Ethical and Legal Implications of Prescribing Drugs
This article reviews a scenario involving an 85-year-old female patient, MA, residing in a long-term care facility. MA has significant cognitive decline. Her physician notes that her death is near as she has terminal health issues such as renal failure and CHF. She has been on blood thinners for two decades due to a valve replacement procedure. She is always in pain during lab draws for her INR. This scenario raises the ethical and legal question of whether continual monitoring of the INR is needed given her terminal status and presents the ethical and legal implications of prescribing drugs.
Ethical and Legal Implications of the Scenario on All Stakeholders Involved
There are various stakeholders involved in caring for MA. These include the prescriber, the pharmacist, the patient, and the patient’s family. MA’s situation has varied ethical and legal implications for each stakeholder involved. For instance, the prescriber in the case has the prescriptive authority to prescribe the INR for continuous monitoring of MA’s condition. Various laws and standards for prescription drugs govern prescriptive authority, whether full or limited authority. Having a prescriptive authority gives one a responsibility to ensure the safety of the patient and avoid complications related to errors in the medication process. Safe and competent prescription and management of medications require an understanding of the drugs and the health conditions they are used for (Rosenthal & Burchum, 2021). It also requires a consideration of the existing regulations and ethical obligations of the health professional prescribing the drugs. The prescriber is ethically and legally obligated to ensure that the benefits of the continued INR outweigh the suffering MA undergoes during every lab draw and ensure that the continued INR monitoring is conducted per the patient’s end-of-life wishes.
The pharmacist is also legally and ethically obligated to ensure that the continued prescription and administration of blood thinners to MA is correct and does not complicate the patient’s current physical and mental health status. Additionally, the pharmacist must ensure the blood thinner therapy improves MA’s quality of life in her end days. The pharmacist should continuously communicate with the prescriber on all orders made for INR to ensure reduced risks for potential errors in the prescription of blood thinners. In collaboration with the prescriber, the pharmacist has the practitioner’s role and responsibility of providing information to the patient and their family and helping them understand the details of the therapy, including the intended therapeutic effect, risk of side effects and unwanted outcomes, and the approaches to be adopted in case of unwanted and unexpected outcomes (Arcangelo et al., 2017, p. 46).
As the patient and recipient of care in the scenario, MA has the right to autonomously decide whether she needs the INR and care provided to continue or discontinued. On the other hand, the patient’s family needs to be a part of the decision-making process in a relational capacity. They can make the end-of-life decision for MA in case her declining cognitive abilities incapacitate her to make such decisions. Healthcare providers must respect the patient’s and her family’s decisions. Ensuring autonomy at the end of life can help support decisions on treatment and care as well as support the patients’ engagement in the care plan as they actively prepare for dying (Houska & Loučka, 2019).
Disclosure and Nondisclosure Strategies in Alabama
In MA’s case, the physician believes that her death is near based on her current terminal status. The physician has the responsibility of disclosing this information to the patient and her family. However, disclosure and nondisclosure in end-of-life care must consider both legal and ethical perspectives. In the state of Alabama, the law provided in the 206 Code of Alabama, AL Code § 22-8A-1 (2016) Section 22-8A-1, the Alabama Natural Death Act, provides procedures for the termination of medical and other life-sustaining procedures. In the disclosure, the physician must provide details on the INR monitoring and the patient’s status to gain informed consent to discontinue treatment at the end of life. Although Alabama has no specific death with dignity legislation, the Alabama Natural Death Act has a provision that requires health providers to disclose the patient’s condition to the patient and their family. The Alabama Natural Death Act provides competent adults to decide on the withdrawal of life-supporting care in the case of permanent terminal conditions resulting in prolonged or permanent unconsciousness.
On the other hand, nondisclosure of the patient’s status and the need to discontinue INR monitoring and MA’s care may be allowed in Alabama for various reasons. Nondisclosure may be allowed in cases where the disclosure violates the patient’s privacy and confidentiality; for instance, when a patient’s visitor has no privilege to know of the patient’s health status. The physician can also consider the cultural views held by MA and her family and their sensitivity to death. It is also important to consider the impact of the disclosure on the patient and their family’s mental health before the disclosure decision is made.
Decision-Making Strategies for the Advanced Practice Nurse
The best decision-making strategies as an advanced practice nurse (APN) in the case of MA are to share the decision-making processes with the patient and her family and consider the ethical principles in decision-making and guiding obligations to error reporting as an APN. Shared decision-making is essential in MA’s situation as it can help avoid provider liability in case of adverse outcomes, including death. As an APN in charge of her care, I would engage the patient and her family in open communication to explain to them MA’s condition and the decisions that need to be made. Shared decision-making in end-of-life care respects and guarantees the autonomy of the patient and the surrogates in the decision-making process (Houska & Loučka, 2019).
Additionally, considering the ethical principles in decision-making ensures that the APN can observe and respect the wishes of the patient. It also helps the APN to provide care that is beneficial to the patient and has the lowest risk of mental or physical harm to the patient and their family. Therefore, it is possible to decide whether to continue or discontinue the INR monitoring and care based on the outcomes of comparing the benefits of continuing the INR monitoring to the harm done to the patient. In case the continued INR monitoring and blood thinner therapy are errors, I will be ethically obligated to report the errors. Reporting the errors can help implement timely and correct interventions to reverse the impact of the errors and reduce or prevent the risk of adverse patient outcomes.
Process of Prescription Writing and Minimizing Medication Errors in Prescriptions
Medication errors can be reduced and prevented in the process of prescription by following the right prescription writing procedures. The correct procedure starts with a review of patient documentation and the physician’s order. This can involve a review of the accuracy of documentation. The next step is to consult or refer to the physician for further clarification and confirmation of the order. Lastly, it is important to double-check after writing the prescription and use an authorized database for prescription writing. Familiarizing oneself with drug interactions and educating patients on drug administration can reduce medication errors in both prescription and administration (Camargos et al., 2021).
Conclusion
In conclusion, MA’s scenario highlights the ethical and legal implications of prescribing drugs for various stakeholders during care delivery. It clearly shows the need for shared decision-making, respecting patient autonomy, and observing ethical principles in making care decisions at the end of life. The specific laws guiding disclosure and nondisclosure in Alabama can help guide decisions on providing care in the end-of-life scenario.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V. F., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach (4th ed.). Wolters Kluwer.
Camargos, R. G. F., Azevedo, C., Moura, C. de C., Manzo, B. F., Salgado, P. de O., & da Mata, L. R. F. (2021). Safety protocol on medication prescription, use and administration: Mapping of nursing interventions. Texto e Contexto Enfermagem, 30. https://doi.org/10.1590/1980-265X-TCE-2020-0511
Houska, A., & Loučka, M. (2019). Patient’s Autonomy at the End of Life: A Critical Review. In Journal of Pain and Symptom Management (Vol. 57, Issue 4). https://doi.org/10.1016/j.jpainsymman.2018.12.339
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier.