Elizabeth M. Seybold, PharmD
LEARNING OBJECTIVES
• Discuss communication skills required when interacting with special populations, including terminally ill patients, patients with incurable but treatable conditions, geriatric patients, pediatric patients, and angry patients.
• Identify specific needs of and barriers to communicating with special populations.
• Apply strategies for communicating with special populations.
KEY TERMS
• Anger
• Empathy
• Nonadherence
• Repression/suppression
• Stages of grieving
• Terminal illness
INTRODUCTION
Effective counseling is an art; it consists of more than simply providing information to patients. Good communication skills can drive the professional relationship with patients and make counseling more effective. Patient counseling on medications offers many well-documented patient benefits, including better management of medication-associated risks and achievement of desired healthcare outcomes.1,2 It is also thought that the communication between the pharmacist and patient must be interactive in order to be effective.2
Pharmacists must utilize a variety of skills in order to counsel patients successfully, especially when faced with special patient populations or difficult patient situations.3 In order to meet the needs of the patient, pharmacists must recognize these situations, identify the associated barriers, and utilize necessary skills to tailor the patient counseling sessions appropriately. This chapter explores patient counseling in the following special patient populations: dying patients, patients with incurable but treatable conditions, pediatric patients, geriatric patients, and angry patients.
STAGES OF GRIEF
Pharmacists who have an understanding of the stages of grief are better able to communicate with terminally ill patients. Pharmacists should understand that dealing with a personal trauma, such as death, is a dynamic process. As stated by the pioneer in the care of dying patients, Elisabeth Kübler-Ross, patients facing personal trauma go through a five-stage grieving process. It is important to recognize what stage a terminally ill patient is in and to understand that these stages are responses to feelings that can last from minutes to months or maybe even longer. Patients do not enter and leave each individual stage in a linear fashion; rather, they may be in one stage and bounce back and forth into the others.3 The five stages of grief are denial, anger, bargaining, depression, and acceptance:4
• Denial. It is common for a person to deny the existence of grief or a terminal illness. A terminally ill patient may say, “I’m too young to die” or “I’m not ready to die.” Even when a physician explains the severity and terminality of their illness, patients may still feel that their diagnosis is inaccurate or that additional treatment options must be available. It is important to give patients time to accept their diagnosis. This is a normal process, and patients can be told that this is nature’s way of letting in only as much as they can handle.5
• Anger. The patient becomes furious that such a devastating thing could occur. They feel as if they are no longer in control of their life. This may make them feel helpless, which, in turn, leads to anger toward everyone, but no one in particular. Let patients know that anger is a necessary stage of the healing process and that feeling anger will help them heal. Anger can be a strength and an anchor, giving temporary structure to the nothingness of loss.3
• Bargaining. During this stage, patients plead to a higher being for an extension of their life. The patient is now willing to compromise, promising to do or not to do specific things in exchange for a longer life.3
• Depression. This stage often occurs when a patient realizes that bargaining has failed. During this stage patients are fully aware that death is inevitable; therefore, they are filled with sorrow as they mourn for themselves and the pain that it is causing them and their family. This depression is not a sign of a mental illness.3
• Acceptance. Patients accept that death will occur and may help others gain this acceptance as well. The patient finally succumbs to the inevitable as he or she becomes more tired and weak and realizes that it is alright to die.3
Patients may not go through these stages in a predictable order, but recognition and understanding of these stages will allow for better communication. This grieving process may also be displayed in patients facing chronic illnesses or even in family members or loved ones of patients who are dying.
COUNSELING TERMINALLY ILL PATIENTS
Pharmacists will inevitably encounter patients who are sick, but the severity of the illness may affect how the pharmacist responds to the patient’s needs.5 A patient with a terminal illness has an incurable disease that often results in the death of the patient in a relatively short period of time. For example, patients with certain cancers and those placed in hospice care are considered terminally ill. Hospice care focuses on the palliation of a terminally ill patient’s symptoms, which can be physical, emotional, spiritual, or social in nature. It also focuses on bringing comfort and self-respect to the dying patient. The goal is to alleviate the patient’s symptoms, including pain, rather than to provide a cure.6
The delicate nature of this patient encounter requires the use of effective communication skills, specifically empathy and compassion. Although the goal of the patient encounter may be to discuss and provide education about medications to alleviate symptoms, it may also consist of addressing the emotional needs of the patient/family member as well. When communicating with the terminally ill patient, certain factors should be considered:7
• If possible, learn as much as possible about the patient by gathering information from the medical record and from communicating with the other members of the healthcare team. Speak with the patient’s healthcare team to determine how much and what information the patient is comfortable speaking about. Obtain a baseline of what the family and patient already knows, understands, and expects prior to providing information and education.
• Considering the sensitive nature of the patient encounter, allow for adequate time and a private, comfortable space that will be free of interruptions. Having additional family members or caregivers present when communicating with the patient may be helpful.
• Once you state your name and introduce yourself as the pharmacist, ensure that you know the name and relationship to the patient of each person who is part of the conversation.
