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MMI Scenario 13
Mrs Adams presents to the community pharmacy with her son, Liam aged 8 years old with his prescription to fill. After handing over the prescription, Mrs Adams informs you she only wants the blue inhaler dispensed and not the brown one. When you enquire further whether she has any at home and why she requests as such, she angrily proclaim ‘No I don’t want Liam using any steroids it is bad for him and he is fine on just using his blue inhaler. He only ever has the blue inhaler issued, check your records.’
How would you manage this situation? What are your concerns and what is most important at this stage?
Example Answer
Patient ICE and barriers to change: Although Mrs Adams may come across assertive it is important to identify her concerns, ideas and expectations with records to her son’’s Asthma medication. What are her concerns with using the steroid inhaler? Is it side effects? Is it previous personal experience she or a close relative may have encountered? Has Liam ever tried using the brown inhaler? It is important to show empathy and understanding of her views as it is likely she has good reason for them, but it is important to balance this with the best interests of Liam, his asthma and his general health.
Shared decision making: It would be important to set some time, in an appropriate environment, like the consultation room to have an open person-centred discussion to ensure the benefits vs risks in using the steroid inhaler to Mrs Adams and aligned with Liam’s beliefs and expectations. Although Liam is young, is he competent? Does he recognise the differences in inhalers and what these can do? Does Mrs Adams know the difference?
Patient/parental understanding: Has Mrs Adams had a detailed conversation with the prescriber regarding the importance of using a brown inhaler in asthma therapy? Is it a short term trial or do the records suggest this is for long term maintenance therapy until review? Has he tried using the brown inhaler before, if so what happened?
Medication review/inhaler technique: It would be prudent to review inhaler technique and reassure Mrs Adams that brown inhalers are safe and effective in the treatment of asthma and limited systemic side effects are documented but provide strategies on how to reduce this. Review inhaler technique and counselling on how to use the pMDI ICS device. Is a spacer device co-prescribed – as this would greatly improve efficacy. This would be a good opportunity for wider health promotion on oral hygiene, teeth brushing and rinsing his mouth after using to further support Mrs Adams in realising there is limited amounts being absorbed if this is her main concern.
Asthma control: It would be useful to explore how often Liam is currently needing to use his blue reliever inhaler as using > 3 x week would indicate poor control and would reaffirm the need to ICS treatment which again could be used to educate Mrs Adams.
Clinical history: It is important to explain to Mrs Jones the evidence base behind using an ICS ‘brown’ inhaler to control the swelling of the lungs and prevent future asthma attacks, and the fact regular usage will prevent future SOB/Wheeze/asthma attacks. It is important to educate Mrs Adams on asthma treatment and the available evidence base behind ICS use, it might also be of reassurance to explain ICS treatment and dose tend to be reviewed and step down is an option especially as Liam develops and dose is not set in stone.
Audit: It is important to document the discussion via an intervention entry on the care record/problem solving folder in case of future audit.
Is her GP aware of this? Has Liam had his annual asthma review and has an asthma action plan been issued? Is this something that can be viewed to support decision making?
CPD: Importantly it is a good reflection on current practice, if it has been the case where Liam’s blue inhaler was only dispensed on previous visits, why wasn’t this flagged by other HCPs/pharmacists? Is this an opportunity for CPD and peer review to support patient safety and national initiatives. This could be a clinical meeting and how this could be prevented going forward by undertaking an asthma workshop/tutorial so all colleagues are in alignment with best practice to enforce standards.
Voluntary organisation/charity: Are there any other resources/organisations we can signpost Mrs Adams to further support her understanding around asthma, i.e. practice nurse/GP, Asthma UK? RightBreathe? It might be also good to print off some information on inhalers from Patient UK so a written patient decision aid can help optimise informed decision making.
Patient preference: Is there an alternative inhaler which can be explored? Perhaps Mrs Adams’ concerns exist with the inhaler format itself, or the brand? This all needs to be considered as part of our holistic approach to medication review. In particular, what non-pharmacological measures can be adopted to support Liam, e.g. explore triggers and devise methods to prevent this, exercise, breathing techniques?
Shared decision making: It would be important to set some time, in an appropriate environment, like the consultation room to have an open person-centred discussion to ensure the benefits vs risks in using the steroid inhaler to Mrs Adams and aligned with Liam’s beliefs and expectations. Although Liam is young, is he competent? Does he recognise the differences in inhalers and what these can do? Does Mrs Adams know the difference?
Patient/parental understanding: Has Mrs Adams had a detailed conversation with the prescriber regarding the importance of using a brown inhaler in asthma therapy? Is it a short term trial or do the records suggest this is for long term maintenance therapy until review? Has he tried using the brown inhaler before, if so what happened?
Medication review/inhaler technique: It would be prudent to review inhaler technique and reassure Mrs Adams that brown inhalers are safe and effective in the treatment of asthma and limited systemic side effects are documented but provide strategies on how to reduce this. Review inhaler technique and counselling on how to use the pMDI ICS device. Is a spacer device co-prescribed – as this would greatly improve efficacy. This would be a good opportunity for wider health promotion on oral hygiene, teeth brushing and rinsing his mouth after using to further support Mrs Adams in realising there is limited amounts being absorbed if this is her main concern.
Asthma control: It would be useful to explore how often Liam is currently needing to use his blue reliever inhaler as using > 3 x week would indicate poor control and would reaffirm the need to ICS treatment which again could be used to educate Mrs Adams.
Clinical history: It is important to explain to Mrs Jones the evidence base behind using an ICS ‘brown’ inhaler to control the swelling of the lungs and prevent future asthma attacks, and the fact regular usage will prevent future SOB/Wheeze/asthma attacks. It is important to educate Mrs Adams on asthma treatment and the available evidence base behind ICS use, it might also be of reassurance to explain ICS treatment and dose tend to be reviewed and step down is an option especially as Liam develops and dose is not set in stone.
Audit: It is important to document the discussion via an intervention entry on the care record/problem solving folder in case of future audit.
Is her GP aware of this? Has Liam had his annual asthma review and has an asthma action plan been issued? Is this something that can be viewed to support decision making?
CPD: Importantly it is a good reflection on current practice, if it has been the case where Liam’s blue inhaler was only dispensed on previous visits, why wasn’t this flagged by other HCPs/pharmacists? Is this an opportunity for CPD and peer review to support patient safety and national initiatives. This could be a clinical meeting and how this could be prevented going forward by undertaking an asthma workshop/tutorial so all colleagues are in alignment with best practice to enforce standards.
Voluntary organisation/charity: Are there any other resources/organisations we can signpost Mrs Adams to further support her understanding around asthma, i.e. practice nurse/GP, Asthma UK? RightBreathe? It might be also good to print off some information on inhalers from Patient UK so a written patient decision aid can help optimise informed decision making.
Patient preference: Is there an alternative inhaler which can be explored? Perhaps Mrs Adams’ concerns exist with the inhaler format itself, or the brand? This all needs to be considered as part of our holistic approach to medication review. In particular, what non-pharmacological measures can be adopted to support Liam, e.g. explore triggers and devise methods to prevent this, exercise, breathing techniques?