Evidence-based Practice.Clinical Scenario - Essay Example

?Evidence-based Practice Clinical Scenario Mr. Miller, a computer programmer, is a moderately obese 51 year old man with type 2 diabetes, first diagnosed 8 years ago with the disease. In an effort to improve his health, he is trying to quit his smoking habit of some 30 years. Recently at work they offered him an employer-subsidized treatment with nicotine patches to help him quit smoking. However this had previously failed once before and he was reluctant to take bupropion as it was an antidepressant, a group of drugs which he had concerns about. No diabetes complications have been detected thus far and his blood sugar levels appear well controlled. He does have osteoarthritis that has manifested in both knees. His blood pressure has recently become mildly elevated averaging 160/94 mmHg during his past two visits. Mr. Miller regularly searches the internet if he has a health question and his wife has encouraged him to take large doses of vitamin E and fish oil for his heart, glucosamine for his knees, and St John's Wort to help him stop smoking, based on health information gained from their internet searches. Introduction This case of Mr. Miller accurately demonstrates the case of a patient who has learned to take on a more active and engaged role in his own care. Being engaged in one’s care is an important part of the recovery process because it can help ensure long-term recovery (Longtin, et.al., 2010). In the current age of computers and the internet, patients can easily be informed about their diseases, their symptoms, their prognoses, including their treatment options (Longtin, et.al., 2010). Problems may however be seen when patients do not adequately understand the information they read and are wrongly influenced to make the wrong decisions on the basis of misunderstood and sometimes inaccurate information (Young, 2011). The routine use of over-the-counter medications as well as herbal and other traditional medicines is also an issue in the current medical practice. These practices however also include significant issues relating to the inaccurate appreciation of facts and information, issues with the product itself, side effects, and the presence of unknown active ingredients in possibly contaminated products (Young, 2011). This essay will evaluate the different communication strategies which can be used and advised for health professionals and patients. It will specifically evaluate evidence relating to Mr. Miller’s use of smoking cessation interventions. A multidisciplinary care plan will also be proposed in order to address Mr. Miller’s health issues. He is already old enough to make a logical and informed decision of his care and therefore it is important to also include him in the decision making process. Based on information gathered on the patient, there are various lifestyle variables which may be affecting his health, including his smoking, his obesity, and his inactive lifestyle. These issues all related to each other, especially as they may make some of the symptoms worse or may be the cause of the other manifesting symptoms. Communication In the healthcare delivery, communication is an ever important requisite, not just between patients, but also between the healthcare professionals managing the patient (Tarn, et.al., 2012). Effective communication is a tool which is needed in order to establish an evidence-based standard, to allow processes to be carried out with the patient and his wife as well as to ensure that informed choices are made on his care (Tarn, et.al., 2012). Communication skills include the establishment of patient rapport, clear and coherent communication, empathy, responsiveness to the patient’s needs as well as his emotions during admission, as well as correctly interpreting non-verbal cues (Tarn, et.al., 2012). The different communication strategies have been presented, relating to specific elements in the decision-making process. These elements include clearly communicating evidence-based data from the health professional to the patient, accurate patient interpretation of the data, and discussions of such data between health professional and client (Tarn, et.al., 2012). Wensing and colleagues (2002) point out the elements of patient-focused communication as well as shared decision making as elements of clinician and patient communication. Patient-focused communication includes different variables including the evaluation of the disease and the illness, understanding of the entire person, inclusion of health promotion processes and illness management, establishing a common foundation for the client and the patient, improving clinician-patient relations, and acknowledging realism (Wensing, et.al., 2002). Shared decision making is a different focus for the assessment of clinician-patient relations based on the decision-making process being shifted from the health professional to the patient who can make an informed decision about his care. The communication process also includes the importance of clearly interpreting and informing the patient of the data he needs in order to help him make the right decisions on his care (Evans, et.al., 2011). This would usually include the process of simplifying technical information for the patients. The words used in explaining evidence-based data to the patient would have to include the use of simply words which the patient can understand (Evans, et.al., 2011). In cases where the patient does not understand the discussion, the clinician must note non-verbal cues, including confusion or simply lack of clarity during the discussion. When these signs of confusion are noted, the appropriate adjustments must be made in order to provide clarity to the patient (Evans, et.al., 2011). Communication also highlights the importance