Are you an advocate of your patient's therapeutic rights?

In the April issue of DVM Newsmagazine (p. 48) we considered application of seven diagnostic axioms with the goal of enhancing patient care.

In review, Axiom 1 emphasized the difference between knowledge (facts)and wisdom (the ability to properly apply knowledge). Axiom 2 emphasizedthe value of accurate definition of a patient's problem(s) in context ofsubsequently identifying solutions for the problem(s). Axiom 3 emphasizedthe importance of discerning the difference between observations (facts)and interpretations of observations (inferences or assessments). Axiom 4focused on the process of collection and interpretation of relevant clinicaldata about a patient's illness with the objective of reducing numerous diagnosticpossibilities to few diagnostic probabilities. Axiom 5 emphasized the differencebetween organ disease and organ failure, especially in context of prognosisand therapy. Axiom 6 emphasized the difference between clinical signs inducedby disease and the body's compensatory response to disease induced signs.Axiom 7 emphasized the fact that just because two or more events occur inconsecutive order does not prove a cause and effect relationship.

Once a diagnosis is established, it is our ethical responsibility toensure the safety and efficacy of various types of treatment given to ourpatients. This month's Diagnote consists of the application of 10 axiomsor principles that I have designated as our patients' "therapeuticrights".

In order for therapy to safely reach its maximum potential in each patient,the 1) right motive based on the 2) right knowledge should be used to 3)prescribe the right drug for the 4) right patient at the 5) right time inthe 6) right amount using the 7) right dosage form and the 8) right routeof administration to bring about the 9) right response. Then, the 10) rightresults should be recorded in the right record in a timely fashion.

The right motive

In recent months, there has been considerable discussion about the ethicaldifference between generating value-based free enterprise fees-for-serviceto maintain the fiscal vitality of a properly staffed and equipped veterinaryhospital, and the motive behind recommending unnecessary services and therapyto increase fees to a maximum determined by what the traffic will bear.

There is no disagreement that responsible and ethical business managementpractices are vital to generate adequate hospital income needed to offerthe standard of patient care that we all took an oath to provide. However,ethics also directs us to put the interest of our patients above our ownfinancial interest. Therefore, formulation of our plan of therapy shouldnot be motivated by self-gain of profit.

Recall that by definition the veterinary profession has a service ratherthan a profit motive. It follows that in caring for our patients, we mustcare about our patients. Thus, we would not endorse the unethical practiceof prescribing "a pill for every ill."

In some situations, an ethical alternative is to dispense reassurancethat self-limiting diseases do not require treatment. Our motive for recommendingtherapy should be solidly based on the principle that we are committed tothe welfare of our patients and our clients first...and last.

The right knowledge

The admonition primum non nocere - first do no harm - is attributed toHippocrates and infers that therapeutic intervention will be based on accurateknowledge, wisdom and understanding. Thus, both the benefits and risks oftherapy should be considered in context of each patient. Drugs should notbe given without a working knowledge of their pharmacokinetics and pharmacodynamics.

Pharmacokinetics refers to how drugs are absorbed, distributed, metabolizedand eliminated from the body. Pharmacodynamics refers to the mechanismsof action of drugs, and the body's physiological, biochemical or psychologicalresponse to a drug or a combination of drugs.

Other factors that should be considered include: 1) species differencesin drug actions and interactions, 2) probable effects of organ failure ondrug pharmacokinetic parameters and pharmacodynamic processes, and 3) possibleinteractions of combinations of drugs. The package insert that accompanieseach drug should be reviewed before prescribing for the first time and inthose situations when specific drugs are used infrequently.

Unfortunately, drugs used to prevent, control or eliminate various diseasesalso have the potential to induce disease. Recall that many pharmacokineticand toxicity studies designed to minimize adverse drug events have beenperformed in healthy animals.

However, these same drugs often are prescribed for patients with diseaseor dysfunction of one or more body systems that play a vital role in thedrug's absorption, biotransformation and elimination.

Pharmacokinetic data derived from studies of healthy animals may notapply to animals with various diseases. If doses of drugs designed for patientswith normal organ function are not appropriately adjusted for patients withorgan dysfunction, the likelihood of adverse drug events is enhanced. Tothe unsuspecting therapist, such adverse drug events may be erroneouslyattributed to progression of the underlying disease or may be misinterpretedas an unusual manifestation of the underlying disorder.

