Patient Rights and Diabetic Diets - page 2

Nursing staff on my unit have been having a debate lately about where the line is with diabetic patients on MD-ordered ADA or carb control diets and patient rights. In particular, a diabetic pt on... Read More

  1. by   llg
    Quote from rn/writer
    .........
    Go beyond the physical assessment. Is the person newly diagnosed and still in denial? Have they been struggling and do they now feel defeated because they ended up hospitalized anyway? Are the bad habits such a part of their familial culture that they feel helpless to even try to break away? Have they reached a point where they have given up and want the pleasurable things for whatever time they have left?

    Each of these requires a different acknowledgment and a different approach to have any chance of success.
    ...............

    Wow! I think this is the best piece I have ever read on this topic. Thank you, Miranda.

    As I read it, I was sitting here on my couch eating my low-carb toast and turkey bacon for breakfast. As a newly diagnosed diabetic, I have to be careful what I eat. :chuckle Fortunately for me, my physician respects my need to make my own choices. She didn't insist on any particular diet and didn't even insist that I see a nutritionist. She left all the decisions up to me, while offering whatever support I wanted. (She knows me.)

    I chose a low-carb diet that includes fewer carbs (and probably a few more fats) that the standard ADA diet. I've lost 25 pounds in the last 4 months and maintained good glucose control. My cholesterol and trigliceride levels have also improved on this diet. It's one I created myself that fits my lifestyle and helps me maintain a feeling of being in control. I even did OK on a recent vacation that included lots of restaurant meals.

    For me, feeling as if I am in control and making my own choices is essential. Being "put in a regimen" of someone else's design would cause me to rebel -- pehaps even to the point of noncompliance. I am very stubborn. With my freedom of choice intact, I can use my stubborness to drive my compliance with MY diet ... and not have it spur me to rebel against a diet imposed by someone else.

    Thank you for your wonderful post -- and for sharing your wisdom here on allnurses in general. (I also love your Gerald Ford quote.)

    llg
  2. by   lsyorke
    Maybe I can throw a different perspective in here. Hubby is a type 1 diabetic for 46 years. He made it until this year before having major complications of his disease. He is now 56. If there's one thing that aggravates him the most is the nurse/doc/resident walking into his room and saying "You need to take care of yourself...see what bad blood sugars have done to you?". Well folks, his blood sugars are well controlled and have been for years. But this disease will take it's toll anyway. He is living with a chronic disease that has taken away so much... to hear the condescending residents just pushes all his buttons.
    Diabetes has controlled all the major decisions in his life. His choice of career, his recreation, his marriage decisions. It has taken his eyesight in one eye, his toes on one foot, his ability to feel his legs, his cardiac health etc... He is now forced to face the fact that he won't make it past 60. Try living a life like that...then put into perspective the occassional piece of cake. When he is in the hospital he always has food at the beside...insulin reactions can happen faster than a nurse can react. He knows how to deal with it, and can correct it fast IF he has the food at the beside.
    So next time to see a diabetic remember my husband. He is as compliant as he can be...but he's still losing the battle.
  3. by   oramar
    Quote from lsyorke
    Maybe I can throw a different perspective in here. Hubby is a type 1 diabetic for 46 years. He made it until this year before having major complications of his disease. He is now 56. If there's one thing that aggravates him the most is the nurse/doc/resident walking into his room and saying "You need to take care of yourself...see what bad blood sugars have done to you?". Well folks, his blood sugars are well controlled and have been for years. But this disease will take it's toll anyway. He is living with a chronic disease that has taken away so much... to hear the condescending residents just pushes all his buttons.
    Diabetes has controlled all the major decisions in his life. His choice of career, his recreation, his marriage decisions. It has taken his eyesight in one eye, his toes on one foot, his ability to feel his legs, his cardiac health etc... He is now forced to face the fact that he won't make it past 60. Try living a life like that...then put into perspective the occassional piece of cake. When he is in the hospital he always has food at the beside...insulin reactions can happen faster than a nurse can react. He knows how to deal with it, and can correct it fast IF he has the food at the beside.
    So next time to see a diabetic remember my husband. He is as compliant as he can be...but he's still losing the battle.
    God bless and good luck to both of you. In my post this is what I was trying to say. I don't think for a moment that bad outcomes automatically mean non compliance. I have seen too many cases where people were compliant, very compliant and still got the complications.
  4. by   widi96
    Educate and Document. Just as they have the right to accept / refuse medication, as long as they are educated on what could happen if they eat sweets, they have the right to eat what they want. Just document that you have educated and they still want to be non-compliant with the recommended diet. Just document to CYA.
  5. by   SassyRedhead
    I am not ripping the candy bag out of her hand. Rather, I am refusing to hand it to her from her belongings. If she wants to have a family or friend give it to her, then so be it. I am just saying that I am not prepared to do it for her.