of providing an engaged discussion with the client regarding his treatment options. Clarificatory questions can be asked during these discussions, allowing the patient to freely ask about his options and to discuss with the clinician why he wants to consider certain choices and why he is refusing other options in his care (Johnston, et.al., 2012). The patient may not understand certain options well. It is therefore incumbent upon the clinician to discuss the medical options with the patient, ensuring that the patient has the right understanding of the treatment options. Evidence Evidence from studies gathered from searches of The Cochrane Library, MEDLINE and CINAHL databases using keywords: "glucosamine", "St. John's Wort", "smoking", "NRT", "bupropion", "diabetes", "osteoarthritis" and "obesity" established significant data which needed to be transmitted to Mr. Miller in order to assist him in making a duly informed choice about his care. The impact of the Mental Health Nurse for the patient within the realm of the multidisciplinary team covering his health problems would be to help him cease his smoking habit and to provide data on possible options and over-the-counter interventions to manage his health issues. Mr. Miller has already expressed a desire to quit smoking and has expressed that he is not eager to take bupropion because of its anti-depressant effects; moreover, he is already wary about taking any antidepressants to manage his health issue. The discussion with Mr. Miller about his preferences and concerns helps support open communication and would likely reveal the concerns and perceptions he has about these drugs. In general, Mr. Miller must be made aware of the best available evidence on the drug. In the study by Mahmoudi, et.al., (2012), the authors carried out a systematic review on the cost-effectiveness of varenicline and buproprion SR for smoking cessation, mostly assessing differences in the models, evaluating which variables impact on discussions of cost-effectiveness. Their review established that varenicline dominated buproprion in terms of cost-effectiveness; nevertheless, the study does indicate that buproprion increases the efficacy of smoking cessation (Mahmoudi, et.al., 2012). However buproprion does present with side effects like nausea, dry mouth, as well as insomnia (Mahmoudi, et.al., 2012). The patient is not too keen about confronting and experiencing such side effects. These side-effects are likely to cause more stress and health frustrations, often making the process of smoking cessation even more stressful and unfavourable. Nicotine Replacement Therapy seems to present with better results for patients. Potential benefits in the use of the drug have been seen, which seem to also increase possibilities in quitting smoking. Risks appear to be relative and are on a case-to-case basis (Stead, et.al., 2012). The presenting side-effects and the risk of stroke do not appear to be an acceptable risk for Mr. Miller; nevertheless, through the process of uncovering details on its use, he can make an informed decision about his medication options. As he is informed more about Nicotine Replacement Therapy, he can also make accurate and evidence-based considerations on his care. In effect, he can use evidence from research to justify his choices and to reassure himself that he is indeed making the right choices regarding his care. Nicotine Replacement Therapy has been used by Mr. Miller before through transdermal patches; however he did not respond well to its use. However, studies do indicate that different types of NRT can increase the efficacy of smoking cessation (Stead, et.al., 2012); in effect, using inhalers, tablets, nicotine gum, or even nose sprays can be used by Mr. Miller in order to aid his efforts to end his smoking habit. Inhalers, nose spray or tablets are alternatives that may be acceptable to Mr. Miller. Evidence also indicates that NRT can present with improved outcomes even without any additional supporting counselling or psychotherapy. In effect, although transdermal patches do not work well with Mr. Miller, he can still consider other options in Nicotine Replacement Therapy including inhalers, tablets, or nicotine gum. He may respond better to these options and can use these options instead in order to assist him in his goal to end his smoking habits. Presenting this evidence to the patient would give him the proper tools and resources he can consider and evaluate in order to make an independent and well-informed choice. Mr. Miller indicated that he is taking large doses of Vitamin E and fish oils, as well as glucosamine and St. John’s Wort. He would therefore appreciate if the health professionals would also respect those choices and would be willing to appreciate the benefits of these choices in his goal to stop smoking (Michie, et.al., 2011). He would therefore appreciate a clinician who would allow him to make his own choices, and is open to the possible improved outcomes from his specific treatments. Based on various studies, patients applying complementary and alternative remedies do so because they believe that these healthcare options are more in line with their health values and beliefs (Brownson, et.al., 2009). There are times however when these patients are not willing to express their treatments because they expect unfavourable responses from clinicians. Some of them feel shame in expressing that they are taking herbal medications, especially as most clinicians are not supportive of these medication options (Brownson, et.al., 2009). Nevertheless, some of these complementary and alternative treatments have beneficial uses for patients. In support of patient-centred care, the clinicians have the burden of ensuring that the medical options, including complementary and alternative therapies for