as applicable to making prescribing decisions, where the paramedic prescriber should gain insight into the patient's ICE concerning the taking of any medication, while always respecting and acknowledging their autonomy. This contrasts with the medical model alone, where the patient's feelings and thoughts are not considered.
Concordance is always a vital issue to consider and address in any prescribing decision. Medication is useless if not taken properly and can even be harmful in rare cases. Only about 50% of patients take medication sufficiently to achieve treatment objectives, and only one in six patients take medication exactly as prescribed (Simon et al, 2020). The costs of poor concordance are physical (not taking anti-hypertensives increases risk of stroke) and financial—over £250 million worth of medication are disposed of each year, with the true cost of wastage estimated to be many times that figure (Simon et al, 2020). While poor concordance can sometimes be wholly attributed to the patient, most of the time, it is poor prescribing practice that leads to it (JFC, 2020). Table 1 shows how concordance can be improved when prescribing.
Table 1. Ways to improve concordance
| Strategy | Explanation |
|---|---|
| Use simple language and avoid medical terminology | This ensures the instructions for taking the medication are clear. Checking the patient's understanding is a good strategy—if they fully understand what you have said, they are much more likely to act on it |
| Explain what the medication is for | Patients are more likely to take medication if they know why it is being given. A lack of explanation may lead the patient to think the prescription is an error, or to underestimating its importance |
| Keep the treatment regimen as simple as possible | A simpler regimen is easier to remember and act upon. For example, a patient is more likely to take a tablet once a day than four times a day |
| Discuss possible side effects | Many side effects are expected and short-lived, such as a drop in mood in the first few weeks of starting an anti-depressant. A patient who is unaware of these may simply stop taking the medication |
| Ensure the patient is able to ask questions | This is vital for facilitating patient autonomy and helps ensure the patient fully understands the regimen |
| Consider the patient as an individual | If the patient has memory problems, will they remember your instructions? Written instructions are very helpful here. If the patient has severe hand arthritis, will they be able to operate an inhaler? Asist devices are available, etc |
| Review the patient if necessary | Ensure the patient knows they can seek help if required and explain possible reasons. For instance, if the patient does not like the taste of their new medication, they may simply stop taking it if the prescriber does not tell them there are other flavours available. Arrange follow-up if problems with concordance are anticipated |
Source: JFC, 2020; Simon et al, 2020
Reflection 2
Reflect on your consultation style or model; how can you apply what you have learned to make it more patient-centred?
Applying literature to the patient
If we approached Mr Smith in a solely medical way, we would simply say to the patient: ‘this medication will help your symptoms; take it once a day and recontact the surgery in 2 weeks if you're no better’. This approach can lead to a vast array of problems: let us assume Mr Smith was being prescribed a statin and he has been influenced by the controversy surrounding statins in the mainstream media. He agrees to the above approach during the consultation, but has no intention of ever taking the statin. He cannot however voice his concerns because he was never given the chance. This means his future cardiovascular risk will be underestimated (National Institute for Health and Care Excellence (NICE) 2016). The other side of this is demonstrated by a question every prescriber should ask themselves when making a prescribing decision; is prescribing necessary (Nuttall and Rutt-Howard, 2019)? If we assume in our patient example that Mr Smith's symptoms were fully controlled with over-the-counter anti-acid medication and an examination was normal, then good practice would be to advise Mr Smith to continue with his current treatment and to recontact if his symptoms worsened (NICE, 2019).
In terms of autonomy, wwif Mr Smith is never told clearly about the likely side effects of the medication being prescribed, he cannot make an informed choice regarding whether to take the recommended medication or not, meaning he cannot have true autonomy in this decision (Wilkinson et al, 2019). The decision about whether the potential benefits of the medication outweigh the potential side effects is the patient's alone to make; all the prescriber can do is provide information, advice and recommendations. Wilkinson et al (2019) advise that this is a founding principle of patient autonomy.
Reflection 3
In what ways do you consider patient autonomy when making prescribing decisions?
Reflection 4
Do you currently discuss patient concordance with your patients? Why or why not?
Conclusion
The patient is at the heart of everything we do as clinicians. Any prescribing decision must include the patient and clinician as equal partners, with information freely shared, and the patient being fully informed as well as given the opportunity to ask questions. The patient's decision regarding their care must be respected, and clinicians should always seek to understands the patient's ideas, concerns and expectations, thereby putting the patient at the centre of the prescribing decision.