    I look at it this way: yes a pt has the right to refuse a medication. I have no problem with that. But if that pt were to bring in a bottle of Vicodin from home to the hospital and insist it be at their bedside to take ad lib on top of other pain medication they may have, we wouldn't dream of doing that. I see my refusal to give her the bag of candy as the same sort of thing. The Vicodin (candy) was not ordered for the pt, therefore, I am not going to be party to giving it to a pt. I hope that makes my thought process clearer.

    ETA: I am trying to do the right thing for both the patient and myself. If someone can link some ethics literature/resources re: this type of situation I would appreciate it. I would like something concrete to back up my decision, one way or the other.
    Last edit by SassyRedhead on Feb 10, '07
  6. by   llg
    Quote from SassyRedhead
    I am not ripping the candy bag out of her hand. Rather, I am refusing to hand it to her from her belongings. If she wants to have a family or friend give it to her, then so be it. I am just saying that I am not prepared to do it for her.
    .
    If my nurse refused to meet my needs for autonomy and not respect my right to make choices that are perfectly legal and not hurting anyone else -- and not against any rules (e.g. smoking near oxygen, etc.), I would be complaining to the administration and insisting that another nurse be assigned to my case.

    ...and if I fell while I was getting out of bed to get the candy myself, I would be sure to state in the lawsuit that I asked the nurse for assistance and she refused to help me.

    That's not good nursing care ... that's imposing your value system onto your patient.
    Last edit by llg on Feb 10, '07
  7. by   GardenDove
    I agree llg. I would feel belittled by a nurse who treated me like a child. Pts are perfectly free to pick and choose what they want from the information and care that we offer them. If they requested a piece of candy that someone had brought them, I would certainly hand it to them. It's theirs, after all.
  8. by   SassyRedhead
    I think you all are reading this incorrectly. I am not imposing my will on her. Frankly, I don't care if she eats the whole bag. This has nothing to do with a value system. Please, if you will, respond to the issue at hand, which is about nurses that arbitrarily follow a MD order. I tried to outline my thought process with the Vicodin example. I would appreciate response to that.
  9. by   rn/writer
    Nursing staff on my unit have been having a debate lately about where the line is with diabetic patients on MD-ordered ADA or carb control diets and patient rights. In particular, a diabetic pt on our unit had a big bag of candy in her belongings and went postal about being allowed to have it, even though she was ordered QID accuchecks with PO antidiabetic meds and sliding scale insulin.
    When a doc orders an ADA diet for the patient, that generally refers to what is available for the patient from the hospital kitchen, what kind of meals the dietary staff will send up. I don't know how far that order extends beyond the kitchen.

    I think you are right to be concerned about doing something that directly contradicts the doc's expressed desire that the patient be on a specific diet. To a point. If the patient were hungry, you would probably try to find a snack that wouldn't be off the charts. But that's where the gray area begins.

    What if the patient wanted three packages of cookies? Or toast and double packets of jelly? I guess the real question is where do doctor's orders leave off and patient rights begin and how do you not get caught in the middle, especially in a situation where visitors are not around, and the patient needs you to help her get what she wants. I don't have any easy answers.

    You might want to discuss this with your manager, as well as with someone from risk management to formulate some kind of staff policy so that your choices are covered either under the doc's orders or under the patient's rights. This shouldn't be a "darned if you do" and "darned if you don't" scenario. It's important to determine ahead of time whose "law" is trump? The docs need to be made aware of whatever is decided, too.

    As for the example of the Vicodin, there is a legal difference between a substance which is controlled for everyone and candy which is legal and has no restrictions save for the arbitrary ones created by the doc.

    In the case you mentioned, would it have been possible to bring the woman's purse or suitcase to the bed so that she could have been the "guilty party" in getting the candy? I know, that probably still seems like enabling, but what good does it do to focus so strongly on the power struggle. If you merely place her belongings within reach, you are not the one making the choice.

    You mentioned having many therapeutic conversations with her. I do NOT mean to criticize or negate your efforts by any means, but I would like to suggest that in many instances, what is thought to be therapeutic by the caregivers is not perceived that same way by the patient.

    Does the candy mean anything to her besides the obvious?

    I do want to acknowledge your reference to the fact that this patient has psych issues along with her physical problems. I worked in psych for many years and see a large overlap between psych issues and diabetic issues. Both populations are historically beleaguered by having decisions made for them and treatments forced upon them. Both have lost control in a deep and drastic manner. And each has a tendency to become suspicious and defiant in the name of retaining autonomy.