Mr. Miller are safe, and that these options have limited issues relating to possible adverse effects (Brownson, et.al. 2009). Assessing their impact on patient safety would be the next best thing that the clinician can do, especially as the patient may find safety and comfort in these choices of care. Based on an assessment of evidence for patients with type 2 diabetes with the use of fish oil supplements, the results indicate that as fats in the blood are reduced, LDL cholesterol levels may also increase. Reduction of blood sugar levels was not affected and no adverse effects were apparent from the interventions applied (Rizza, et.al., 2009). The authors indicate that specific trials on sufficient duration and outcomes are essential in understanding whether the application of fish oils by patients with type 2 diabetes is justified. Based on findings for Mr. Miller and discussions on the advantages and disadvantages on the application of fish oils, there is a need to facilitate a shared decision making option on the favored integration on the product in his management. The Mc-Ewen, et.al., (2010) study indicates that based on reviews and studies relating to the use of fish and omega-3 LC-PUFA, reduction in total cardiovascular mortality was seen, including a lower platelet activation and aggregation, better lipid profiles, as well as decrease in triglycerides and very low density lipoprotein, as well as decreased blood pressure levels and decreased inflammation (McEwen, et.al., 2010). The authors concluded that diets with high levels of fish and omega-3 LC-PUFA provided improvements on cardiovascular issues relating to diabetes as it decreases platelet aggregation, improved lipid profiles, and decreased cardiovascular risks. Fish and omega-3 LC-PUFA is therefore a highly recommended treatment for patients with diabetes, and can be included in the diabetes management program (McEwen, et.al., 2010). Mr. Miller is also applying glucosamine to manage his osteoarthritis. Glucosamine has been evaluated much in the past few years, especially on its benefits in management symptoms for patients with osteoarthritis (Wandel, et.al., 2009). Most recent evidence indicates that glucosamine is a safe placebo and in the span of 2-3 months, it may decrease pain and support better functions, even if there is limited evidence supporting such indication (Wandel, et.al., 2009). Studies carried out on the Rotta brand indicated reasonable benefits. Mr. Miller may or may not actually feel that he is managing well from his glucosamine use, especially as it seems to be a safe alternative; there are no apparent disadvantages on its use. In a Cochrane Review carried out by Townheed, et.al., (2009), the research generally discussed that patients with osteoarthritis have experienced decrease in their pain levels, improvements in their physical functions, and were less likely to experience side-effects. Studies which evaluated that use of the Rotta brand indicated that glucosamine improved their pain more than did the fake pills. Those who took fake pills expressed pain at 6 on a scale of 0 to 20, while those who took Rotta expressed pain 3 points lower than those who took the fake pills (Townheed, et.al., 2009). Various studies indicate that glucosamine provided better functions more than fake pills hen evaluated by one kind of scale, and improved at the same degree with fake pills when assessed in another scale. Studies evaluating only the use of the Rotta brand indicated that glucosomine improved functions well, much more than the fake pills (Townheed, et.al., 2009). Those who took fake pills indicated function scores of 22 points on a scale of 0-68. Those who took the Rotta brand improved their functioning by 2 points when compared to those who were not on glucosamine (Townheed, et.al., 2009). Based on these results, the Rotta brand presents with favourable options for patients, especially Mr. Miller who has an engaged attitude about the use of Rotta and glucosamine in the management of his osteoarthritic pain and compromised functions. Vitamin E is also non-prescription choice which Mr. Miller has made for himself. He is supported in this choice by his wife because it is said to assist and improve his heart functions. Studies carried out on the potential benefits of Vitamin E indicate improvements in cardiovascular health; however, there is no reasonable evidence which would support such theory (Shekelle, et.al., 2004). Moreover, studies also suggest that there is no statistically relevant relationship between vitamin E at high doses and mortality; this indicates that doses at 400IU/d or higher must be applied with care (Braun, 2006). Understandably, Mr. Miller believes that Vitamin E presents with better options in the management of cardiovascular diseases because general health information indicate that Vitamin E is an antioxidant which helps protect the body from tissue damage. They also assist in strengthening the immune system and in the formation of red blood cells; however, “whether vitamin E can prevent cancer, heart disease, dementia, liver disease, and stroke is still not known” (Evert, 2011). Mr. Miller is taking high doses of Vitamin E. However, with inadequate evidence supporting the efficacy of this option, it is important for him to be given sufficient evidence on such inadequate evidence in order to empower him in his choices relating to the product as well as to secure relevant applications of medical and scientific variables of practice (Evert, 2011). St. John Wort is an herbal supplement which acts as an anti-depressant. It is being taken by Mr. Miller believing that the supplement can help him in quitting smoking. Quitting smoking has been associated with depression; however the benefits of St. John’s Wort towards quitting the habit of smoking have not been