• It is acceptable for you to be affected by your patient’s situation, but how you deal with it is vital. It may be acceptable for you to say that you are sorry or to show your feelings; however, do not overshadow the patient’s emotions. If you are unable to control your feelings, it may be better to excuse yourself until you are more composed.
• Speak with the patient in a straightforward and compassionate manner, while avoiding medical jargon. Using words such as cancer or death is acceptable.
• The role of nonverbal communication skills is especially significant during the patient encounter. Silence may be vital, because the patient may need time to reflect and/or feel certain emotions, including sadness. Do not to let silence or tears make you uncomfortable, because the patient may need to talk, share, and listen at his or her own pace.
• Assess the emotional reactions that the patient and family are experiencing. Make note that they may already be starting to demonstrate some of the five stages of grief.
Effective counseling for patients who are terminally ill and their families can be a unique and challenging experience.4 It is often difficult to balance the response to patients’ emotional needs while continuing to focus on the provision of necessary medical information.
COUNSELING PATIENTS WITH INCURABLE BUT TREATABLE CONDITIONS
Conditions such as HIV, certain cancers, or other chronic illnesses, such as renal failure, heart failure, or diabetes, are considered incurable but treatable diseases. Patients with such conditions may experience the same emotions as someone who has been diagnosed with a terminal illness. They are usually on an aggressive treatment regimen to manage the disease state. They are also often very involved in the self-management of their disease state.6 The nature of these treatment regimens has led to increased pharmacist interaction with this population of patients. It is very important that these patients feel comfortable not only speaking to their pharmacist about their medications, but also have confidence that the pharmacist has a good understanding of their disease state. The pharmacist–patient relationship that is built through the pharmacotherapy management counseling session is very important. The pharmacist must understand that these are difficult and sensitive disease states to communicate with the patient about.
Communication with patients with incurable but treatable conditions is multi-faceted, and, as in other situations, requires several skills and considerations to be effective. Certain factors that should considered when counseling patients with incurable but treatable conditions are detailed in Table 7.1.
TABLE 7.1 Factors to Consider When Counseling Patients with Incurable but Treatable Chronic Illnesses
| Factor | Example |
| Transportation | The patient may not have adequate access to transportation, which may limit his or her contact with the pharmacist, leading to fewer counseling sessions. |
| Adverse effects | The patient may have had an adverse effect from treatment in the past and may want to avoid further treatment. |
| Cost of medication | The patient may not fill a medication due to its high cost. |
| Alternative medications or treatment | In addition to traditional treatment, some patients may also be undergoing alternative medication treatments or taking alternative medications such as herbal supplements. |
| Complicated information about treatment options | The patient may become overwhelmed when presented with all of the different treatment options. |
| Nonadherence | Nonadherence typically occurs due to several factors, including cost of the medication, lack of understanding of how to take the medication, lack of information provided by the physician and/or pharmacist, adverse reactions, palatability of the medication, or fear of drug–drug interactions. |
Source: Rantucci M. Pharmacists talking with patients: A guide to patient counseling. Baltimore: Lippincott Williams & Wilkins; 2007.
Counseling this population of patients can be quite challenging. Tailoring the counseling session will result in more effective communication between the patient and the pharmacist. Some strategies to accomplish this include the following:8
• Be an active listener and provider of information.
• Be empathetic to the patient, family members, and/or caretakers.
• Deal with personal issues. Address personal fear or bias about the condition.
• Identify the patient’s needs. Ask detailed questions to gauge the patient’s understanding and attitude toward the illness and treatment. Document this with the use of assessment forms when appropriate.
• Help the patient adjust to daily life. Consider complex medication regimens and strategies to improve adherence (reminders, log books for side effects, pill-boxes, etc.).
• Refer the patient to support groups or self-help tools.
• Assist the patient in understanding the illness. Reinforce with written information, and discuss risks and terminology when appropriate.
• Encourage patient participation. Provide information on monitoring medication therapy and taking responsibility for treatment when possible.
• Provide motivational counseling. Continue to reinforce adherence due to the lengthy nature of treatment.
• Provide follow-up. Offer follow-up phone calls and/or home visits when appropriate.
• Provide an appropriate counseling environment. Offer the patient privacy and consider the patient’s physical limitations.
• Provide support to the patient and caregivers. Consider the patient’s emotional stage. Be honest and genuine. Listen and allow silence when necessary. Defer counseling if the patient is not feeling well, because if the patient is not feeling well during the counseling session he or she may not pay attention to the key points that you are trying to relay. Tell the patient that you acknowledge the fact that he or she is not feeling well and that it might be better to reschedule for a later time.
• Consider all treatment approaches. Provide the patient information about alternative therapies without bias and recommend appropriate resources for such therapies. Encourage patients to share all treatments they have tried, including pharmacologic, nonpharmacologic, and alternative therapies.
• Serve as the patient’s advocate. Assist in researching community resources when appropriate.
• Be a member of the patient care team. Keep communication lines with other healthcare professionals and patient open. Be ready to discuss treatment decisions, medication adjustments, and monitoring.