For ethical reasons, therapeutic plans should include the expected outcome(or goal). Therefore, we should be able to describe the rationale for thetreatment we are recommending, and be familiar with the scientific evidencesupporting our choice of therapy. Why? Because, goal-setting fosters precision,and precision fosters quality patient care. No patient should be worse forhaving seen the doctor. Once the goal of therapy is defined, the feasibilityof such therapy must be assessed.

In many situations the final choice will represent a balance betweenthe optimum therapy for the problem(s), the availability of optimum therapy,and the type of therapy our clients can or are willing to afford. Theremust be no misunderstanding about what is wanted and what is given. In asymbolic way, we must determine whether our clients want "a dog, acat, a horse, etc." or "this dog, this cat, this horse, etc.",while at the same time trying to be our patient's advocate.

The right drug

Drugs may be given with the goal of providing specific, supportive, symptomaticor palliative therapy. Specific treatment is given to eliminate, destroyor modify the primary cause(s) of the disease process. Examples of specifictreatment include use of antibiotics for bacterial infections, antidotesto counteract toxins and replacement hormone therapy.

* Supportive treatment consists of therapy that modifies or eliminatesabnormalities that occur secondary to primary disease. Treatment designedto correct deficits and excesses in fluid, electrolyte, acid-base, endocrineand nutrient balance caused by primary renal failure is an example of supportivetherapy. Successful specific therapy is often dependent on successful supportivetherapy.

* Symptomatic treatment consists of therapy given to eliminateor suppress clinical signs. Examples of symptomatic treatment include useof antiemetics to control vomiting, and use of glucocorticoids to controlpruritis.

* Palliative treatment consists of therapy chosen to suppressthe clinical signs of patients with diseases for which the underlying causecannot be cured and is likely to be progressive.

* Inappropriate therapy consists of therapy that is not neededby the patient, or therapy for which the associated risks outweigh the probablebenefits.

Choice of the right drug should encompass knowledge of the patient'sprevious history of adverse drug events (e.g. rash, tremors, anorexia, vomiting,diarrhea). To minimize adverse drug interactions, it is best to avoid unnecessaryuse of multiple combinations of drugs.

The right patient

Giving the right drug with the right motive based on the right knowledgeto the wrong patient is obviously of no benefit. It may even be detrimental.When a hospital team approach is used to dispense and administer varioustypes of medication, specific names of drugs and accurate prescribing ordersfor in-hospital use should be identified by the patient's name in additionto the patient's location. In addition, clients should be advised of thehazards of giving medications prescribed for home treatment of one patientto another animal that develops illness with similar signs.

The right time

The effectiveness or toxicity of many drugs is influenced by the frequency(so-called maintenance intervals) with which they are given. For example,a common reason that antimicrobial therapy is ineffective in eliminatinginfections is that clients are unwilling or unable to follow recommendeddosing intervals.

For example, rather than following directions to give the total dailydose of the antibiotic in two equally spaced subdoses, they may give one-halfthe total daily dose once per day. Thus, the right drug becomes ineffectivebecause it dos not attain therapeutic concentrations at the site of infection.

Lack of compliance with administering drugs at the proper time intervalsis especially common when multiple drugs are to be given at frequent orvarying time intervals. Improper dosage intervals may also be associatedwith inability of clients to administer drugs by the oral or parenteralroute. Before prescribing complicated therapeutic protocols, the clientshould be asked if they are willing and able to comply with the therapeuticplan.

The right amount

Several factors may influence selection and administration of the rightamount of drug. They include counteracting or potentiating effects of multipledrugs. The influence of organ function or dysfunction on the absorption,biotransformation and excretion of drugs is also of great significance.For example, in addition to the potential effect of renal dysfunction onreducing the elimination of drugs and their metabolites by the kidneys,consumption of reduced quantities of dietary protein may further reducerenal clearance of some drugs and their metabolites.

Therefore, if drugs primarily excreted by the kidneys are given to patientswith renal failure, appropriate adjustments in dosage should be considered.The same caveat applies when drugs that are metabolized by the liver oreliminated via the hepatobiliary route are being considered for patientswith hepatobiliary disorders.

