PATIENT COUNSELLING

Introduction

Counselling is done at the end of long course of treatment just before discharge, but that is
not a hard and fast rule. Counselling can also be at the beginning or middle of the treatment
depends on the need. During the patient medication history interview, information about the
patient is gathered, whereas information is given during counselling. After the diagnosis, the
treating physician give some outline about the disease suspected and probable treatment and
duration. If more information is required to be given to the patient, counselling is conducted.
Similarly during the treatment, in order to ascertain patients feeling about his disease, its
severity or comfort, problems in medicine usage etc, counselling session is conducted.

At the end of the treatment just before discharge patient is instructed, about continuation of
treatment in home, do's and dont's regarding diet, exercise, repeat visit to hospital etc. This
session of counselling will be worthwhile because after discharge, patient looses the
supervision by doctor, pharmacist and nurses and hence a careless attitude of the patient may
result in relapse of the disease or more complications.

Patients used to hide some facts or mistakes committed by them to the doctor. By
counselling, a good counsellor can bring out those hidden truth by winning the confidence of
patients. Thus counselling is beneficial to both health care team and patients.

Need for Counselling and Privacy

Counselling involve two way exchange of information between the pharmacist and the
patient and hence it is better than written communication.It should be in sufficient quantity
and in language the patients understands. Hence the need for counselling is obivious. Again if
the counselling has to be effective, it should be conducted in a place free from noise,
interruption or distractions. If such a privacy is provided, patient will understand the
importance given to it and co-operate with unsellor. It improve the image of the pharmacist
and he will be recognized as one contributing to his welfare. Generally disease a private affair
of the patient hence he is hesitant to speak about it openly. When such a foolproof privacy is
provided, he tends to speak more about his inner problems and feelings.
Thus a fruitful counselling can be conducted when privacy is provided.
Classification

Counselling can be classified into:

1. Direct counselling (face to face) and
2. Distant counselling through phone

Though direct counselling is the one advised, distant counselling can also be useful for the
patients who could not visit hospitals or clinics for the reasons of disease, immobility or other
problems. In developed countries such services are available for a service fee, patients
themselves can opt for it. Usually, out- patients with chronic illness and elderly patients seek
these services.

Suitable Person to Give Counselling

Generally doctors, nurses and pharmacists can conduct counselling for the patients. However
the first two, do not have required time or environment for such services. As both doctor and
nurses need to attend emergency cases at any time, their services remain confined to the
ward. Moreover, waiting period, restlessness, anticipation, apprehension and even fear make
the patient out of mood to cooperate with counselling by doctors. The smell, fellow patients
and their disease complications, administration of different medicine through different route
to other patients, various surgical instruments and apparatus present in the hospital ward-
surrounding affect patients mind set, to be counselled by nurses. In these circumstances,
pharmacist is more suitable, as he is away from these environment and has no emergency to
attend and available at all times. By nature of his job, he is an expert in human relations (HR)
and has knowledge about drugs and its side effects. Thus pharmacists can take care of
patients need and direct him suitably if needed.

Selection of Patients for Counselling

Routine counselling of all patients is both impossible and unneccessary. Patients are selected
according to the need. For others, few minutes of counselling is sufficient and
given during regular ward rounds or at the time of administration of drugs. Relatively long
counselling sessions are needed for:

A. Patients to be subjected to long term treatment

e.g.: Epilepsy cases.
B. Patients with diseases but without severe symptoms
e.g.: Prophylactic cases of TB
C. Patients using drugs with narrow therapeutic index.
e.g.: Warfarin.
D. Patients with danger of abrupt stopping of treatment.
e.g.: Corticosteroid therapy.
E. Patients with potential for non-compliance, abuse of drugs.
e.g.: treatment with tranquilizers.

Patient Education and Councelling

Patient counselling is nothing but a form of patient education as majority of information

given during counselling is for the purpose of educating the patient. If it is considered as an
education, then it need not be restricted to few patients. As many patient as possible should
be educated so as to achieve best clinical outcome of the treatment.

