Case Study: Exercising Critical Thinking and Judgement

November 16, 2016

“Just because you can; doesn’t mean that you should” - by Greg Eberhart, Registrar

In the May, July, and September 2015 editions of ACP News, I wrote a three-part series reminding pharmacists about our responsibility to exercise critical thinking and judgement in our professional practices. These are cornerstones to demonstrating professionalism. They are foundational to our responsibility to serve individuals within the limitations of our personal competence, guided by our Code of Ethics, and in compliance with ACP’s Standards of Practice for Pharmacists and Pharmacy Technicians. We are privileged to have the authorities provided through our scope of practice, we are responsible for using these privileges to best meet the health needs of individuals, and in doing so we must each be accountable to use them in a professional manner.

The following case illustrates an example of a pharmacist acting independently, failing to consider the importance of the health team, and initiating drug therapy absent of required evidence. It serves to remind us about critically evaluating the limitations of our roles and the services we provide, the evidence upon which we base our decisions, and the importance of working together with other members of individuals’ health team.

A middle-aged female suffering from severe Crohn’s disease was being treated by her gastroenterologist with Azathioprine and Infliximab. The patient presented to her pharmacist indicating that she had discontinued the treatment prescribed by her gastroenterologist for several months. The pharmacist prescribed Naltrexone, based on several publications, suggesting its efficacy for some autoimmune diseases such as psoriasis and Crohn’s disease.

The gastroenterologist expressed concern that:

  • Crohn’s disease is a complex condition requiring tight coordination of care, and that the pharmacist had failed to consult with the prescribing physician prior to instituting medical therapy on their own accord; and,
  • The use of Naltrexone is an off-label indication. Naltrexone has been demonstrated to have no benefit in inflammatory bowel disease (see Cochrane Systematic Review from February 2014). Low dose Naltrexone does not meet current standards of care and would fall outside any clinical practice guideline for the management of Crohn’s disease.

Analysis and Conclusion

Our investigation of this case confirmed that the pharmacist had acted independently, and had based his/her decision on published articles having little evidence. Naltrexone is not officially indicated to treat Crohn’s disease (Standard 11.6(a).) While there were published articles, they were limited and the “n” treated was small. Nothing was apparent in the literature establishing the use of Naltrexone to be a best practice or accepted clinical practice for the treatment of Crohn’s disease (Standard 11.6(b)). This was not prescribed as part of an approved research protocol (Standard 11.6(c)).

When learning that the patient had discontinued treatment, the pharmacist did not pursue discussion with the gastroenterologist or other relevant members of the individual’s health team (Standard 1.7(d) (iii)). Rather, the pharmacist assessed the individual and proceeded to independently treat the individual with a drug, lacking the necessary evidence for treatment.

In conclusion, the pharmacist did not exercise critical thinking to support the necessary reasonable judgement in this case. In this case the pharmacist should have contacted the gastroenterologist to discuss his/her assessment of the individual, and shared that the individual had chosen to discontinue the Azathioprine and the Infliximab. When doing so, it would have been appropriate to discuss the individual’s wishes and alternative treatment possibilities. The opportunity to discuss the health status of the individual and treatment alternatives with the gastroenterologist, could have leveraged the knowledge and experiences of each professional, to formulate the best alternative for the individual.

Takeaway

Next time that you assess an individual and identify a drug therapy problem, ask yourself:

  • Have I collected all of the information required to develop an informed conclusion about the problem?
  • Which other health professionals should I consult with, and what information should I share with and/or seek from them to develop a treatment plan?
  • What is the quality of evidence that will inform my treatment plan?  
  • Do I have the authority, the knowledge and the skills to treat the condition; and if so, what steps will I take to monitor the individual’s response? Alternatively, what recommendations might I provide to other members of the individual’s health team?

ACP Standards Relevant to this Case

1.7 A pharmacist must:

d) be aware of the circumstances in which the pharmacist should refer the patient to another appropriately qualified regulated health professional, including when:

i. the pharmacist does not have the training, experience or skills necessary to address the patient’s needs;

ii. the condition of the patient cannot be effectively treated within the practice of pharmacists; or

iii. the patient’s condition has not adequately or appropriately responded to drug therapy or other therapy within the practice of pharmacists.

11.6 A pharmacist must not prescribe a drug or blood product unless the intended use:

a) is an indication approved by Health Canada,

b) is considered a best practice or accepted clinical practice in peer-reviewed clinical literature, or

c) is part of an approved research protocol.


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