Evidence-Based Practice: Clinician-Patient Communication Strategies - Essay Example

Evidence based practice Table of Contents Clinical scenario Introduction ……………………………………………………………….………………..1 Communication ……………………………………………...……………………………..3 Evidence ……………………………………………………..……………………………..4 Care plan ……………………………………………………………………………………8 Summary …………………………………….…...………………………………………..12 Conclusion …………………………………………………………………………………12 References ………………………………………….………………………………………13 Clinical Scenario Presented in a clinical setup is Mr. Miller, a 51 years old man, a computer programmer, in a moderately obese with type 2 diabetes, initially diagnosed eight years ago. The client has been trying to stop his smoking habit of some 30 years. In his area of employment, he was offered an employer-subsidized management with nicotine patches to help him quit smoking. Nevertheless, nicotine patches had previously failed, and he has been skeptical to take bupropion, an antidepressant, a group of medications that he had concerns about. No diabetes complications have been detected so far, and his blood sugar levels appear to be well controlled. The client has osteoarthritis that has manifested in both knees. Mr. Miller reports mild elevation in his blood pressure to averaging 160/94 mmHg during his past two visits. The patient is a regular searches of the internet for answers to his health care questions, with his wife encouraging him to take megadoses of fish oil for his heart and vitamin E. St John’s Wort to help him cease smoking, and glucosamine for his knees, based on health care information gained through internet searches. Introduction Proactive approach in individualized health care concern has been on the rise with Mr. Miller portraying a typical example of such a patient. Through the internet and computer technology, patients today have unprecedented access to information about their diagnoses and treatment options. Challenges may however manifest in an event that patients do not fully understand the material they read or are influenced in their decision-making by inadequate or inaccurate information (Jennifer, 2010). In the united states and in the global market, there has been a contemporary use of over-the-counter medications and natural botanicals in particular are associated with significant problems including: commonly held but incorrect assumptions about a product or agent; a lack of oversight and regulation resulting in products with claims without substantiation; and problems with the product itself including side effects and interactions with other drugs, Unknown active ingredients of varying dilution and potentially contaminated products (Jennifer, 2010). In an intrinsic manner, this paper will analyze clinician-patient communication strategies; drawing inference for the use of Mr. Miller’s choice of OTC formulations and medication available to aid smoking cessation; in summary, the paper will propose a multivariate strategy care plan to address Mr. Miller’s health problems. Inferring to his educational background in relation to health care, the client is well educated thus approaching his health problems from an evidence-based perspective will require his involvement in decision-making. He has multivariate lifestyle factors, which may be impacting, on his health, including smoking, obesity, and a sedentary job. Implications of communication in the patient management Effective communication is the bedrock to the management of a patient. In relation to Mr. Miller, sufficient communication is required to provide evidence-based health education and to collaborate both with the client and the spouse to ensure they make informed choice. Effective communication skills in cooperates; being empathetic and being responsive to patients, establishing an effective rapport, ensuring a patient-centered approach, as well as the cognitive and affective measures are provided for (Renata & Lenore, 2007). Multiples of communication strategies have been proposed, Melnyk & Fineout-Overholt (2011) insinuates that the three primary elements in face to face decision making are the interpretation of that information by the patient, provision of evidence-based information by the clinician to the patient, and then discussion of that information between the clinician and patient. According to Deep, Griffith, & Wilson (2008) the article discusses the concepts of Communication and Decision Making About Life-Sustaining Treatment. It is described as having six elements: an understanding of the whole person, the finding of common ground between clinician and patient exploration of the disease and the illness experience, incorporation of health promotion and illness prevention, enhancement of the clinician-patient relationship and the practice of realism. Decision-Making About Life-Sustaining Treatment is an alternative focus for the analysis of clinician-patient communication based on the locus of decision-making shifting from the clinician to the patient who exercises informed choice. Literature evidence supporting the study In an attempt to validate the management of the client through a literature framework, evidence was gathered from searches of the Cochrane Library, MEDLINE