Patient Rights and Diabetic Diets - page 3

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   Myxel67
    A diet order is a different animal from a chest xray, ultrasound, etc. It's not an all or nothing kind of thing.

    If the doctor orders an 1800 calorie diet for pt & pt simply has no appetite and eats only 900 calories, are you going to try to carry out that order by going in and force feeding the pt. That amounts to about the same thing as refusing pt access to her belongings. There really isn't a legal issue here related to not enforcing the doctor's order. With diet, enforcing is a better term than carrying out. (Except for tube feedings and TPN, of course)

    BTW, even though doctors continue to order it, the ADA diet no longer exists. In its place are recommendations to determine energy requirement of pt (based on height, weight, age, level of physical activity, and disease process). The energy requirement is expressed in calories. Dietitians in our diabetes care center recommend that the calorie count be split as follows: 50% carbohydrate, 20% protein, & 30%, but even that is not endorsed by the ADA.

    Below is an excerpt from an article that appeared in 2002 in "Clinical Diabetes", the Journal of the American Diabetes Association.

    To best understand the problem, it is important to look at the recently published ADA position statement titled "Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications."3 We are reprinting this position statement in this issue (p. 53).

    There are several key points that require emphasis. First, the total amount of carbohydrate in meals and snacks is more important than the source or type of the carbohydrate consumed. Although different forms of carbohydrate do induce differing glycemic responses, the data reveal no clear trend in outcome benefit for any specific type of carbohydrate. The position statement notes that dietary sucrose does not increase glycemia more than isocaloric amounts of starch. Therefore, "intake of sucrose and sucrose-containing foods by people with diabetes does not need to be restricted because of concern about aggravating hyperglycemia. Sucrose should be substituted for other carbohydrate sources in the food/meal plan or, if added to the food/meal plan, adequately covered with insulin or other glucose-lowering medication."3

    Because there is a great deal of individual variation in response to different sources of carbohydrate, it is difficult to make recommendations that apply to everyone with diabetes. By considering the total amount of carbohydrate in a meal and reviewing premeal and postmeal glucose measurements, it is possible to see how individuals respond to different types of food. Certainly, we see this on a daily basis in our clinic, particularly in those who frequently measure their blood glucose level.

    Also relevant to my patient is the fact that he was acutely ill and had additional nutritional challenges other than his chronic illness. Why is it that everyone with diabetes seems to end up with the same dietary prescription when hospitalized? The ADA does not even endorse the "ADA diet"; it no longer recommends any single meal plan or any specified percentages of macronutrients for people with diabetes.4

    Meal plans that specify "no concentrated sugars" or "no sweets" are no longer appropriate. These diets do not reflect current nutrition recommendations and unnecessarily restrict sucrose. Furthermore, they perpetuate the notion that restricting sucrose will result in improvement in diabetes control.

    http://clinical.diabetesjournals.org...t/full/20/2/51

    So you see, the physician has written a diet that can't be followed because that diet doesn't exist. By continuing to perpetuate outdated information, we do our pts a disservice. We should be crusading to get the hospitals to get rid of the insulin sliding scale and learn how to manage diabetes in hospitalized pts.

    (You could count out 900 calories worth of the candy and tell her that's her carb allowance for the day. Remove carbs from tray. If she wants any of the carbs on the meal tray, she'll have to trade some candy for it.)

    Sorry about the long post, but sometimes it's just got to be said.
    Last edit by Myxel67 on Feb 11, '07 : Reason: typo
  2. by   GingerSue
    [quote=ckben;2061074]

    but by agreeing to be in the hospital, they agree to the care which nurses will give them, which includes giving them an appropriate diet.

    [quote]


    not sure about this agreement

    eg. a diabetic lady was prescribed insulin and she refused the insulin, preferred to manage her diabetes other ways - according to her religion and alternative activities

    I think that as nurses we have to respect the client's choice, try to inform and provide educational material, respectfully, and support their wishes
    Last edit by GingerSue on Feb 11, '07
  3. by   cookie102
    all you can do is educate , educate, educate-----then document, document, document
    people make all sorts of choices, unfortunately not all of them are good ones
  4. by   GardenDove
    Just because you're in the hospital doesn't require you to surrender your free will to everything ordered by the doctors and nurses. You are entitled to refuse things, even if your nurse disagrees with your choices.
  5. by   GooeyRN
    When I see a diabetic eating something they shouldn't be eating, I strike up a conversation on how it is sometimes difficult to be compliant with the diabetic diet. I then let them talk. If they are adults who know what they are doing and know the consequences, I will not take food away from them. Its their decision. But I do document about the conversation and if they continued to eat the food.

    I try my best to not make them feel guilty for their choices, while trying to encourage healthier choices. (like sugar free chocolate pudding with sugar free whipped cream on top, instead of chocolate cream pie for example, or blueberries with whipped cream instead of blueberry pie)

    I am not a diabetic. I think it must be difficult to follow the diet day after day, for the rest of my life. I don't think I could handle it, either. We all have our unhealthy things in life. Mine is diet soda. I know the aspartame or splenda in it is really bad for me. But I choose to drink it anyway. I would be furious if a nurse took it out of my hand and did this. I am an adult of sound mind. I know the consequences of diet soda. But I choose to drink it anyway.
  6. by   Myxel67
    I expected a flurry of indignant replies in response to my long post (#27) Appaarently, it was so long nobody read it!