    You definitely have your work cut out for you. I would say that having a good policy and procedure in place for this kind of situation would give you a measure of comfort and protection as well as some idea of how to proceed.
  10. by   SassyRedhead
    Thanks Miranda. This gal is a frequent flyer here and we have done so much on so many occasions to attempt to accomodate, special dietary consults, talking to docs, etc. Every meal is at best unpleasant or at worst an all-out meltdown. I totally understand about her perceived lack of control and I really do empathize.

    It's one of those situations however that as you attempt to accomodate you get hooked in for more and more "exceptions" to the rule. This time around she totally denied that she had diabetes, although she has been on meds for years. Doc d/c'd all meds, put her on a general diet and her BS skyrocketed, doc re-educated and restarted meds/special diet, nursing is supporting. Pt still angling for extras/special favors.

    We are all just trying to do what is right. As I'm typing, I'm dusting off my nursing books to try to find some answers.
  11. by   rn/writer
    I can appreciate your dilemma. The sad truth is we can't save people from themselves.

    I would encourage you to discuss this further with your manager and others. Even when a patient isn't so extreme, there can still be a clash between doc's orders and patient's rights. I'll be the first to admit that I don't know where that line is, and chances are, it's one of those that has a tendency to move.

    As we all seem to agree, documentation is key. But beyond that, how do we, as nurses, navigate between the rocky shoals? Which principle takes precedence?

    I don't envy you having to work with a patient who doesn't seem the least bit interested. Is the doc aware of her psych limitations?

    I wish you the best.
  12. by   SCRN1
    I'd just try my best to educate them and then document very carefully everything I see and document with quotations everything they say. I'd also verbally tell the MD.

    A different subject, but similar with trying to get a patient to comply with treatment...

    I recently had a patient who was a hateful little thing who didn't want to do anything she was told. She refused being turned. Refused having a 3-day old INT d/c'd, refused dressing changes to her decub, etc. She was so exhausting to everyone who tried to work with her that no nurse had to be assigned to her two days in a row. When it was my time to take her, I went in with my supplies and just announced to her, "I'm here to do _____". (This was a different trip in after the initial assessment the beginning of the shift.) She looked and me and nastily said, "do you know about patient's rights? I have those rights!". In a calm, cool, collected & professional voice, I answered, "yes m'am, I do and you're right that you do. But did you know that if you don't allow the care that the doctor has ordered, he can release you from the hospital for noncompliance?" I might not should've said that, but it worked! She didn't argue with me about anything, allowed me to do everything I said I was there for and even became nicer and more agreeable with all the other nurses after that.
  13. by   Indy
    I'd have to agree with the poster who won't hand the lady her candy, if the patient can reach it herself. And if she's a fall risk then I would have to tell her not to get out of bed, please hit the call light if you need to get up. And document.

    I have not had this exact scenario but I can understand where it would be like a catch 22. You're telling her to not get up, you won't hand her what she wants, and she's probably all sorts of ticked off. And to top that off you gotta document more than normal just to cover your butt.

    I put her in the "broken hands" category of patient; it's my pet stereotype name for people who want things done for them that they can do for themselves. I do not now, nor have I ever, made it my personal practice to cater to that syndrome. And yes, it is tiring to write over and over again that things are within the patient's reach and that they do not voluntarily do range of motion for themselves, etc. But I believe I'm doing the patient harm if I allow them to get what they want, versus what they need. I'll explain to them what's going on, so they at least hear, if they don't believe, that I have their best interests in mind.

    I usually get the opposite type of diabetic; the one who's deathly afraid of their bedtime snack and has to be educated on the value of a small snack in keeping the blood sugar decent at night. I do listen to my patients, and keep food available for the insulin-sensitive ones who say they bottom out; we all like to avoid brain damage. But I do not believe in handing people what's bad for them, if it's right there where they can get to it themselves.

    Where I more often have this type of dilemma is the smoker who wants to avoid AMA discharge per the doc, so they'll try to stay in the room to sneak a smoke. As I remove the O2 adapter from the wall and stick it in my pocket, I say sweetly, "I sure hope you don't happen to need this oxygen, because if you're going to light fires in your room I can't have oxygen that close to it. In case you didn't know, that could start a real fire and I won't allow you to endanger the lives of my other patients." Usually that gets them to hand over the cigarette lighter, and the O2 goes back where it belongs. The policy is to call security and have them handle it. I haven't had to do that yet.

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