and CINAHL databases using keywords: “vitamin E”, “fish oil”, “glucosamine”, “St John’s Wort”, “smoking”, “NRT”, “bupropion”, “diabetes”, “osteoarthritis” and “obesity” yielded some important information which should be conveyed to Mr. Miller to enable him to make informed choices about his health care. Through a multi-disciplinary team in addressing Mr. Miller’s health problems, a mental health nurse has a role in assisting him with his efforts to give up smoking and to provide him with advice on the available evidence for his use of over the counter remedies. Inferring to the situation of the patient, Mr. Miller would like to give up smoking and has stated that he is not keen to try bupropion because it is an anti-depressant and, therefore, belongs to a group of medications which he has concerns about. Discussing with Mr. Miller his preferences and expectations will facilitate open communication and may unearth the perceptions he has about these medications. Certainly Mr. Miller should be presented with there is for the use (or not) of this drug. Through 53 trials examining nortriptyline and bupropion as the sole therapy for smoking cessation, while reviewing antidepressants found both medications having more side effects than the advantages (Aveyard, Parsons, & Begh, 2010). A comparison of the effects of bupropion and varenicline through three trials revealed that smoking cessation was more likely with the former than the later. Nevertheless, achievement of the optimum effects of the medication will need a balance of the side effects and the actions of the drugs. Moreover, application of selective serotonin reuptake inhibitors has no implication on smoking cessation. Antidepressants, particularly bupropion and nortriptyline, do not prove significant clinical benefits as frontline therapy for smoking cessation as a replacement for nicotine replacement therapy (Aveyard, Parsons, & Begh, 2010). Side-effects and the risk of stroke may or may not be acceptable to Mr. Miller, but at least with the most up to date available evidence, he can make an informed choice. According to his past medical history, the client had previously used Nicotine Replacement Therapy (NRT) in the form of transdermal patches. However, the regimen did not prove effective in helping the client to quit his smoking habit. Multiples of scholar sources points to a fact that all forms of NRT magnify the chances of successful smoking cessation (Chaplin & Hajek, 2010), therefore, the use of inhalers, gum, tablets or nose spray are options that may be permissible to Mr. Miller. With or without additional counseling, evidence also revealed that NRT is effective. By presenting the client with the evidence and exploring his sociocultural dynamics, he can be empowered to developed informed decision concerning his management options. According to the history of his current medications, the client has disclosed that he is using glucosamine, large doses of Vitamin E and fish oils, and St John’s Wort and preffers a health care provider who is respectful of those choices, willing to listen and is open-minded to the potential benefits of his chosen treatments. Researches on the social instigators of medicine usage reveals that patients use alternative therapies or complementary because they find these healthcare alternatives to be individually tailored to meet their individualised values, beliefs and philosophical orientations towards health and life (Shirwaikar, Govindarajan, & Rawat, 2013) although they are sometimes unwilling to disclose use of such treatments in anticipation of negative responses from their clinician (Shirwaikar, Govindarajan, & Rawat, 2013). The clinician has an added responsibility of ensuring that any treatments the client uses is safe and carries a minimal risk of adverse effects. Glucosamine Glucosamine has been under researched for its potential benefits in improving symptoms in people with osteoarthritis. Mr. Miller is using glucosamine for his osteoarthritis. The most recent evidence available suggests that glucosamine is as safe as a placebo to use and that use over a 2-3 month period may reduce pain and improve function although there is no definitive research to prove this (Yang, et al., 2014). Fish oil According to Rastmanesh (2013), recent review of the evidence for people with type 2 diabetes using fish oil supplements revealed that although the levels of fats in the blood were decreased, the levels of low-density lipoproteins (LDL) were increased. Management of blood glucose levels was not affected, and there were no adverse effects of the interventions either. The authors conclude that further trials of sufficient duration and looking at outcomes (such as cardiovascular events and death) are needed to establish whether the use of fish oils by people with type 2 diabetes are justified. Sharing the findings with Mr. Miller and discussing the advantages and disadvantages of using fish oils should facilitate a mutual decision about the safe integration of this product in his health care. St John’s Wort In an attempt to control his smoking habit, the client uses the herbal anti-depressant St John’s Wort. Cessation of smoking has been linked