Scenario 1: Advising on over the counter medications
A patient comes to the clinic for an assessment of acute neck pain. The patient reports that they are not currently taking any medications, then asks the physiotherapist if they should be taking an over the counter anti-inflammatory. What can the physiotherapist say in response?
As already stated, it is outside the scope of physiotherapy practice to provide recommendations regarding medication use. Therefore, the physiotherapist should not provide direction about what medications to take or how often to take them.
This does not mean that the physiotherapist cannot provide patient education about medications, provided they have the knowledge to do so. For example, the physiotherapist could say the following:
“The best people to talk to about the medications that are right for you are your physician or your pharmacist.
I can say that anti-inflammatories may help to reduce some of the pain and swelling you are currently experiencing. I also understand that how frequently you take some anti-inflammatory medications will impact whether you experience a primarily pain-relieving effect or an anti-inflammatory effect.
However, as with all medications, anti-inflammatories come with side effects, and can interact with other medications and supplements you may be taking. I recommend that before you start taking anything regularly you to speak to your doctor or pharmacist.”
Scenario 2: Advising on changes to prescription medications
A patient with Parkinsons’ disease reports that their doctor recently increased the dose of one of their medications and that since then they’ve been experiencing dizziness and nausea. The physiotherapist regularly works with people with Parkinson’s Disease and knows that these are common side effects of the medication. The patient is not due to see their doctor again for several weeks. The patient asks the physiotherapist about going back to their old dose of the medication. What should the physiotherapist do?
The physiotherapist should not make any recommendations to the patient about changing the dose of their medications. Providing specific suggestions about medication use or dose is not within the core competencies of the physiotherapy profession. Furthermore, the physiotherapist is not likely to know the physician’s rationale for the change in dose, the intended outcome, anticipated side-effects or how those side effects can be mitigated.
However, the physiotherapist does have a duty of care to the patient and has a few options for how to support the patient’s optimal care. The physiotherapist may encourage the patient to speak to their pharmacist or physician about the situation and recommend that the patient not wait until their next appointment to do so. The physiotherapist could also choose to directly contact the physician to discuss what the patient is reporting and facilitate more rapid follow-up by the physician.
Scenario 3: Conducting a best possible medication history
A patient has just been discharged from the hospital following a total joint replacement. A physiotherapist has been asked to review the patient’s hospital medication record and compare it with the one that their pharmacy has provided since they have returned home. Can the physiotherapist do this? What should they keep in mind?
A duly trained physiotherapist who understands the process and importance of gathering a “best possible medication history” may choose to engage in the task of comparing the two documents. Before they do so they should consider the following:
- What employer policies are in place to ensure patient safety when the physiotherapist is engaging in this task, and are those policies and procedures followed by the health-care team of which they are a member?
- What will they do if they identify any discrepancies in the two documents?
- What resources or supports are in place to enable them to address discrepancies identified? (For example, is there a pharmacist on the health-care team who can address discrepancies on an urgent basis?)
The physiotherapist should not take on the role of interpreting the appropriateness of the medication orders or any other task that requires knowledge and medication-related expertise.
Similarly, a physiotherapist would not have the knowledge and skills necessary to identify if a patient’s BPMH included “high risk” medications. However, they could use their observation skills to identify if the patient exhibits certain, pre-determined risk signs, (e.g., the patient is on a pre-specified number of medications deemed to be a risk threshold, or showing objective evidence of unopened bubble packs), and report this information to a health-care team member with the competence, mandate and a pre-defined service timeline to follow up on the concerns the physiotherapist identifies.
Scenario 4: Referring for medication assistance by an unregulated health provider
The physiotherapist is completing an intake assessment for a new patient who lives in a designated supported living facility, and notices that the patient has significant arthritic changes to her hands. The patient is cognitively intact and agreeable to taking her medications but identifies that she sometimes misses her pills as she is sometimes unable to open their packages or get help to do so. The physiotherapist would like to arrange for one of the facility’s Health Care Aides (HCA) to come in and help the patient by opening the packages for her. Can the physiotherapist do this? What does the physiotherapist need to keep in mind when arranging the support?
Physiotherapists clearly have the necessary skills and competencies to identify when physical impairments are impacting function.
However, the physiotherapist is not qualified to supervise medication assistance activities performed by an HCA, so another duly qualified health professional will need to agree to do so. The physiotherapist will need to collaborate with the facility to ensure that there are health-care professionals on staff who are willing and able to supervise the HCA in providing the assistance.
Scenario 5: Requesting changes to prescription medications
A physiotherapist works as a homecare case manager. Today the physiotherapist heard from a nurse working with one of the patients for which the physiotherapist is the case manager. The nurse informed the physiotherapist that the patient has been given a prescription for antibiotics that is “wrong” and that the physiotherapist needs to call the patient’s doctor to get it “fixed.” What should the physiotherapist do?
The physiotherapist is not the best person to discuss the nurses’ concerns about the medication, nor would they have the necessary skills to recognize an “appropriate” medication prescription or ask clarifying questions to ensure that the corrected prescription was complete and appropriate. The physiotherapist should direct the nurse to contact the health professional who prescribed the medication to discuss their concerns and obtain the corrected order.
Scenario 6: Providing medication assistance
A physiotherapist works in homecare within a low-income neighborhood. Many of their clients are marginalized, and several have mental health concerns. One of the physiotherapist’s patients requires court-ordered daily assistance to ensure that his anti-psychotic medication is taken as prescribed. The patient does not need assistance to take the pill, but a health-care worker must bring the medication to him and observe him taking the medication. The physiotherapist’s nursing colleagues know that the physiotherapist is going to see the patient and ask if the physiotherapist can take the medication to the patient and observe the patient taking the medication. Can the physiotherapist do this?
This looks like a simple request; however, the physiotherapist should carefully consider how they would react if the patient had questions about their medication, had developed new symptoms that led them to question whether they should take their medication, or deviated from the “plan” in any way.
Does the physiotherapist have the skills necessary to make sure that the patient takes their medication rather than pocketing it? If they are signing a document to say that the patient took the medication, are they prepared to take responsibility for this? Does the physiotherapist have the necessary knowledge to answer the patient’s questions about interactions between the medication and other substances they’ve consumed? Does the physiotherapist have the necessary knowledge to provide patient education and information if the patient identifies changes in their health status, or to independently identify such changes? If there is a problem, is there an on-call nurse or pharmacist available that the physiotherapist can easily reach for direction and assistance?
Overall, engaging in this activity exposes the physiotherapist and the patient to risk. The physiotherapist should ask themselves:
- Is this an emergency?
- Are there other health professionals better qualified to provide this support to the patient?
- Are there additional processes and professional supports in place to ensure patient safety?
If it is not an emergency and there are other health professionals on the team who are better qualified to provide the assistance, or if robust processes and supports are not in place to ensure patient safety, the physiotherapist should not engage in the activity.