In addition to the strategies pharmacists can use to communicate effectively with patients with incurable but treatable conditions, individual factors should also be considered to further tailor the counseling session. Some of these factors include assisting individuals with intellectual, cognitive, or developmental disabilities, such as those patients who are hearing impaired, blind, or unable to speak. Recognition of patient barriers and development of necessary skills to minimize or overcome these barriers is an integral part of counseling.
COUNSELING GERIATRIC PATIENTS
Another population requiring special attention is the rapidly growing geriatric population. Geriatrics is the branch of medicine concerned with conditions and diseases of the aged. The geriatric population now includes the well-known subpopulation known as the baby boomers. The U.S. Census Bureau defines the baby boomers as those born between January 1, 1946, and December 31, 1964.9 In 2011, the first baby boomers started to turn 65 years of age. It is estimated that the U.S. population aged 65 years and older will grow from 35 million in 2000 to 78 million in 2050.9
The incidence of chronic conditions and diseases increases with advanced age.7 Although comprising only 12% of the U.S. population, more than 30% of all prescription medications and 40% of over-the-counter (OTC) medications are taken by those who are 65 years of age or older. This group is at increased risk of adverse drug effects, drug interactions, inappropriate medication use, and/or other drug-related problems due to metabolic and physiological age-related changes.8
Many geriatric patients have limitations and disabilities, such as hearing loss or vision impairment. They often also have diminished economic resources.8 The potential health and financial consequences of managing medications in the geriatric population are serious, warranting the need for pharmacists to communicate effectively regarding appropriate medication use.10 For example, many geriatric patients will adjust their medication regimen by taking their medication every other day versus daily in order to save on medication costs. This can potentially lead to detrimental health consequences. It is imperative that the pharmacist counsel geriatric patients on their medication regimen and encourage adherence. The barriers and special circumstances that affect the counseling of geriatric patients are summarized in Table 7.2.
Despite the multitude of factors to consider when counseling geriatric patients, pharmacists can utilize various skills to tailor their sessions for effective counseling. Three out of five geriatric patients claim loyalty to one pharmacy, and they are more willing to pay for information services from pharmacists compared to other age groups.10
The American Society of Consultant Pharmacists has created guidelines for pharmacist counseling of geriatric patients. These guidelines address counseling challenges and offer guidance on providing effective counseling to the geriatric population. To effectively communicate with the geriatric population, pharmacists should increase their baseline knowledge of geriatric pharmacotherapy and the effects of aging. Pharmacists should also understand the culture and attitudes their elderly patients have regarding their health and treatment of illness, in addition to being aware of any sensory or cognitive impairments.11
TABLE 7.2 Barriers Associated with Counseling the Geriatric Population
| Barrier | Example |
High prescription drug use | More than two-thirds of those older than age 65 take at least one prescription or OTC medication. |
High incidence of illness | 80% of geriatric patients report at least one chronic illness. |
Increased risk of drug-related problems | Up to 75% of geriatric patients experience at least one drug-related problem, which can result in increased incidence of emergency room visits. |
Increased limitations | Geriatric patients often experience one or more of the following: • Hearing or vision loss • Dementia • Language disorders (secondary to stroke) • Altered pain threshold • Other physical disorders (arthritis, etc.) • Transportation difficulties • Reduced economic resources • Lack of energy or motivation These limitations may lead to reduced access to care as well as decreased medication adherence. They may also result in communication being directed to a family member or caregiver rather than the patient directly. |
Reduced cognitive functioning | Geriatric patients may have reduced short-term memory, confusion about complex medication regimens, reduced problem-solving skills, or suffer from lack of sleep. |
Decreased medication regimen adherence | Although nonadherence rates are similar in this group to other groups, the causes are different. Nonadherence may occur due to age-related misunderstanding, forgetfulness, physical limitations (e.g., unable to open vial), beliefs about their medication, and cost. Geriatric patients may also have difficulty distinguishing tablets from one another. |
Pharmacists may have negative perceptions of aging or may find it difficult to understand the geriatric patient’s point of view. Younger pharmacists in particular may have difficulty understanding a geriatric patient’s point of view. They may stereotype the patient as frail, confused, slow, and needy. Geriatric patients may also have perceptions from their younger years, such as the need to hoard medications, embarrassment about their body functions, and the belief that health matters are private. | |
Literacy and cultural issues | Geriatric patients are more likely to have difficulty understanding educational materials due to low levels of education or their cultural background. It is important for the pharmacist to assess patients’ reading and comprehension abilities without embarrassing them. An easy assessment tool is to give patients some literature and ask them if they understood everything. If a patient does not understand the written material, it is important that the pharmacist counsel the patient in an easy-to-follow manner. For example, if a patient is taking a medication in the morning and evening, you may have to draw pictures of the sun to depict the morning and the moon to depict night. |
Healthcare service access and affordability | Fixed or reduced income may be a barrier, especially as medication costs rise. It is important for the pharmacist to let the patient know that there are resources to assist with financial hardships. The pharmacist should become aware of the services offered by the local public health department or other government entity. |
Source: Rantucci M. Pharmacists talking with patients: A guide to patient counseling. Baltimore: Lippincott Williams & Wilkins; 2007.