American Society of Health System Pharmacists [ASHP] says "Pharmacists should educate
and counsel all patients to the extent possible, going beyond the minimum requirements of
laws and regulations." ASHP also emphasize, "Pharmacists should encourage patients to seek
education and counselling and should eliminate barriers to providing it."
Though guidelines are given above to select patients for counselling, pharmacists should try
to accommodate as many patients as possible, in the interest of the patient, society and his
own profession which earn respect from the patients by these services.

Patient education and counselling can be carried out in all the four types of pharmacy
practice, viz, Inpatient care, Outpatient care, Home care and Community care settings.
However counselling requires some prior preparation to be useful to the patient and to the
institution.
Preparation for Counselling It differs between the four settings mentioned above. If the
counselling is for an inpatient at the time of discharge, needed information about the patient
can be obtained from hospital records.
However, if counselling is to be carried out at the time admission of the patient or few days
after the admission or for outpatient or in community pharmacy settings, pharmacist should
gather all relevant information about the patient before starting counselling.
If pharmacist could acquire knowledge about patient's cultures, especially his health and
illness beliefs, attitude and practices it goes a long way in dealing with him. If the counselling
is done after few days of admission and in the middle of the treatment, counselling has to be
in different plain, so as the patient to realize his disease can be cured, if he adheres to the
instructions of health care team.
After all every patient want to go home earlier after curing their disease, hence getting their
co-operation not be a problem. Small complaints like frequent injections, lab procedures and
big bitter tablets they start tolerating if the counselling is effectively done.
Similarly outpatients will realize whatever the doctor, pharmacist or nurse told was for their
welfare, after a brief counselling. Hence for the counselling to be successful the pharmacist
should get himself ready for it.

As there is no effective supervision of patient after discharge, proper counselling is needed to

prevent relapse and readmission of the patient. Appropriate learning aids like graphics,
anatomical models, medication devices, memory aids, printed pamphlets and audio visual
resources should be kept ready in the counselling room.
Whichever aid needed must be used to boost the level of understanding of the patient, if
necessary by demonstration.

This apart, while getting ready for counselling, pharmacist should review discharge
prescription, ensure clear medication list and instruction for discharge. The patient's follow
up plan should also be ready.
As mentioned above fairly good idea about the patient to be counseled can be collected from
hospital records. The patient may be a child or aged patient or mentally ill or terminally ill
patient. Depends on the type of patient, pharmacist has to plan his counselling content. For
example to counsel a child prior idea about its level of understa
 elderly patient may be vision or hearing impaired, a terminally ill patient may not be
interested in counselling at all and may not listen and mentally ill may not understand and co-
operate with counselling. Before counselling a pharmacist must prepare to face all the above
situations.

Scope of Counselling or Contents of Counselling

The scope or purpose of patient counselling is for giving instruction and motivation to
patients and monitoring them. The counselling for outpatients differ from counselling for
inpatients. To inpatients, certain points like, how to open or administer drugs, timing and
amount of dose etc need not be discussed, as they are taken care of by nurses. Those
instructions need to be given only at the time of discharge along with storage conditions refill
information etc. However all these informations have to be conveyed to outpatients, along
with possible side effects, what to do if one or two doses are missed and duration of
treatment. For complicated regimen like multiple drug regimen or sophisticated or complex
packings, drugs has to be shown to the patient and explained. This, not only make them
understand better, but also helps the pharmacist in detection of dispensing or prescription
error. A few words about use and importance of each drug will lead to better compliance and
consequent success of treatment.

Moreover patients may be interested in knowing expected duration of treatment and expected
benefits. They can be briefly mentioned while discussing the importance of adhering to the
instructions. Possible drug- drug interaction and drug-food interaction should be informed.
Technique of self monitoring of treatment should be taught to the patient. Depending on the
patient's disease management and therapeutic plan some education can be given regarding the
disease state, its effect on normal life and identification of disease manifestations.

