Back into Study mode

For the last three days I have been working at my teaching job and today was the first day I got stuck into the studying again after my clinical placement.

This is what I got done today:
Reading
• Stockings for DVT prevention – how they work and how to use them
• Intravenous Therapy
• Guidelines for use of the National Inpatient Medication Chart

Pharmacology Online Tutorial
• Answered and submitted about 10 questions. This took quite a while because I had to research and provide references for the answers.

Online Ethical Discussion for Medications in Nursing
• I should have done this ages ago but kept putting it off. Had to contribute to two of the ethical issues on the subject's online discussion board. These were the questions I chose and the answers I wrote:

1. Your patient is confused and is refusing their prescribed medicatons which include an antihypertensive drug. Your patient's BP is 160/95 and the RN Div I asks you to crush the medications and mix them with the patient's breakfast. What do you do?

Medication should not be crushed and added to an adult patient's food without their knowledge. If you do not have the patient's consent to administer the drug, it is unethical and beyond scope of practice to do so. As a student, you can and should refuse to follow an order from an RN nurse if you know it is unethical, illegal or not best practice.

In the case of this patient, I would try to find out why the patient is confused, and why they are refusing their antihypertensive. It may be a good idea to come back an hour later when the confusion might have eased. If they are still refusing I would ask them to give their reason why. It might be necessary to re-educate them about what the drug is for.

I would educate them that the reason they have been prescribed the drug is that persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysms, and is the leading cause of chronic renal failure.

His blood pressure of 160/95 suggests he is on the borderline between Stage 1 and Stage 2 Hypertension. It is normal for blood pressure to be highest in the morning [www.merck.com/mmhe/sec03/ch022/ch022a] so on average he probably has Stage 1 hypertension and therefore taking the anti-hypertensive is very important in preventing him from getting to Stage 2.

If he is still refusing, I would page his doctor to come up and have a chat with him.

2. Is it okay to provide a placebo medication if it is in the patient's best interest?

Firstly, the placebo response is when the mere taking of a medicine has a psychological effect that produces a beneficial physical response. This response is often an important contribution to the overall effectiveness of a chemically active drug. It is most commonly seen in analgesics, antidepressants, and anti-anxiety drugs. There are also certain types of people, known as "placebo responders" who are more likely to experience the effect than others. (Royal Australian College of Practitioners New Guide to Medicines and Drugs, 2008)

In my opinion, as an ethical rule, doctors should not prescribe placebos because it is dishonest. Transparency and informed consent are very important aspects of medical treatment, and it would not be fair on the patient to provide a placebo but make them believe they are taking a real drug.

However in some situations it can be okay to provide a placebo, such as:
- in drug trials, to find out the differences between placebo responses and chemical responses, and the effectiveness of the drug. However, whether providing a placebo in this case is 'in the patient's best interest' or not is questionable. If it is part of their informed consent that they understand some participants will be provided with a placebo, then I think it is ok.

- in children when they bump their head or have a tiny scratch on their leg but are crying really uncontrollably, you could rub a little bit of lipbalm into the skin and tell them 'this is special ointment that will make it better'. In this case it is definitely in their best interest because it will help calm them down.

These are the only two ethical examples I can think of where it would be ok to provide a placebo.