Even though manufacturers specify therapeutic dosage ranges for drugs,drug doses must be individualized for each individual patient. In additionto considering body weight, proper dosage may be influenced by such factorsas magnitude of weight loss, magnitude of obesity, state of hydration orabnormal accumulation of substantial quantities of extravascular fluid (e.g.ascites). For example, if doses are calculated for patients at one bodyweight, but not subsequently adjusted in association with substantial weightloss or weight gain, overdosing or underdosing might be a consequence. Consideralso that highly fat-soluble drugs may have increased duration of effectin obese patients. Likewise, drugs that are safe in normal adults may createproblems in pediatric or aged patients.

The effect of food on absorption of orally administered drugs may alsobe a factor. Absorption of drugs may be decreased, delayed, increased orunaffected by physiological changes that occur in the gastrointestinal tractduring fed and fasting states. In general, food reduces the bioavailabilityof drugs. Likewise, the bioavailability of drugs may be affected by administeringthem with food through nasogastric tubes or gastrostomy tubes.

The right dosage form

Drugs are available in a variety of forms, including powders, capsules,tablets, liquids, lotions, ointments, suppositories, nebulizers and injectables.Numerous factors influence choice of dosage form, including ease of administration,patient tolerance, rate of absorption, state of hydration, status of thegastrointestinal tract and desired timing and duration of effect. Clientsshould be advised not to crush tablets that have special coatings, becausethis will negate the purpose of the coating. They should be advised of whataction to take if they are unable or unwilling to administer drugs in thedosage form prescribed.

The right route of administration

As with dosage forms, numerous factors influence choice of the routeof administration of drugs. Vomiting, diarrhea or impaired ability to swallowall have an impact on whether to choose orally administered medications.Likewise, inability of a client to give an animal the proper dosage andfrequency of oral medication will have an impact on the choice of routeof administration of a drug. Likewise, the magnitude of dehydration influenceswhether rehydrating fluids will be given by the intravenous, subcutaneousor oral route, or a combination of these routes. Desired onset and durationof drug action, as well as cost of drugs, are also important.

The right response

The definition of the right response is that which accomplishes a therapeuticgoal. How can we determine if we are making satisfactory progress towardaccomplishing our therapeutic goals?

An effective and practical method that will facilitate evaluation ofthe effectiveness of therapy is use of therapeutic-specific databases (seeexample in Table 1). The simplicity or complexity of therapeutic-specificdatabases is influenced by the nature of the disorder being treated, aswell as the probable safety and efficacy of the treatment selected for use.

Use of therapeutic specific databases as reference points often helpin educating clients about the nature of problem(s) identified in theiranimals. The probable future course of events (prognosis), and the reasonsand schedule for therapy.

The veterinarian's prediction of the progress of the case should be discussedwith the owner with the goal of helping him/her to recognize deviationsfrom the expected course of events, and also providing him/her with a balancedperspective of the significance of such deviations. Then if significantchanges from the expected occur, the clients will be more likely to callfor help or return the patient to the hospital for reevaluation.

The right issues

Recording the right results in the right record. Properly designed andcompleted medical records play a key role in enhancing proper care of patients.Why? Because medical evidence is usually transient; it can be preservedonly by recording it.

The strongest memory is weaker than the palest ink. Medical records facilitate:1) planning of patient care, 2) communication between the doctor and otherindividuals involved with patient care, 3) monitoring the progress of thepatient's illness, and 4) a basis of review which in turn serves as an excellentsource of continuing self-education.

Properly constructed medical records provide important reminders thatfoster effective and timely medical action. Notes about therapeutic plans,and entries about drugs that have been dispensed, should be entered intothe medical record in a timely fashion, and in a legible and reproducibleform that is readily retrievable. Hospitals with inaccessible, incompleteor poorly constructed medical records have little advantage over hospitalsthat do not keep medical records.

Epilogue

It is our ethical responsibility to be strong advocates of the therapeuticrights of our patients. The motivating force that will help us to consistentlyuphold and apply these "rights" to all of our patients is theGolden Rule.

Specifically, we should take the initiative to provide the quality oftherapy that we would desire if we were the patients, rather than the doctors.When uncertainty exists as to whether or not a particular drug, medicalor surgical procedure is or is not in the best interests of the patient,please consider the following questions.

* Based on the information available, would I choose this courseof therapy if I were the patient?

* Based on my assessment of my own knowledge, skill and experiencewith this type of problem, would I consent to the proposed plan of therapeuticaction if I were in this patient's exact situation?

* What therapeutic goals are likely to be achieved?

* If I follow the proposed plan of therapy, in all probabilitywill the overall benefits of this plan justify the associated risks andcosts?