Tearing my hair out over noncompliant DM2 patients!

  1. I am a new NP and don't know how to "wake up" noncompliant DM2 patients. Unfortunately, a significant number of these patients are in denial and refuse to make any lifestyle changes and some even refuse to take their medications and/or insulin as prescribed. I experienced this during clinical rotations and now am seeing this as a practicing NP. Has anyone had success with this situation and can share some tips?

    Examples:
    1. Patient who is DM2 for 20 years comes in and says he/she eats whatever they want, whenever they want. A1C1 > 12 !!! Shrugs at everything I say. Their biggest concern is hypoglycemia, although they are only on a low dose of basal insulin and can't specify their last episode of hypoglycemia. Called clinic today to say they no longer want to use insulin and only want to be on one oral medication (I refused and said patient must make appointment to see me). This patient also has refused to get any annual lab work for past 3 years or other exams such as eye, foot, etc.

    2. Another long-term DM2 patient with A1C1 > 10 and random BG > 180. This patient's biggest concern is hypoglycemia and is convinced that a BG of 150 is perfect and that an A1C1 of 10+ is just fine; became agitated when I explained this is not the case. Patient admitted close relative had just had a foot amputation due to DM2, but was indifferent. Patient had lost weight due to other health issue, is still slightly overweight, and was concerned about being too thin and frail. Patient stated they don't know what they eat and don't care. I had a hard time convincing this patient to obtain routine lab work, but they did it. I had a panic attack when I received CMP: eGFR < 10 (yes, it was a single digit), BUN > 65, Creatinine > 3.0. I was amazed this patient was still alive! Patient was sent to ER, of course.

    Any suggestions would be welcome!
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  2. Visit FullGlass profile page

    About FullGlass, MSN, NP

    Joined: Dec '17; Posts: 416; Likes: 523

    37 Comments

  3. by   djmatte
    You can't change or fix everyone. You can't force someone to take a medication or participate in a therapy regimen they aren't interested in. Being ok with this is the first step. The only advice I have is to document the hell out of it and educate each and every time. Sometimes it's a matter of finding the right piece of information that hits it home... Other times there will be none. Perhaps there are underlying mental health issues helping them not place value on improving (or even managing) their health.
  4. by   FNP2B1
    I run into this daily, multiple times a day in my rural clinic. I start by asking my patient's how would their lives change if they went blind and then listen. I then ask how would they feel if they lost their feet. For men I ask how would you feel if you never got an erection again. After listening to their answers I tell them all of these things can happen if they don't take their insulin daily as prescribed, change their diets and lifestyles. 80% of the time it works especially with men if you talk about never being able to get it up again. The feet thing works fairly well with women as Ive yet to meet a woman who doesnt like to wear a nice pair of shoes. No feet/no shoes. Get used to having lots of patients like these in rural communities The Hispanic community where I work in So Cal views insulin injections as a death sentence. It's just a cultural thing you have to overcome and you will.
  5. by   broughden
    Quote from FullGlass
    I am a new NP and don't know how to "wake up" noncompliant DM2 patients. Unfortunately, a significant number of these patients are in denial and refuse to make any lifestyle changes and some even refuse to take their medications and/or insulin as prescribed. I experienced this during clinical rotations and now am seeing this as a practicing NP. Has anyone had success with this situation and can share some tips?
    Any suggestions would be welcome!
    If someone manages to pass on the cure for human stupidity to you please share with the rest of us. Between opioid addicts with multiple overdoses/NARCAN interventions or all the new granola hippie parents who refuse to vaccinate their children and think they can treat a child's meningitis with an epsom salt bath "cleanse"....I am amazed our species ever learned to walk upright.
  6. by   LibraSunCNM
    I'm a CNM, not an NP, but my first job as an RN was on a vascular surgical floor. The vast majority of the patients were longtime, frequent-flying, non-compliant diabetics who would come in for a toe amputation...then another toe...then the top half of their foot...then the whole foot...then a BKA...then an AKA. After both legs had been amputated they usually died from complications within a year or so (research supports this). They were in complete denial about their health (and of course, vascular surgeons profit off of this), and I learned there's nothing you can do about it. Who knows what the deep-rooted, underlying issues are that contribute to the denial, it's just too complex for us to be able to magically fix. All you can do is tell it straight to the patients, it's up to them to make changes or not. It's also a fact that we have a broken health care system that offers no incentive for preventative medicine and instead prefers to spends billions upon billions of dollars for wasteful care. It's sad, but it's life.
  7. by   traumaRUs
    My favorite saying from my absolutely most favorite doctor in the whole world:

    "You can't care more for the patient then they care about themselves."
  8. by   djmatte
    Quote from traumaRUs
    My favorite saying from my absolutely most favorite doctor in the whole world:

    "You can't care more for the patient then they care about themselves."
    That quote made my morning. Thanks for that!
  9. by   broughden
    Quote from traumaRUs
    My favorite saying from my absolutely most favorite doctor in the whole world:

    "You can't care more for the patient then they care about themselves."
    It's my hypothesis that a number of these addictive behaviors including both narcotics and overeating, have an underlying issue of suicidal ideation.
    When you tell somebody that their behavior is ultimately going to kill them and they do nothing to change it, then you have to wonder if that is their ultimate goal.
  10. by   ruby_jane
    Quote from LibraSunCNM
    They were in complete denial about their health (and of course, vascular surgeons profit off of this), and I learned there's nothing you can do about it. Who knows what the deep-rooted, underlying issues are that contribute to the denial, it's just too complex for us to be able to magically fix. All you can do is tell it straight to the patients, it's up to them to make changes or not.
    ^Yes.^ You are obviously frustrated because you KNOW where this ends. And frankly, they probably know it, too.

