Ms. N, age 51, was a nurse practitioner ­working independently in a rural family practice. The community in which Ms. N practiced was extremely small and close-knit, and the clinician had known most of her patients for years. 


Mrs. V, age 70, who Ms. N had been treating for the past 11 years, had a medical history of a myocardial infarction, cardiac arrhythmia, hyperlipidemia, and hypothyroidism. Mrs. V had also been diagnosed with metastatic colon cancer and was undergoing chemotherapy and radiation treatments at the nearest medical center, which was an hour’s drive away. 


The travel was very difficult for the patient. Because she was unable to tolerate the long drive for additional doctors’ appointments, the patient often called Ms. N for medication refills, rather than make appointments with her oncologist and/or cardiologist. 


One day, Mrs. V’s husband showed up at Ms. N’s office, requesting a refill of amiodarone for his wife. The drug had initially been prescribed four months prior, due to a cardiac event during Mrs. V’s colectomy and resection procedure. 


“She’s really feeling poorly,” Mr. V said of his wife. “The chemo has made her so sick. She is nauseous and throwing up. She really can’t handle the 60-minute drive to the cardiologist. Can you please refill this?” 


Ms. N, who understood the difficult situation the patient was in, felt sympathetic toward both Mr. and Mrs. V. The patient’s illnesses had been difficult for the couple, who were just about to celebrate 50 years of marriage. The medical center was a long drive away, and it was winter—the roads were not in good shape. 


“Okay,” Ms. N said to Mr. V. “I’ll give her a 30-day refill as a courtesy. I know what that drive is like, especially if she’s feeling queasy, but please make an appointment with her cardiologist for future refills.” 


Mr. V said he would, thanked her, and left with the prescription. 


Thirty days later, however, he returned by himself again asking for another refill of amiodarone. 


“I’m so sorry,” Mr. V told the clinician. “She missed her appointment with the cardiologist because of the big snowstorm we had, and her medication will be finished before the next appointment.” 


Again, Ms. N refilled the prescription without speaking to the cardiologist, evaluating the patient, or looking up the medication, with which she was not terribly familiar. 


Three weeks later, Mrs. V experienced shortness of breath and was admitted to the hospital for acute respiratory failure. While at the hospital, Mrs. V was diagnosed with pulmonary fibrosis and amiodarone lung toxicity, and she died shortly after admission.