Patient Rights and Diabetic Diets

SCRN1 · Feb 10, 2007

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.

Indy, LPN, LVN · Feb 11, 2007

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.

Myxel67 · Feb 11, 2007

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/cgi/content/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.

GingerSue · Feb 11, 2007

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

cookie102 · Feb 11, 2007

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

GardenDove · Feb 11, 2007

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.

GooeyRN, ADN, BSN, CNA, LPN, RN · Feb 11, 2007

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. :nono:I am an adult of sound mind. I know the consequences of diet soda. But I choose to drink it anyway.

Myxel67 · Feb 11, 2007

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/cgi/content/full/20/2/51

morte, LPN, LVN · Feb 11, 2007

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

Myxel67 · Feb 11, 2007

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

nurse4theplanet, RN · Feb 11, 2007

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.

llg, PhD, RN · Feb 11, 2007

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