Effective Communication Needed between Providers and Patients with Allergic Rhinitis - Essay Example

?Patch 2 nose allergic rhinitis looks at advanced communication skills and models available with patients also relevance of patient being an adolescent Allergic rhinitis is also known as hay fever. It is an inflammatory condition of the nasal mucosa and caused by an exaggerated immunologic (immunoglobulin E [IgE]) response to an allergen. Symptoms include nasal congestion and discharge, sneezing, pruritus. The patient will experience the symptoms only during a time of the year when seasonal rhinitis attacks, usually varies seasonally. Allergic rhinitis is caused by an exposure to an outdoor allergen such as pollens, environmental molds, or sometimes, foods (Marple, Fornadley, Patel, Fineman, Fromer, Krouse, Lanier, Penna, PharmD, and the American Academy of Otolaryngic Allergy Working Group on Allergic Rhinitis, 2007). However, other patients may s experience symptoms all year-round and this is called perennial rhinitis. It may be caused by exposure to indoor allergens such as animal dander or dust mites. About 40% of patients suffer from both seasonal and perennial rhinitis this is why allergic rhinitis was classified by frequency and severity of symptoms (Storms, 2002). The Gallup Study of Allergies (2005) has established that allergic rhinitis is characterized by sneezing, rhinorrhea, nasal discharge, nasal congestion, itchy or watery eyes, or headaches. Common mediators are histamine and leukotrienes. While the disease itself is not very serious, the symptoms of allergic rhinitis are bothersomeand considered by by many patients as serious and debilitating. Some 59% of patients with allergic rhinitis consider their condition moderately severe or severe. It was indicated in the study that in one out of five patients, they feel their health care provider downplay their allergy symptoms (Gallup Study of Allergies, 2005). However, it was also found that most patients avoid getting medical care to treat their symptoms. Many patients manage their illness using one or more over-the-counter (OTC) medications. They select the OTC based on the most troubling symptom or symptoms (Gallup Study of Allergies, 2005). Patient with allergic rhinitis feel that their symptoms are bothersome, serious or debilitating. Many want rapid-onset and long-lasting symptom relief without side effects from treatment according to the Asthma and Allergy Foundation of America (AAFA, 2005). However, the most appropriate allergy treatment should be based on the results of allergy tests, medical history such as triggers and seasonality of symptoms, family history of allergies, past and current treatment, and severity. Medical practitioners, however, should take into consideration patient expectations and tolerances. “Treatment can include avoidance of allergen, pharmacotherapy, and/or allergen immunotherapy. The treatment plan must also consider co-morbid conditions,” (Marple et al, 2007, S108). Affected persons can still lead normal and productive lives through proper management and patient education. Treatment should have a rapid onset and convenience, safe and cost effective, immune tolerant, improved patient adherence, and recognized and treatment co-morbidities (Marple et al, 2007). Allergic rhinitis impacts on patient well-being and functioning as it impairs the quality of life such as vitality, psychological and social aspects of the patients’ lives, energy and behavior of children, cognitive functioning and mood, and school or work performance (Tanner et al, 1999). Children with symptomatic allergic rhinitis are inattentive, absent-minded, irritable, preoccupied, or impaired in learning and school performance. Children aged 10 to 12 years had significantly deficient learning retention as exaggerated by the use of a sedating antihistamine and partially mitigated by the use of a non-sedating antihistamine as compared to children without the disease (Vuurman et al, 1993). It is highly possible that allergic children may be asked to leave the classroom due to disruptive behavior. Worse if they may be misdiagnosed as having attention deficit/hyperactivity disorder (ADHD). Allergic rhinitis on children may be further complicated by increased absenteeism and diminished academic performance (Vuurman et al, 1993). Effective Communication Needed between Providers and Patients In the AAFA (2005) survey of allergic rhinitis patients, many have indicated that they were not satisfied with the care they were receiving from their health care providers. Almost half or 48% of the discontented patients said that the practitioner was not giving enough time discussing their condition. Almost a third (29%) of the patients surveyed who were taking a prescription allergy medication said that they are not made aware of what class of medication they were taking or how the medication relieves their symptoms (28%). The study suggested for a need for health care providers to open a dialogue with their patients about the allergies and the specific allergy medications they were given. The patients should be informed about the mechanism of action of medicines, potential side effects, and interactions with other medications (Marple et al, 2007). 