to mild/moderate depressive symptoms; however, there has been very little research into St John’s Wort as an aid for smoking cessation (Sood, et al., 2010). Additionally, St John’s Wort is thought to interfere with the liver’s processing of major medications (McCarthy, 2012) thus its use should be reviewed at Mr. Miller’s next medical consultation for potential interactions with his current medication. Vitamin E Research into the potential benefit of Vitamin E to promote good cardiovascular health indicates that there is no significant evidence to synergize the claim (Shargorodsky, et al. 2010). Furthermore, some research suggests that there may be a statistically significant relationship between high doses of vitamin E and all-cause mortality indicating that doses of 400IU/d or greater should be used with caution (Draeger et al., 2014). Mr. Miller is known to be taking large doses of Vitamin E; therefore, it is important that he be provided with the evidence of potential harm in order that he is empowered to carry out decision-making on an informed approach regarding use of this product and to maintain accepted scientific principles and standards of medical practice (Patel et al., 2013). The St. Francis Heart Study randomized clinical trial (Arad, 2005) was a double-blinded, placebo-controlled randomized clinical trial involving 1005 asymptomatic men and women aged 50 to 70 years. They were given atorvastatin 20mg, vit. C 1gm and vit. E 1000units daily versus matching placebos. The average treatment duration was 4.3 years. All were CT scanned for coronary calcification. It was found that the treatment made no difference to the progression of coronary calcification. A recent review showed that Vitamin and antioxidant supplements do not prevent adverse cardiovascular event (Rembold, 2013). Medication interventions to the client’s situation Statins Atorvastatin confers a primary protective effect against cardiovascular events in diabetic patients without concomitant vascular disease (Raikou, et al., 2007). The same implications are evident in hypertensive patients as shown by the placebo-controlled Anglo- Scandinavian Cardiac Outcomes Trial – Lipid Lowering Arm (Sever, et al., 2011). Antihypertensive According to the Heart Outcomes Prevention Study (HOPE, 2005), Ramipril 10mg daily over 5 years in high-risk patients (10 year predicted CV mortality > 5%) lowered the risk of MI, CVA and CV death (Donzelli, 2013). Ramipril, or possibly another ACE-inhibitor would be an ideal first step medication for Mr. Miller. Pioglitazone Among the most commonly used oral hypoglycemic for type 2 diabetes Metformin. The Prospective Pioglitazone Clinical Trial in Macro vascular Events (2007) was a large RCT that showed pioglitazone to decrease the incidence of death, MI or CVA by 16% when used with another oral hypoglycemic (Moneta, et al, Aspirin Inferring from the American Diabetes Association and American Heart Association, low dose aspirin in type 2 diabetics over 40 years old with hypertension, smoking, dyslipidemia or albuminuria (Pignone, et al., 2010). It is used as both a primary and secondary preventative. Many trials have shown an approximately 30% reduction in MI and 20% reduction in CVA (Pignone, et al., 2010). 2007). Exercise Oliveira (2012) reviewed 403 articles and 28 studies about combined exercise for people with type 2 diabetes mellitus. In comparison to isolated exercise, combined exercise protocols improve glycemic control to a greater extent. Nevertheless, duration, length, number, mode, intensity, mode of exercises, varied significantly among studies. Recommended structured exercises supervised training sessions and splitting aerobic, (Sontheimer, 2008). Clearly, exercise will be of benefit to Mr. Miller (Darden, Richardson, & Jackson, 2013). Among the elderly, Exercise training has a significant effect in reducing morbidity or mortality from coronary artery disease patient is a controversial issue. According to the British Regional Heart Study, men with coronary artery disease and an average age of 63 years who partakes light-to-moderate exercise had a significantly lower mortality over the 5-year in comparison to their sedentary counterparts (Darden,Richardson, & Jackson, 2013). Lifestyle Sedentary lifestyle breeding weight gain is a risk factor for coronary artery disease (CAD), diabetes, and hypertension. Exercise and dietary manipulation have been shown to have variable, but positive, effects on managing the lifestyle conditions. The American Heart Association Council on Nutrition, Metabolism and Physical Activity reviewed the literature and advised that intentional weight loss in obese patients can improve or prevent many of the obesity-related risk factors for CAD (Mozaffarian, et al. 2012). Weight reduction reduces blood volume, stroke volume, cardiac output, pulmonary capillary wedge pressure and left ventricular mass. It decreases resting oxygen consumption, systemic arterial pressure, resting heart rate and QTc interval (Després, 2015). With regard to hypertension, Cochrane (2011) searched MEDLINE and the Cochrane Library and identified 6 adequate trials that showed that weight loss of 3-9% resulted in a blood pressure