adequately studied (Barnes, et.al., 2001). A Cochrane Review by Barnes (et.al., 2001) did not refer to results indicating the efficacy of St. John’s Wort in relation to quitting smoking. In addition, St. John’s Wort also seems to impact on liver functions in relation to medication processing. The recent randomized controlled trial carried out by Sood and colleagues (2010) indicated the use of St. John’s Wort did not soothe withdrawal symptoms among smokers wanting to quit. The abstinence rates were also not different for the different study groups among the subjects who had 75% of the study medication. No relevant side effects were seen with St. John’s Wort. Nevertheless, the remedy did not improve the rates of smoking cessation (Sood, et.al., 2010). In effect, the drug has little support in terms of improvements relating to smoking cessation. There is a need therefore to reassess Mr. Miller’s follow-up consultation in order to assess potential relations on his current intake of St. John’s Wort. Care Plan 1. Problem: Obesity Goals: • Lose weight, reach a BMI of 25 or even below • Decrease weight by improving diet, shifting to healthy foods and increasing exercise. Needs • There is a need for Mr. Miller to discuss with the dietician a viable and effective weight loss diet, especially one which would still promote blood glucose balance, avoiding hypoglycemic incidents. This plan must be based on his preferences and the diet he can actually work with • The patient also needs to work out a plan with a physiotherapist, mostly in relation to an exercise program which would support weight loss while still maintaining sustainability and allowing for effective management and participation in daily activities. These exercises should include those exercises which would work well for him, which can help ensure compliance and effective weight loss and subsequent maintenance. 2. Problem: Type 2 Diabetes Goal(s): • Maintain Mr. Miller’s blood glucose levels within normal levels, avoiding extreme levels of glucose – too high (hyperglycaemia) or too low (hypoglycaemia). • There is also a need to inform and education Mr. Miller about the expected consequences and complications of high blood glucose levels, mostly in terms of the complications of hyperglycaemia and hypoglycaemia. Needs: • Advice and more information on the management of diet especially of glycaemic balance. • Health education with the physician and the nurse 3. Problem: Hypertension Goal(s): • Keep blood pressure levels within normal parameters. Needs: • Lose weight • Quit smoking 4. Problem: Smoking Goal(s): • Smoking cessation Needs: • Information on the use of varenicline v. buproprion to support a well-informed decision on the options for smoking cessation. • Support from family and friends, depending on Mr. Miller’s choices in support system. 5. Problem: Osteoarthritis Goal(s): • Management of pain and symptoms relating to limits in general mobility attributed to osteoarthritis. • Slow the degeneration process Needs: • Significant weight loss • Physiotherapy 6. Problem: Use of over the counter products Goal(s): • Safe application and adequately understanding of complementary and alternative medication options. Needs: • Advice relating to open discussions and shared decision making processes. • Ability to understand and access quality data, mostly on research sites he can easily access, including Medline, PubMed, Cochrane, and EMBASE in order to help him understand the importance of quality information in order to support informed choices in terms of possible other health care needs which may arise in the future. Summary This essay was initiated based on the condition of Mr. Miller, who is a moderately obese computer programmer who is also a smoker. He also has osteoarthritis, and type 2 diabetes, which is the major health issue which he is suffering for now. Mr. Miller has and is often checking the internet in order to be informed about his general health condition. He has also been taking various over the counter medications in order to assist him in ending his smoking habit. Effective communication with the patient was considered in order to ensure that he understands the issues of evidence-based practice and to support open discussions and shared decision-making, mostly highlighting discussions on challenging issues. Specific evidence on smoking cessation and over-the-counter medications which the patient is taking was established following with a multidisciplinary care application to support Mr. Miller’s health issues. Conclusion The case of Mr. Miller refers to a case indicating how most people have now become more informed about their health. They can easily access information through the internet and through health professionals. Most of the patients today are not inclined to support paternalistic decision-making processes and mostly seek to establish active roles in decisions on the management of their care. Effective communication for patients which cover patient preferences, values, as well as expectations with the best evidence will lead to significant research results, which can help clinicians and patients on choices relating to their care. References Barnes, J., Anderson, L., & Phillipson, J. (2001). St John's wort (Hypericum perforatum L.): a review of its chemistry, pharmacology and clinical properties. Journal of Pharmacy and Pharmacology, vol. 53, no. 5: 583–600. Braun.com. (2006). Baby and toddler nutrition. Retrieved from http://braunhousehold.com/global/baby-nutrition-centre/baby-and-toddler-nutrition/ Brownson, R. C., Fielding, J. E., & Maylahn, C. M. (2009). 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Recommendations for Using Online Social Networking Technologies to Reduce Inaccurate Online Health Information. Online J Health Allied Sci., vol. 10, no. 2: 2. Read More