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Acting in the patient’s best interests: how far would you go?

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As pharmacists we have an obligation always to act in the patient’s best interests. After all, according to the General Pharmaceutical Council’s “Standards of conduct, ethics and performance”, the first principle is “Make patients your first concern”. But just how far are you willing to go to justify your actions?

Recently, while working on a Sunday in a community pharmacy, one of our regular supervised consumption methadone patients came in. I knew something was wrong when I saw her because, as far as I know, she usually receives a takeaway dose on a Sunday.

I asked her what had happened. She explained that, due to unforeseen circumstances, she was unable to reach the pharmacy yesterday. She asked if she could just have today’s dose. 

“Let me check your records,” I said. In my head I thought to myself “please let the official Home Office wording be on the prescription so that I could give her today’s dose”. (For more information regarding the Home Office wording, have a look at Chapter 3.3.7 of ‘Medicines, ethics and practice’.) She had picked up all her other doses until Saturday.

Of course the wording was missing from the prescription, of course it had to be a Sunday when the drug clinic is not open, and of course it had to be my shift when such a situation arose. I explained to the patient that, unfortunately, without the official Home Office wording, I was unable to supply her today’s dose legally. Before she fully burst into tears I told her I would do what I could to rectify the situation.

I decided to ring the support helpline at head office for advice (fortunately, the company had decided to extend its support services to seven days a week recently, just in time to advise me on my dilemma). I told the support pharmacist on the telephone the situation, and asked if contacting a nearby out-of-hours surgery to explain the situation would be a good idea. The pharmacist said I could certainly try, but that surgery might not be licensed to issue methadone prescriptions or it might have a strict policy of not issuing emergency methadone prescriptions.

Another option, which involved me taking a risk, was to dispense the day’s dose for the patient and ask a colleague to contact the drug clinic and case worker the next day, explain the situation and ask for a prescription to cover the dose dispensed. I would have broken the law and illegally dispensed a Controlled Drug, but the support pharmacist said I needed to consider the welfare of the patient as well. 

The patient had gone for a walk to “clear her head”. This gave me the opportunity to clear my own head and decide on the next course of action.

I decided to ring the nearby out-of-hours clinic first. I discussed the situation with the receptionist. She said the surgery does provide methadone prescriptions but only to patients who are on its records already. There was an hour or so left before our pharmacy closed and the waiting time was about an hour at the surgery at the moment. I thanked the receptionist and said I would look into other options.

I telephoned the regular weekday pharmacist and told her the situation. I told her I had decided to give the dose to the patient and asked if she would contact the case worker and doctor tomorrow to try to obtain a prescription to cover that dose. She agreed.

I documented my courses of action. The patient returned. I gave her the dose and she was grateful. Afterwards she explained she had been having stomach cramps and diarrhoea, and was tempted “to use”. I was glad I gave her the dose.

The doctor, later that week, had generated a prescription to cover the dose I gave the patient.

There are no black-and-white answers for pharmacists on how to handle such situations. A pharmacist who turned the patient away would have been perfectly entitled to do so. I chose to take a risk and believed I was doing the right thing for the patient.

At the end of the day, as long as we can justify our actions, we have to be ready to face such ethical dilemmas. After all, that is what sets healthcare professionals apart from other professions.

 

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