92% of the survey respondents admitted being comfortable discussing their disease with a health care provider. Physicians should therefore initiate such conversations because patients usually assume a passive role when speaking with their physician about availability of treatment options (Marple et al, 2007). Health care providers must understand patient expectations to encourage medication adherence, patient satisfaction, and confidence (Marple et al, 2007). It is important that health care providers initiate an encouraging dialogue with their allergy patients in order to increase patient knowledge about allergic rhinitis and its treatment. Clinicians will better understand patient expectations in this manner. Clinicians must spend enough time during an office visit to find out the patient’s preferences for treatment such as which symptoms or side effects bothers him the most, prior experiences with allergy medications, and other information that will enhance treatment procedure. Some of the needed information may include previous experience with the use of a nasal spray, problems associated with taste or smell, nosebleed, headaches, dripping or burning sensation, and others. “A clinical decision about treatment can then be made based on the best available evidence, with the clinician selecting from the vast array of available medications one that matches the patient’s clinical profile and medication attribute preferences. Such a discussion allows a clinician to select a medication that is tailored to a patient’s needs rather than being arbitrary (eg, from samples in the cabinet). Emerging templates for the office visit advocate evidence-based choice and decision making that is shared with the patient; this approach emphasizes respect for patients who want to be involved in their own health care decisions,” (Marple et al, 2007, S110). Clinician should strive to provide information about patient condition and instruction on the correct way to use medication, and then be monitored for satisfaction during a follow-up contact/office visit to increase the favorable outcome (Marple et al, 2007). It is also important that the patient’s access to the prescribed medication such as helath plan coverage or availability be considered in treatment choice (Marple et al, 2007). It was found that physicians typically spend an average of less than 1 minute during an office visit discussing treatment and planning with their patients (Braddock, 1999). The study by Braddock (1999) also indicated that physicians incorporate informed decision making in 9% of office visits, and ask patients if they have any questions in less than half of outpatient visits. The study highlighted the lack of optimal communication patterns between physician and patient. Health care providers must strive to involve non-physician practice personnel in patient communication and education efforts since there was lack of effective communication between the health care provider and patient which is a crucial element for optimal treatment. This lack of effective communication leads to poor disease control, poor compliance, and unhappiness in a significant portion of patients (Braddock, 1999). It was also noted that out-of-pocket costs such as co-pay against cost of drugs not within health plan coverage also influence adherence of a patient to treatment for a chronic disease (Marple et al, 2007). Communication model to discuss evidence with patients Health care providers should follow five steps in communicating decisions with their patients that will advance the likelihood for improved adherence and outcomes: 1. Understand the patient’s and family members’ experience and expectations 2. Build a partnership using active listening and empathy, and pausing to check for patient understanding 3. Provide evidence, including a balanced discussion of uncertainties 4. Present recommendations informed by clinical judgment and patient preferences 5. Check for patient’s understanding and agreement with recommendation (Epstein et al, 2004, 2360). Patch 3 Julius Sim. 1998. Respect for autonomy: issues in neurological rehabilitation. Clin Rehabil 1998 12: pp. 3-10 Patch 3 Respect for decision-making In decision making, autonomy of the patient is respected as well as promoted. Autonomy is defined as the “capacity to think, decide and act on the basis of such thought and decision freely and independently,” (Gillon, 1985, 1806; Sim, 1998). Sim (1998) suggested that physical impairments restrict autonomy of action but may not affect autonomy of decision-making. “Cognitive impairment may undermine autonomy of decision-making while leaving autonomy of action largely