    Research motivational interviewing (in your spare time, right? I know). The theory behind MI is that you can't "make" patients compliant but you can get them to respond to things that are intrinsically important to them. And it will reinforce the "you can't care more about them than they do."

    Example: I had a T2DM patient in a hospital having necrotic tissue amputated - the result of not wearing house shoes and stepping on a nail or a tack or something.

    He could not have cared less about this (so I thought). He wanted pie more than an A1C of 8. What he did care about was his woodworking, and when we discussed that there was a chance he might not be able to continue his woodworking if his sight failed due to prolonged hyperglycemia, it was literally like a light came on for him.

    Ultimately, if you document rigorously, you have done your job. Sometimes I say out loud "So I'm documenting that you're declining X,Y, and Z and leaving without treatment. Amazing how effective that is...
  11. by   ksisemo
    I would consider that it is very hard for people to understand what they cannot see or feel. As a clinician, you understand the true ramifications of ongoing elevated levels of HbA1c or glucose or what their BUN and creatinine levels really mean. Sure, they may be FEELING it, but people adjust to chronic disease over time. To them, that's just how life is.

    Your patient who fears hypoglycemia, I bet they had a VERY bad experience with an insulin "overdose" so to speak. Or they took their insulin and then didn't get to food at the appropriate time. Now THAT was out of the norm for that patient. That's the kind of stuff you need to dig up in your interviews. Have you always been scared of being hypoglycemic? Have you heard stories from others? Did something happen to make you fear it?

    I wonder if there are certain educational tools you could employ that could show them the REAL cost of the disease? Pictures, etc. I don't know.

    Finally...I know you've said you work in a rural area of CA. I'm wondering about the cultural climate there. Is there a certain religion or ethnic group you are working with? If so, I would research the beliefs of the area (if that applies) and figure out what makes them tick. Do you look different than the predominant group there? There could be a disconnect in your approach or even the initial feeling of connection or trust. It also just may take some time, if they see you as an outsider, for them to believe you have their best interests at heart.
  12. by   djmatte
    Quote from ruby_jane
    ^Yes.^ You are obviously frustrated because you KNOW where this ends. And frankly, they probably know it, too.

    Research motivational interviewing (in your spare time, right? I know). The theory behind MI is that you can't "make" patients compliant but you can get them to respond to things that are intrinsically important to them. And it will reinforce the "you can't care more about them than they do."

    Example: I had a T2DM patient in a hospital having necrotic tissue amputated - the result of not wearing house shoes and stepping on a nail or a tack or something.

    He could not have cared less about this (so I thought). He wanted pie more than an A1C of 8. What he did care about was his woodworking, and when we discussed that there was a chance he might not be able to continue his woodworking if his sight failed due to prolonged hyperglycemia, it was literally like a light came on for him.

    Ultimately, if you document rigorously, you have done your job. Sometimes I say out loud "So I'm documenting that you're declining X,Y, and Z and leaving without treatment. Amazing how effective that is...
    Sometimes it's finding the thing that motivates them. I don't know how many males I've effectively weened off opiates when I pointed out the member of long term young opiate users who I've seen need Viagra because they can't get an erection.
  13. by   FullGlass
    Thank you everyone for your very helpful suggestions and comments. I really appreciate it.
  14. by   FullGlass
    Quote from ksisemo
    I would consider that it is very hard for people to understand what they cannot see or feel. As a clinician, you understand the true ramifications of ongoing elevated levels of HbA1c or glucose or what their BUN and creatinine levels really mean. Sure, they may be FEELING it, but people adjust to chronic disease over time. To them, that's just how life is.

    Your patient who fears hypoglycemia, I bet they had a VERY bad experience with an insulin "overdose" so to speak. Or they took their insulin and then didn't get to food at the appropriate time. Now THAT was out of the norm for that patient. That's the kind of stuff you need to dig up in your interviews. Have you always been scared of being hypoglycemic? Have you heard stories from others? Did something happen to make you fear it?

    I wonder if there are certain educational tools you could employ that could show them the REAL cost of the disease? Pictures, etc. I don't know.

    Finally...I know you've said you work in a rural area of CA. I'm wondering about the cultural climate there. Is there a certain religion or ethnic group you are working with? If so, I would research the beliefs of the area (if that applies) and figure out what makes them tick. Do you look different than the predominant group there? There could be a disconnect in your approach or even the initial feeling of connection or trust. It also just may take some time, if they see you as an outsider, for them to believe you have their best interests at heart.
    Excellent points - I'm going to put together my own handout with pictures to drive home the risks of uncontrolled diabetes. Definitely will probe more on hypoglycemic episodes.

    The area where I live and work is predominately white working class. I am half Asian, but most people think I'm white, so there shouldn't be a cultural issue at play here, But a good point to consider.

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