reduction of ~3mm Hg systolic and diastolic. Care Plan Patient Summary Social: 51-year-old computer programmer, married, smoker of 30 years, ex-sportsman, interest in CAM therapies. Health problems: Mild hypertension, uncomplicated diabetes type II, moderate obesity, osteoarthritis both knees. Currently, Mr. Miller has four major risk factors for cardiovascular disease. No known allergies. Problem Goal Intervention Desired outcome Diabetes, Type II Mr. Miller needs to ensure he maintains glycemic control. Needs the relevant information to ensure he is able to reduce the risk of diabetic complications. Maintain normal Blood sugar levels and promote diet and exercise. Dietetic advice to manage diet and glycemic balance Medical therapy Refer to Diabetes Educator at Community Health and appropriate websites for information. Regular self-testing of blood sugar levels Pathology, as per GP orders Mr. Miller is informed and empowered by knowledge and more likely to comply with healthcare recommendations Maintenance of normal blood sugar levels, resulting in less complication related to same. Hypertension Control BP to within normal range Promote understanding, alert to risks of high blood pressure (BP) Discuss hypertension in context of chronic illness and explain risk factors in relation to heart disease. Medical therapy. Reduce weight. Mr. Miller has sound understanding of hypertension and more likely to take measures to reduce BP Ensure BP maintained within normal limits, minimize risk of heart disease Obesity Weight loss without compromising glycemic balance Aim for ideal weight in accordance with recommendations of Heart Foundation Discuss and refer to: Diabetic educator for information on diet and exercise to maintain stable blood sugar levels with view to weight loss to optimum weight goal Mr. Miller aware of risks associated with obesity and is motivated to lose weight, minimize risk of heart disease Osteoarthritis (OA) Symptom management. Monitor progression of disease. Weight reduction Medical therapy Physiotherapy Mr. Miller informed, likely to comply with GP recommendations Monitor disease progression Optimize symptom management. Smoking history Quit smoking Provide Mr. Miller with information on negative impact of smoking on his health Recommend a quit program. High quality information on NRT v Bupropion (as outlined) to facilitate informed decision. Individual support if Mr. Miller feels it would be helpful Motivate Mr. Miller to cease smoking - again, minimizing risk of heart disease. Interest in CAM Therapies Safe and appropriate use of appropriate Complementary and alternative medicine therapies. Discussion of CAM therapies and their place in healthcare provision Ensure Mr. Miller is aware of importance of ensuring a good evidence base for use of CAM therapies and divulging their use to GP. Suggest interaction between GP and CAM therapy provider (Frenkal & Borkan, 2003) CAM therapies recognized as having a place in patient’s healthcare. Safe use of CAM therapies. Patient empowered by ability to have input to healthcare decision making. Reduce potential for conflict between healthcare providers Lifestyle and Exercise Encourage Mr. Miller to do regular exercise, in accordance with Heart Foundation Guidelines. Discuss with Mr. Miller the importance of regular exercise and refer to National Heart Foundation Guidelines. Mr. Miller is aware of importance of regular exercise and motivated to comply with recommendations, minimizing risk of heart disease Summary of the study This study commenced with portrayal of the clinical situation of Mr. Miller. The client is a regular searcher of the internet for answers to his health questions. If he has a health question and has been taking several over the counter preparations based on information he and his wife retrieves. Individualized and effective communication with the client was discussed to introduce him to the concepts of evidence-based practice, to facilitate open discussion and shared decision-making. Detailed evidence on smoking cessation and the over-the-counter preparations that Mr. Miller is taking was presented next, and finally a multidisciplinary care plan was proposed to address Mr. Miller’s health problems in turn. Conclusion Lifestyle conditions have become on the rise in the community, thus appropriate mitigation measures in the control of the conditions is paramount in protecting the population from the disease burden. The client presented in the study above is an example of today’s patients who are educated and proactive in their care. Quality evidence-based information, coupled with appropriate health education when used in a well-coordinated manner is beneficial both to the client and to the clinician in the management of the condition as well as alleviating the disease burden in the society. In the modern world, most patients are reluctant to accept the medical model in decision making concerning their health, where the physician has absolute power in decision making concerning the patient treatment. In reaction to this, the development in technology is encouraging decision making that in cooperates the client in the process. To Engaging Mr. Miller in decision making concerning his health is thus a crucial undertaking in the management of the patient and ensure compliance to the treatment regimen. References Aveyard, P.,Parsons, A.,& Begh, R. (2010). Smoking cessation 4: antidepressants for smoking cessation – bupropion and nortriptyline. Primary Care Cardiovascular Journal (PCCJ), 3(1), 32-34. Arad Y, Spadaro L, Roth M, et al. Treatment of asymptomatic adults with elevated coronary calcium scores with atorvastatin, vitamin C, and vitamin E: the St. Francis Heart study randomized clinical trial. J Am Coll Cardiol. 