untouched. The fully autonomous person must possess both types of autonomy,” (Sim, 1998, 3). Autonomy is also similar to the idea of informed consent where patient has voluntary and revocable agreement to participate in a therapeutic or research procedure but with adequate understanding of its nature, purpose, and implications (Sim, 1986, 584). In relation to patient autonomy, informed consent has four constituent elements of disclosure of which adequate information is provided by the practitioner; comprehension of which the patient understands the information; competence of which ability of the patient can make a rational decision based on the information received; and voluntary of which undue influence on the patient’s decision was absent (Sim, 1998). Autonomy is provided and encouraged on patients when they are allowed to participate fully in decisions concerning their health, future, and consent to decisions properly obtained prior to being carried out by members of the health or rehabilitation team (Sim, 1984). “Accordingly, the ethical principle of respect for autonomy requires health professionals to preserve, and to enhance the ability of patients to exercise such self-determination. If we accept that autonomy is a valuable part of people’s lives, there is clearly an onus upon those working in rehabilitation to promote the autonomy of their patients,” (Sim, 1998, 5). Problems of Decision-Making and Communication Patients who have neurological insult frequently have communication disorders such as dysarthria, receptive or expressive aphasia (Sim, 1986). This results to difficulty in conveying their desires and intentions to the health professional as well as not understanding the information imparted to them by the professional. In the patient-professional relations, these are required if informed consent is to be fulfilled. If these channels of communication are blocked or disrupted due to the patient’s neurological condition, it is difficult for the health professional to ensure that adequate consent has been achieved for any planned rehabilitation. “It is no solution to suggest that if consent is not forthcoming the professional should simply not intervene, because this is itself a decision to which the patient’s consent should normally be sought. Another response to this situation is for the professional simply to do what seems to be in the patient’s best interests, thereby following the principle of beneficence,” (Sim, 1998, 7). Problems of Decision Making Competence Problems of decision-making or competence occurs when: 1. The patient may have difficulties understanding the implications of a decision in terms of its likely consequences 2. Even if the patient can comprehend the consequences of a chosen course of action, he or she may be unable to utilize this understanding in a process of rational judgment and evaluation […] this presents difficulties in respect of gaining informed consent. These psychological problems occur for patients with traumatic conditions such as head injury although other conditions such as cerebrovascular accident, motor neuron disease, and multiple sclerosis may also be likely (Sim, 1998). In issues of competence or difficulties in deciding, the health professional should weight those wishes or intentions that the patient express. The goals or aspirations expressed by the patient may seem unrealistic and at variance with the patient’s welfare such as a patient with multiple sclerosis whose problems seem to be amenable to rehabilitative intervention decides to refuse treatment. This may be very hard to accept as a rational choice but the principle of respect for autonomy would require the health professional to respect choices even when unwise or unreasonable (Sim, 1998). The principle of respect for autonomy requires that the rational wishes of the patient should be honored. However, the principle of beneficence requires that the patient’s wishes should not be honored if they are irrational and may be against the patient’s best interests (Sim, 1998). Challenges arise when the professional errs too far on observing the beneficence and overrides the patient’s autonomy; the accusation of paternalism may be raised. Paternalism was defined as “interference with a person’s liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests, or values of the person being coerced,” (Dworkin, 1972. p .65 ). Strong paternalism which involves deliberate disregard for the competence of a patient is difficult to justify. But ‘weak’ paternalism may be appropriate in the case being discussed as this is a form of paternalism where an action is taken for the best interests of a patient who cannot understand an information for some reason, or where a patent is not afforded the full possibility of free choice (Pellegrino, 1988. p. 7). The practitioner may be considered as justified in acting in accordance with beneficence above the respect for autonomy in this case. The disability