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Citation
- Clinical Pharmacist
- 2010;
- 2:
- 110
I pause, think... then stop the drug (Emma Graham-Clarke)
By Clinical Pharmacist Columnist
Another day, another ward round, but many of the patients remain the same. Critical care is a mixture of fast turnover patients, in and out in about 24 hours, and long-stay patients, some of whom remain on the unit for several weeks. However, the medicines all need reviewing regardless of the patient.
3 Apr 2010
Emma Graham-Clarke
First bed, a patient gradually getting better and now absorbing his nasogastric feed. I pause, think and then stop the IV ranitidine he’s been getting for stress ulcer prevention; I know that it’s important to prevent stress ulcers but I also know that acid suppression is associated with gastric bacterial overgrowth and an increased risk of ventilator-associated pneumonia if aspiration of stomach contents occurs.
Prescribing for this patient as in so many cases is an act of balancing risk and benefit.
I move on to the next bed. This patient has been on laxatives and prokinetics for a few days, but I note she hasn’t had the previous couple of doses of laxatives. A chat with the nurse reveals that the patient is now absorbing her feed and that her bowels have opened — several times. Needless to say, I can’t consult the patient since she’s sedated and ventilated. I cross both prokinetics and laxatives off. The patient may not be aware of what’s happening but the nurse is grateful that there may be less cleaning up to do.
We then get a phone call from microbiology with a vancomycin level for another patient. She’d needed vancomycin for an infection, which had been started at an appropriate dose. However, the first level had come back a little high, so the next dose was omitted, and then the dose reduced. Unfortunately the next level is even higher so I cross the vancomycin off completely — we’ll wait for the levels to drop before we give her anything else. And so my morning continues, crossing off sundry unneeded medicines.
I attended a recent Intensive Care Society meeting and was struck by the first session themed “less is more”. The gist of that part of the programme was that just because we could do an intervention, or give a medicine, didn’t mean we should.
I have noticed that prescribers tend to be very good at starting medicines, but less good at stopping the ones that aren’t needed. As I thought about this session and how it related to my practice I reflected that since I completed the prescribing course I’ve probably stopped more medicines than I’ve started.
Less is more is a good mantra, and one that I fully intend to continue following. Will my patients know? I doubt it. But with luck there’ll be fewer complications and side effects.
Emma Graham-Clarke is consultant pharmacist for critical care at Sandwell and West Birmingham Hospitals NHS Trust
Shared Decision-making
Emma
That was a cracking article and a really interesting insight into your work. I was particularly interested in your 'less is more' musings, something that many other pharmacists will be familiar with, often as a result of discussions with patients about their medicines and what *they* want to do. Often this is after an explanation of the likely risks and benefits of an intervention, where a patient's ideas, concerns and expectations and indeed their wishes, may be different to that of the healthcare team.
I realise that communicating the risks and benefits to patients on ITU is impossible in many cases. But I wonder if you ever have a discussion with families about the risks and benefits of a particular therapy? After all, there is evidence to suggest that people have very different values from one another and while some may be willing to accept a theorectical risk for a perceived benefit, others may not.
Of course by not having this discussion at all, you are imposing your views about the risks and benefits of a therapy. Clearly, in many cases this is the only way but it may be interesting to reflect on instances where that may be possible.
Interested in your views
Jonathan Underhill,
Head of EBT, NPC
Consent?
Thank you for your interesting comments.
There are a number of aspects that govern our treatment which are worth reminding ourselves of:
1) The Mental Capacity Act. The only person who can consent is the patient. Family may be able to give an indication of what they think the patient would want (but this is their view, not necessarily the patient’s) but cannot consent. The exception to this is if one of them has a Lasting Power of Attorney.
2) Treatment for necessity. In the absence of the patient having capacity to consent, then treatment is initiated in order to improve the patient’s condition. Likewise treatment would be stopped if the risks now outweigh the benefits of that treatment.
Ultimately we aim to get the patient back to a state where they can participate in decision making again. As you mention, we all have different views on the relative risks and benefits, and this is no less true of family as it is of healthcare professionals.
Emma