Before closing the counselling session patient may be encouraged to speak his mind
regarding the treatment. This is very important because, they have many unanswered
questions, misunderstandings and problems which they may not reveal to health care team. In
the absence of answers to these problems, they make their own decisions regarding the
treatment. Only when they are prompted, they tend to open up and ask questions and share
their experiences with treatment.

After clearing patient's doubt pharmacist can ask few questions at the end to estimate the
patient's level of understanding and knowledge about counselling points. If required,
pharmacist can once again clarify his doubts with materials and demonstrations. At any point
time, pharmacist should not assume that patient has understood all the information given and
think if there is problem he will contact him. Also he should not assume that some one else in
the health care team-doctor or nurse-might have already told everything to the patient while
he was in the ward.
Effect or uses of Counselling

DUE to Counselling

1. Knowledge of disease and its treatment among the patients improved.

2. Patient compliance improved.

3. Repetition of drugs already under use or used can be avoided.

4. Pharmacist contribution towards disease documentation increased.

5. Since compliance improved, disease aggravation reduced.

6. Because of it, emergency visit to hospital or hospitalization or subsequentexpenses

reduced.

Thus counselling plays an important role in disease management. Hence clinical pharmacists
should be appointed in all Indian hospitals.

Barriers or Problems in Patient Counselling

Though there are many advantages in patient counselling, in practice it has barriers many or
problems. They are,

1. Hospital Environment: The hospital ward environment is not always suitable for patient
counselling. Unless the patient is admitted in a separate room called special ward, it is not
conducive to go for counselling in a crowded general ward where dozens of patients are
admitted in beds close to each other. Thus there is no privacy and hence patient may not
openly discuss his or her problems, doubts and observations of their body conditions. Also
the noise or sound level in the general ward is distracting and disturbing and it is especially
difficult for the patient to raise their voice. The remedy is to take the patient-even on a wheel
chair- to a separate counselling room if provided in the hospital. If it is not provided, at least
one common room for two wards- the counselling become a ritual.

2. Language Barrier: Many patients of Govt. hospitals are from poor families and they are
the people actually requiring counselling. But majority of them only know their mother
tongue and use of English or other languages and technical terms during counselling make it
useless. Hence counselling pharmacist should able to speak in the language the patient
understands.

3. Educational Level: It is fallout of above situation where the patient's education level is
poor. Hence they may not be in a position to read the label or written instructions or
information given to them. Even if they read it comprehending or understanding that
information is very low.

4. Disabilities of body: Many patients are in their advanced age and hence their eye sight and
hearing abilities are below normal. Such patients have to be counseled with written materials
if they are able to read or with sign language, if they can see it. Repeated instructions during
counselling until the patient understand it may be required.

5. Patient motivation: It is one of the important factor that any amount of counselling goes
waste unless the patient is motivated to listen and learn. If the patient is suffering from
chronic illness or not completely cured or has to continue treatment in his home or depressed
or at the tail end of their life they tend to show disinterest in counselling. Clinical pharmacist
should understand it and conduct counselling according to ground realities. Definitely it is
one of the difficult situations in his career.

6. Inadequate time or training: Usually senior, experienced clinical pharmacists are

assigned the duty of patient counselling. But on some rare occasions or during trainings,
juniors may be counselling. That may reflect on the quality of counselling. Sometimes due to
lack of time or pressing other engagements Clinical Pharmacists tend to cut short counselling
sessions and that also considered as one of the barriers in counselling.

Documentation

Pharmacist should document counselling points in patient's permanent medical record as per
the guidelines of hospital or law. If the above medical record is not available for any reason,
pharmacist can record it in patient's medication profile or in specially designed counselling
record of the pharmacy department of the hospital. In this record pharmacist should note
when, where, how and for whom the counselling was given and also the specific points
discussed including drug-food interaction warnings He should also record the patient's level
of understanding as perceived by him. These records should be safe guarded as patient's
confidential personal record till the time it is legally.