has impaired the patient’s decision-making capacity and his decision can be overridden. There is a lack of valid and reliable tests of patient competence that can be used in the everyday clinical context in rehabilitation, and judgments of incompetence should be made with caution (Sim, 1998). A patient may weight short-term considerations over long-term ones and this is not an indication of irrational decision-making. It can represent a difference in values and priorities between patient and professional. In addition, incompetence in one area of life does not always mean inability to make decisions in all areas of his or her life (Sim, 1998). “In cases of uncertainty, it is usually safest to take competence, rather than incompetence, as the initial assumption,” (Sim, 1998, 7). Strategies for protecting patient decision-making Continuing negotiation and renegotiation of the goals and methods of rehabilitation, instead of a one-off discussion, may improve the process of communication between patient and professional. This helps promote mutual clarity of goals and expectations. Another advantage is that the rehabilitation team will be able to monitor the patient’s psychological reactions to the changes in functional status that occur in the course of the rehabilitation process. This approach makes informed consent as more of a ‘process’ than an ‘event’ (McGrath, 1992). The health professional should also be aware that the repertoire of communication skills open to the patient may be limited by virtue of his or her disability (McGrath, 1992). Therefore, the professional health care provider should be sensitive to statements of disagreement or refusal that are quite inarticulately voiced, or are not reinforced by nonverbal behavioral cues. The choice of patient-relevant and patient-defined outcomes related to the domains of handicap and quality of life will facilitate the incorporation of patient preferences within rehabilitation goals. It will also help to monitor the extent to which these have been achieved (McGrath, 1992). The situation will “remind professionals that it is in relation to the decision subjective experience of handicap, rather than objective impairments, that patients respond to their situation and readjust their lives,” (Sim, 1998, 8). A multidisciplinary or interdisciplinary process of decision-making will ensure that decisions were not made by a single professional who may not be most aware to the client’s personality, values or desires (McGrath, 1992). This process allows the person best equipped to do so – who may be a clinical psychologist – to explore the patient’s precise wishes and goals (McGrath, 1992). Caplan (1987) suggested that the rehabilitation team should explore the dynamics of the family and find out “which family members, if any, have ongoing relationships of intimacy and trust with a patient” (14). This may indicate how the professional can mediate between apparently conflicting perspectives by seeking to find out what is best for the patient through the close family member of the patient. As suggested by Kuczewski, family members play an important part in informed consent: “Because we discover our values in dialogue with those closest to us, the family is naturally an integral part of this process,” (Kuczewski, 1996. p. 34). Involving family members may enhance the patient’s exercise of his or her autonomy. It may also help reconcile some, if not all, of the communication conflicts that exist. However, the rehabilitation team should always regard the patient’s wishes as ultimately decisive (Kuczewski, 1996). Patchwork four: - sore throat Vincent (2004) described sore throat due to tonsillo-pharyngitis as a type of acute pain linked with upper respiratory tract infection. It is one of the most common reasons for physician visits by adults (Vincent, 2004). Sore throat has been developed as a general pain model (Schachtel et al, 1988) based on the clinical condition amenable to the testing of analgesic agents for acute use under double-blind, placebo-controlled conditions. Schachtel et al’s (1984) model followed the fundamental principles of clinical trial methodology, such as confirmation of the pain-causing condition, elimination of confounding clinical features, a relatively severe pain intensity (PI) at baseline, homogeneity of the pretreatment status of patients, and disease-specific rating scales. The sore throat pain model is similar to the post–oral surgery and periodontal pain models used to distinguish the analgesic efficacy between active treatments and placebo, between different analgesic agents, and between doses of analgesic agents in adult patients (Schachtel et al, 1988). According to Schachtel et al (1996), the sore throat pain model has also been adapted to distinguish between active treatments and placebo in children and recognized by the Food and Drug Administration and the European Agency for the Evaluation of Medicinal Products as a