PATIENT INVOLVEMENT IN

THERAPEUTIC PROCESS
on Clinical Pharmacology.

Suryawati; Rustamadji; Sulanto Saleh-Danu.

Clinical Pharmacology Division,

Pharmacology & Therapeutic Department,
Fac of Medicine; Universitas Gadjah Mada.
Objectives of the session
After attending this lecture, students are
expected to be able to:

1. Explain the importance of patient involvement

2. Explain the patient rights on therapeutic
decision
3. Explain the steps in therapeutic decision
process
4. Explain techniques to involve patients in
therapeutic decision process
A case study
A 60-year old woman with atrial fibrillation, heart failure,
hypertension, diabetes mellitus, osteo-arthritis, depression and
insomnia, who has an acute urinary infection received the
following prescription:

Propranolol 80 mg 3xday
Bendrofluazide 10 mg 1xday
Digoxin 0.25 mg 1xday
Ibuprofen 400 mg 3xday
Chlorpropamide 250 mg 1xday
Cotrimoxazole 2 tabs 2xday
Amitryptiline 25 mg 3xday
Nitrazepam 5 mg night only

How will she organize the medication..???

Patients adherence to treatment

Studies shown that about 50% of what doctors

prescribe for chronic illness does not get taken
About the same percentage was found for each
indication studied, e.g., hypertension,
glaucoma, hypercholesterolaemia, etc.
Factors affecting
patients adherence to treatment
Why do I have to I doubt this is
take this drug? a good drug

She is nice, but ..too expensive,

her prescription I cant afford..
is too simple..

too
complicated..
Drugs wont help,
this is a curse
How to improve patient
adherence to treatment ?

Give a well-chosen treatment

Create a good doctor/ nurse-patient
relationship
Take the time to give information,
instruction and warning
To minimise non-adherence.

Simplify dosage regimen

Involve patients in
therapeutic decision process
Patients rights
Patients have a right to determine what happens to their own
bodies (WHA 47)
Patients have a right to be given information about medicines
they are prescribed, and patients should have access to
appropriate and understandable information about medicines
and their side effects (WHA 47)
Patients have a right to be fully informed about the potential
benefits and risks of the medicinal products before they are
prescribed (WHO, 1994)
Patients have a right to be fully informed about the proposed
medical procedures, together with the potential risks and
benefits of each procedure, about alternatives to the proposed
procedure, including the effect of non-treatment (1994).
 Your patients are not illiterate.

Town
Drugstore 35%
Clinics 2%

Hospital 1%

Neighborhood
Store 40%
Doctor 7% MEDICINES
(n=1324)
80%..!
Neighbors and
10%..! Relative 5%

Household Stocks
and Free Clinics 8%
Neighborhood

Anita Hardon, 1991

Problems in communication
Gaps between doctor-patients in social level or language
Doctor fails in providing enough consultation time
Lack of skills in retrieving information from the patient
Mis-interpretation of information
Patient does not agree with the treatment
Patient forgets the information/instruction
Patient is not capable to do the instruction
Information/instruction is too complicated
Information/instruction is incomplete
Patient has inconvenient experience with the doctor
Etc.
Doctors bias
about the patients
Doctors think that patients have the same
concepts about illness and disease etiology
Doctors think that patients have the same
concepts about cure
Doctors think that patients understand the doctors
language
Doctors think that when patients say yes (or
nod), it means they agreed or understood
Etc..
Different concepts
about illness/disease etiology
Different people have different concepts of
disease
Evil eye,
bewitching. Faith,
. immorality.
Bacteria, .
viruses..

Cold,
heat,
wind..
Differen
t foods..
Different concepts of cure

Destroy bacteria?
Remove symptoms?
Take away visible lesions?
Control measured signs, e.g.,
blood pressure?
Etc?
Different concepts
about the value of medicines
Colors: blue, red, green, yellow?
Forms: tablet, capsule, injection, suppository?
Taste: sweet, Pain relief score after taking different
bitter, sour, colors of placebo
2
tasteless?
Price?
1.5

Source?
1

Packaging? 0.5

Provider? 0
0 1 2 3 4 5 6

Etc..? Huskisson, BMJ 1974 Time (hours)

Effect of
promotion and marketing

Direct promotion to consumer of even

prescription drugs is common
Advertisements usually promote brand
names, may be inaccurate or misleading
Consumers are very sensitive to some
advertising messages
Six steps of
therapeutic decision process
(WHO, 1994)

Step 1: Define the patients problem

Step 2: Specify the treatment objective
Step 3: Select medicine
Step 4: Start the treatment
Step 5: Give information to the patient
Step 6: Monitor (or stop?) treatment

If you start talking to patients at step 5, it is too late..!!!!

Discuss with your patients.

Nature of the disease

Treatment objective(s)
Choice of treatment, including non-drug
treatment
Benefits and risks of treatment, including
those of no-treatment
Dosage regimen
Treatment cost
How, when to monitor the result of treatment
Unlimited
techniques to involve patients
1. Share with the patients what is in your mind
(Yati Sunarto, Senior Pediatrician)
2. Ask the patients opinion when you have options
(Inu Wicaksono, Popular Psychiatrist)
3. Make encouraging statements, e.g.,
You are absolutely right, could you tell her not to ..

4. Use open-ended questions to check understanding

Correct: could you tell me how would you take this suppository?
Incorrect: you know how to take this suppository, dont you?
Correct: when will you see me again?
Incorrect: come again next week, OK
5. Etc?
Techniques to check adherence

Counting pills
Monitoring therapeutic effect
Simple technique to monitoring
drug concentration:
Color of urine
Smell of urine
Objectives of the session

After attending this lecture, students are expected to:

1. Understand the steps in therapeutic decision process

2. Understand the patient rights on therapeutic
decision
3. Understand the importance of patient involvement
4. Understand how to involve the patients in
therapeutic decision process
 Miaaaauww
*

*Translation: Till meeting you in the practical work