2005 Jul 5;46(1):166-72. Cochrane, Darryl. (2011). Shaking weight loss away - Can vibration exercise reduce body fat?. Journal of Human Sport and Exercise, 6(1), 33-39. Chaplin,S.,& Hajek, P.(2010). Nicotine replacement therapy options for smoking cessation. Prescriber, 21(19),62-65. Donzelli A. (2013). The 2013 ESH–ESC Guidelines for the management of arterial hypertension: new targets, old policies. OA Evidence-Based Medicine, 01; 1(1): nine. Draeger, C. et al (2014). Controversies of antioxidant vitamins supplementation in exercise: ergogenic or ergolytic effects in humans? J Int Soc Sports Nutr, 11(1), 4. Darden, D., Richardson, C.,& Jackson, E.A. (2013). Physical Activity and Exercise for Secondary Prevention among Patients with Cardiovascular Disease. Curr Cardiovasc Risk Rep, 7(6), 411-416 Després, J.P. (2015). Obesity and Cardiovascular Disease: Weight Loss Is Not the Only Target. Canadian Journal of Cardiology, 31(2), 216-222. Deep, Kristy. S, Griffith, Charles H. & Wilson, John F. (2008). Communication and Decision Making About Life-Sustaining Treatment: Examining the Experiences of Resident Physicians and Seriously-Ill Hospitalized Patients. J GEN INTERN MED, Vol 23 (11), 1877-1882. Jennifer Fong Ha & Nancy L (2010). Doctor-Patient Communication: A Review. The Ochsner Journal: Vol. 10(1), 38-43. Melnyk B ,& Fineout-Overholt E. (2011).Evidence-based practice in nursing & healthcare. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. McCarthy, D.M. (2012). Doctor–parent communication. Patient Education and Counseling, 87(3), 289-290. Mozaffarian, D. et al. (2012). Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association. Circulation, 126(12), 1514-1563. Moneta, G.L. et al.(2007). Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Yearbook of Vascular Surgery, 2007(1), 14-15. Oliveira, César. et al. (2012). Combined exercise for people with type 2 diabetes mellitus: A systematic review. Diabetes Research and Clinical Practice, 98(2), 187-198. Patel, D. et al. (2013). Discordant Association of C-Reactive Protein With Clinical Events and Coronary Luminal Narrowing in Postmenopausal Women: Data From the Womens Angiographic Vitamin and Estrogen (WAVE) Study. Clin Cardiol, 36(9), 535-541. Pignone M, Alberts MJ, Colwell JA, et al.(2010).American Diabetes Association; American Heart Association; American College of Cardiology Foundation. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Diabetes Care; 33:1395– 1402. Rembold, C.M. (2013). Review: Vitamin and antioxidant supplements do not prevent adverse cardiovascular events. Annals of Internal Medicine, 158(12), JC10. Renata K. & Lenore M (2007). Exploring Doctor–Patient Communication in Immigrant Australians with Type 2 Diabetes: A Qualitative Study. J Gen Intern Med. 22(4): 459–463. Raikou,M. (2007). Cost-effectiveness of primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes: results from the Collaborative Atorvastatin Diabetes Study (CARDS). Diabetologia, 50(4), 733-740. Rastmanesh R, Javidi A, Taleban FA, Kimaigar M, Mehrabi Y (2013). Effects of Fish Oil on Cytokines, Glycemic Control, Blood Pressure, and Serum Lipids in Patients with Type 2 Diabetes Mellitus. J Obes Weight Loss Ther 3:197. doi: 10.4172/2165-7904.1000197. Shirwaikar, A., Govindarajan, R., & Rawat, A. (2013). Integrating Complementary and Alternative Medicine with Primary Health Care. Evidence-Based Complementary and Alternative Medicine, Vol 2013(1), 1-3. Sood, A. et al. (2010). A Randomized Clinical Trial of St. Johns Wort for Smoking Cessation. The Journal of Alternative and Complementary Medicine, 16(7), 761-767. Sontheimer, D. (2008). Review: Statins reduce all-cause mortality in elderly patients with coronary heart disease. Annals of Internal Medicine, 148(10), JC3. Shargorodsky, M. et al . (2010). Effect of long-term treatment with antioxidants (vitamin C, vitamin E, coenzyme Q10 and selenium) on arterial compliance, humoral factors and inflammatory markers in patients with multiple cardiovascular risk factors. Nutr Metab (Lond), 7(1), 55. Sever, P.S. et al.(2011). The Anglo-Scandinavian Cardiac Outcomes Trial: 11-year mortality follow-up of the lipid-lowering arm in the UK. European Heart Journal, 32(20),2525-2532. The Heart Outcomes Prevention Evaluation Study Investigators (2005). Long-Term Effects of Ramipril on Cardiovascular Events and on Diabetes: Results of the HOPE Study Extension. Circulation, 112(9),1339-1346. Yang, S. et al. (2014). Long-term effectiveness of glucosamine and chondroitin in treating knee osteoarthritis: an analysis with marginal structural modeling. Osteoarthritis and Cartilage, 22(1), S203. Read More