method for the evaluation of analgesic drugs. It has proven useful as a clinically relevant pharmacologic assay for acute analgesic activity (Schachtel et al, 1996). There is direct relationship between antibiotic overuse and antibiotic resistance based on mounting evidence. Physicians are encouraged to decrease prescriptions of antibiotics for self-limited illnesses such as upper respiratory infections (URIs) due to the evidences found (Schwarz et al, 1997). According to Schwarz et al (1997), the physicians’ attitudes together with patient expectations for antibiotics towards the prescription of these medications were blamed for the continuing high rate of antibiotic use in URI (Schwarz et al, 1997). Patients visit their doctors to reassure that they or their children do not have a serious illness when prescribed with antibiotics as there had been unnecessary prescriptions. There are more reasons based on patient and physician characteristics that affect the prescription of an antibiotic (Schwarz et al, 1997). There has been little consideration given to the role that clinical factors may play in unnecessary antibiotic use even as clinical findings, such as colored nasal discharge in children with rhinitis or colored sputum in adults with bronchitis, were observed to be influenced by prescribing decisions (Schwarz et al, 1997). According to Poses et al (1993), clinical findings influence prescribing disproportionately and individual physicians may vary in how they weigh the importance of these findings. Antibiotic treatment has been linked with some URIs, such as pharyngitis due to group A streptococcus. However, it was estimated that only 10-20% of patients with sore throat in general practice will harbor this microorganisms (Shank, 1984). However, it is difficult to distinguish clinically these cases from URIs due to viral causes. Shank (1984) observed that physicians frequently rely on clinical judgment to decide whether or not to take a throat culture or prescribe antibiotics for patients with sore throat. Studies found that the use of clinical judgment to diagnose group A streptococcal infections in pharyngitis lacks specificity (Dajani et al, 1995). It is often that physicians tend to overestimate the probability that the infection is present. Clinical estimation errors may be an important factor in unnecessary antibiotic use as antibiotics were not indicated when throat cultures are negative for group A streptococcus (Dajani et al, 1995). Infection with group A streptococcus is the major indication for antibiotic treatment of patients with sore throat (Dajani et al, 1995). Dajani et al’s (1995) study found that unnecessary antibiotic use in such patients was linked to over estimation of the likelihood of infection with group A streptococcus among physicians. In addition, the greater the degree of overestimation leads to unnecessary antibiotic prescription. It was demonstrated that physicians overestimated the probability group A streptococcal infection in adults with sore throat attending a university student health service (Poses et al, 1993). The decision to prescribe an antibiotic was directly related to the physicians’ estimate of a streptococcal infection. The amount of clinical error present during a given patient encounter was measured and found to be directly related to the outcome of an unnecessary antibiotic prescription, against any prescribing decision (Poses et al, 1993). This indicates that clinical uncertainty might be playing an important role in antibiotic overuse in the light of concerns about the impact of current antibiotic-prescribing practices on levels of antibiotic resistance (Schwarz et al, 1997). Some clinical findings influenced prescribing decision in sore throat and URI disproportionately more than other findings. This was similar to reports regarding the effects of colored sputum and nasal discharges on antibiotic use (Schwarz et al, 1997). Some symptoms that also lead to unnecessary antibiotic prescription include history of a fever or the presence of a red throat. A study of 450 community-based family physicians that assessed adults with sore throat, the adjusted odds ratio for an antibiotic prescription was when a red throat was documented (McIsaac et al, 1998). It should be noted that a red throat is a relatively non-specific finding present in as many as 71% of encountered cases where throat cultures are negative (McIsaac et al, 1998). The reliance on red throat and other non-specific findings such as the color of a discharge, in the management of respiratory infections could lead to substantial unnecessary antibiotic use (Schwarz et al, 1997). The wrong estimates of the likelihood of streptococcal infection illustrate the uncertainty inherent in the clinical diagnosis of infection due to group A streptococcus. Uncertainty influence antibiotic use for other respiratory tract infections as well indicated in a study of lower respiratory tract ‘illness’. The