We should not be afraid to discuss death (Paul Forsyth)

Prognosis and death are topics that pharmacists historically have not had to broach with patients. Does becoming a prescriber change this?

After a first acute hospital admission for heart failure, for example, a patient has a worse prognosis than for most common types of cancer.

Pharmacist prescribers are likely to become involved in the care of these patients during an acute hospital admission or at a chronic management clinic.

During an initial admission patients in heart failure will be prescribed many medicines — taken to reduce mortality as well as to prevent hospital readmission and relieve symptoms. Therefore, if pharmacists are going to be involved in prescribing and up-titrating these medicines then it only seems fair that these pharmacists should be available to discuss with the patients the reasons why.

Patients should be monitored regularly for worsening of symptoms. Different medicines are indicated for heart failure as the patient progresses through his or her illness. Spironolactone is a good example of this, since it is typically considered when a person becomes either breathless upon very light “less than normal” activity or potentially breathless even when at rest.

It stands to reason that if a pharmacist becomes involved in a heart failure clinic and chooses to prescribe drugs like spironolactone then he or she must be prepared to explain this decision to the patient — and discuss the long-term pros and cons of the therapy. This, by its very nature, involves the topics of prognosis and death.

When I first qualified as a prescriber I was uncertain how to broach these with patients. In some ways I was scared about how the person might react. I certainly felt that the course hadn’t prepared me for this. But I also felt that my patients had a right to be given all the information they needed about their condition. National guidelines, heathcare standards and patient groups now all recommend as much.

Talking about long-term prognosis and death isn’t a skill that can be learnt and perfected overnight. All patients react differently to the subject and some patients don’t want to discuss it at all. Since qualifying as a prescriber in 2007 I have developed more confidence through shadowing colleagues and hearing how they managed the issue.

This also meant simply talking to patients and seeing what they knew about their heart failure and, most importantly, what they wanted to know.

Premature death is an inevitable end to many patient journeys. If, as pharmacists, we want to get involved in prescribing for chronic conditions, we shouldn’t be afraid of this and, using respect, tact and compassion, should be happy to discuss it.

 

Paul Forsyth is a heart failure pharmacist working in primary care for NHS Greater Glasgow and Clyde