    At least check out article in link from the clinical journal of the ADA.

    http://clinical.diabetesjournals.org...t/full/20/2/51
  7. by   morte
    You could count out 900 calories worth of the candy and tell her that's her carb allowance for the day. Remove carbs from tray. If she wants any of the carbs on the meal tray, she'll have to trade some candy for it.)

    this is something she had refused to do.....

    I expected a flurry of indignant replies in response to my long post (#27) Appaarently, it was so long nobody read it!

    yup, i tried, couldnt get throught it, will try again.....and i have more than a passng interest in nutrition.....appeared somewhat disjointed, as i said will try again
  8. by   Myxel67
    No, she had the full tray and refused to give up any of the carbs on it in exchange for candy. Here she has the candy, but can't get any of her other meal time carbs unless she exchages some of the candy. Not the most nutritious, but she wouldn't exceed carb allowance for the day
    Last edit by Myxel67 on Feb 11, '07
  9. by   nurse4theplanet
    Quote from SassyRedhead
    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.

    My comment was that I am the licensed personnel in the situation responsible for carrying out MD orders (carb control diet in this case), and the pt was insisting on NOT exchanging anything off the tray for some of the candy but, rather, that she have it ad lib at the bedside. I feel that in allowing her to have the candy, I would be going against MD orders and could be held liable for any adverse consequences if she ate herself into a huge BS.

    Now, I am not going to ever rip something out of someone's hands, but this was tucked into belongings and I would not get it for her after reminding her of the order and how this would impact her BS. If a pts family brought in a milkshake, for example, and the pt was consuming it and refused to give it up, I would just document the heck out of it after also informing the visitors that the MD has not given orders for such food and that this goes against the pts plan of care. For what it's worth, this pt also has known psych issues.

    Am I right? Wrong? Completely off base?
    I feel your frustration. This happens alot on our unit (well...for those who CAN actually eat and are not on TPN lol). Whether it is a diabetic diet, renal diet, or AHA...psych issues or no psych issues...some pt's just will not comply. If they aren't going to do it in the hospital during a health crisis, then you can bet your last dollar that they will not comply once they are at home. You can't force them to follow any MD order, including a diet. You document everything just as you said you did in your post and make sure the MD is aware so he doesn't make unnecessary adjustments to the sliding scale insulin or oral meds that could result in severe hypoglycemia. You can not be held liable for pt non-compliance.
  10. by   llg
    Quote from Myxel67
    BTW, even though doctors continue to order it, the ADA diet no longer exists. In its place are recommendations to determine energy requirement of pt (based on height, weight, age, level of physical activity, and disease process). The energy requirement is expressed in calories. Dietitians in our diabetes care center recommend that the calorie count be split as follows: 50% carbohydrate, 20% protein, & 30%, but even that is not endorsed by the ADA.

    Below is an excerpt from an article that appeared in 2002 in "Clinical Diabetes", the Journal of the American Diabetes Association.
    .
    Hi, Myxel67. Thanks for putting this information here. It's exactly what is needed. :chuckle
  11. by   GardenDove
    Lets face it, most people who get diabetes already have problems with their weight. That's what got them in trouble in the first place, their food addictions. It's unrealistic to expect that to suddenly change. Food addiction is a real thing, just like drug addiction.
  12. by   oriezo
    i am a new nurse and still learning to adapt to the nursing profession. i have been reading the various posts and this is the one that made me re-evaluate my perspective on patient care.

    your views are truly wonderful. they help shape my point of view and how i can deal with my patients with compassion and still be within the legal bounds of the nursing responsibility.

    to all, pls accept my heartfelt thanks...
  13. by   ckben
    [quote=GingerSue;2062815][quote=ckben;2061074]

    but by agreeing to be in the hospital, they agree to the care which nurses will give them, which includes giving them an appropriate diet.



    not sure about this agreement

    eg. a diabetic lady was prescribed insulin and she refused the insulin, preferred to manage her diabetes other ways - according to her religion and alternative activities

    I think that as nurses we have to respect the client's choice, try to inform and provide educational material, respectfully, and support their wishes
    that's a different scenario. the pt. can refuse what they like, nobody's arguing that. but i, as a nurse, am not required to provide bad care to a pt. simply because they prefer it that way. they have a right to good care, and continually giving candy to someone whose blood sugars consistently remain in the 300s despite the insulin treatment we give them is NOT good care. as i said, i'm not going to take their candy away from them, but i won't be the one giving it to them and thus be directly responsible for enabling these habits and further contributing to the adverse effects of their disease process.

    disagree if you like, but i personally would rather have a healthy patient who is upset at not having a privelege (yes, candy is a privilege, not a right) than an unhealthy one who likes me simply because i will let them do whatever they want. and in my experience, if you simply explain the reasons behind your actions, most people will not get upset anyway. but if you give in and allow the candy, the patient often perceives the issue as not that important, because "if it was really important, then all the nurses would care, and not just some of them, right?"

close