physicians were asked whether they thought an antibiotic was warranted (McIsaac et al, 1998) and it was given in every instance where the reply was either ‘definitely’, ‘probably’ or ‘probably not’ indicated. The only instance when antibiotic was not prescribed as when the physicians answered ‘definitely not’. In short, when there was uncertainty about the need for an antibiotic, antibiotic was prescribed. This indicates that clinical uncertainty and errors in clinical judgment play greater roles in antibiotic overuse than has been previously cited. While it was already established that overestimation of streptococcal infection led to decisions of these physicians to prescribe antibiotics, the practice has not waned (McIsaac et al, 1998). It was suggested that tools such as scoring rules might correct this problem by providing more consistent estimates of the true chance of group A streptococcal infection. While physicians were trained to make more accurate predictions using such an approach in one study, this did not lower their antibiotic prescribing rates (McIsaac et al, 1998). It could be that physicians raised their estimates for the likelihood of a streptococcal infection in prescribing an antibiotic or felt that the patient expected it. This occurrence indicates that distribution of estimates have been expected to be bimodal, with clustering around a high estimate when antibiotics were prescribed and at lower estimates when antibiotics were not prescribed. Messages to physicians to decrease antibiotic prescribing in the belief that patient’s expectations and physicians attitudes toward the use of antibiotics in viral illnesses drive antibiotic overuse (Schwarz et al, 1997) were sent out. It has been found in research that family physicians are aware that antibiotics are not warranted for viral infections. The current study suggests that clinical error in identifying which patients with sore throat have infections due to group A streptococcus is likely to be an important factor in unnecessary antibiotic use. It has been recommended that clinical error and uncertainty in prescribing decisions needs further investigation. Antibiotic resistance should be limited through decreased unnecessary antibiotic use. Clinical approaches should be introduced to help physicians deal with the uncertainty associated with the decision to prescribe an antibiotic (Schwarz et al, 1997). Reference: Asthma and Allergy Foundation of America (AAFA). (2005). Consumer Survey. www.aafa.org/display.cfm?id_7&sub_92&cont_529. Braddock C.H 3rd, Edwards K.A, Hasenberg N.M, et al. (1999). Informed decision making in outpatient practice: time to get back to basics. JAMA; 282: 2313–20. Marple, Bradley, MD, John A. Fornadley, MD, Alpen A. Patel, M,D, Stanley M. Fineman, MD, MBA, Leonard Fromer, MD, John H. Krouse, MD, PhD, Bobby Q. Lanier, MD, Peter Penna, PharmD, and the American Academy of Otolaryngic Allergy Working Group on Allergic Rhinitis, (2007). Keys to successful management of patients with allergic rhinitis: Focus on patient confidence, compliance, and satisfaction. Otolaryngology–Head and Neck Surgery. 136, S107-S124 Epstein R.M, Alper B.S, Quill T.E. (2004). Communicating evidence for participatory decision-making. JAMA; 291: 2359–66. Gallup Study of Allergies. (2005). (Phase II Report). http://multisponsorsurveys. com. Storms WW. (2002). Rethinking our approach to allergic rhinitis management. Ann Allergy Asthma Immunol; 88(4 Suppl 1): 30 –5. Tanner L.A, Reilly M, Meltzer E.O, et al. (1999). Effect of fexofenadine HCl on quality of life and work, classroom, and daily activity impairment in patients with seasonal allergic rhinitis. Am J Managed Care; 5(suppl): S235– 47. Vuurman E.F, van Veggel L.M, Uiterwijk M.M, et al. (1993). Seasonal allergic rhinitis and antihistamine effects on children’s learning. Ann Allergy; 71: 121– 6. Dajani A, Taubert K, Ferrieri P, Peter G, Shulman S. (1995). 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(1984). A five year experience with throat cultures. J Fam Pract. 18; 857-63 Gillon R. (1985). Autonomy and the principle of respect for autonomy. BMJ; 290: 1806–808. Sim J. (1986). Informed consent: ethical implications for physiotherapy. Physiotherapy; 7 2: 584–87. Dworkin G. (1972). Paternalism. Monist; 5 6: 64–68. Pellegrino E. D, Thomasma D. C. (1988). For the patient’s good: the restoration of beneficence in health care. New York: Oxford University Press. McGrath J. R, Davis A. M. (1992). Rehabilitation: where are we going and how do we get there? Clin Rehabil; 6: 225–35. Caplan A. L, Callahan D, Haas J. (1987). Ethical and policy issues in rehabilitation medicine. Hastings Center Rep; 1 7(4, suppl): 1–20. Kuczewski M. G. (1996). Reconceiving the family: the process of consent in medical decision-making. Hastings Center Rep; 2 6(2): 30–37. Patch 4 learning out is better needs to be focused around antibiotic tx vs watch and wait not surgical intervention Read More