Patient Rights and Diabetic Diets

[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?

[GardenDove]

I personally figure that they are adults. I just try to educate and document. It's not like someone with psyche issues is going to suddenly be okay because you forced them to eat right.

I had a frequent flyer pt, post kidney transplant rejection, dialysis pt, with a colostomy, who was highly 'noncompliant' with her diet. She was just addicted to sweets. She was actually a pleasant lady, I hear she's died since then. What are you going to do, lock her up and not allow her any contact with her family?

[GardenDove]

I had an 800 pound pt once who came from a 'loving' family of almost as morbidly obese brothers, he was a frequent flyer for horrible cellulitis of his utterly grotesque lower extremities. His family would bring huge meals of fastfood, like 5 or 6 burgers, plus other junk. His younger brother weighed at least 500 lbs, and was a brittle diabetic who also was a frequent flyer and ended up losing a leg.

[ckben]

we've had lots of these same situations. basically, my philosophy is similar to yours in that i will not personally hand them something that is restricted from their diet. i just won't, for personal and professional reasons. but, as you said, if it's something they brought from home (and they can get it themselves), then i don't really feel i have the right to physically take it from them, either. i guess it's kind of a freedom of choice thing. if they choose to have their family bring them candy, that's their right. 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. just my personal feelings, anyway...

[lauralassie]

All you can really do is educate, document very well. The Dr. may be able to discharge her ama if she refuses to comply. If there isn't good documentation one of those ambulance chacer lawers will be the next step. After all, when something bad happens to a pt it's not ever the pt's fault. Even if they over eat, smoke, no exersie, drink, take drugs etc. It's always a medication, Dr , nurses fault .

[kat911]

You can't force a pateint to follow the diet oredered and you can't touch thier personal belongings unless they are trying to do something that would be harmful to others, trying to torch the curtains for instance. I think you'd be safe taking away the lighter! Human beings have frailties, they make mistakes and do things that are bad for them. All we can do is educated them and document responses. I am sometimes amaxed at the venom directed at noncompliant patients on this site. I wonder where is the compassion and understanding for a fellow human being. I am not perfect and I don't expect my patients or coworkers to be, either. I think some nurses and docs take it personally when a pateint is noncomplaint. It's not personal and it's not directed at anyone, it just is the way the patient wants to be, and they have that right. Please excuse my minirant. Had to get that off my chest.

[jimthorp]

basically, my philosophy is similar to yours in that i will not personally hand them something that is restricted from their diet. i just won't, for personal and professional reasons. but, as you said, if it's something they brought from home (and they can get it themselves), then i don't really feel i have the right to physically take it from them, either. i guess it's kind of a freedom of choice thing. if they choose to have their family bring them candy, that's their right. 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. just my personal feelings, anyway...

This is exactly the way I feel. I try to educate them then chart their noncompliance.

[rn/writer, RN]

Rather than judge the person or even offer education they've probably heard a thousand times before, it might be more effective to talk to them, person to person, and ask how things look to them. Don't come in with preconceived notions, but rather offer a genuine listening ear.

"I know you've heard the scare stories and the shoulds and shouldn'ts a million times. I'm wondering what those ideas mean to you and if there's a way we can work together on some of this."

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.

We look at the situation from a nursing/medical point of view. It's an entirely altered perspective when it's your LIFE. Especially when you know the people who are supposed to be helping you are looking at you with judgment and maybe even contempt. Even kind-hearted nurses sometimes come across like they're dealing with naughty children.

This tends to evoke an oppositional response, not because the patient is diabetic, but because they're human.

The word "non-compliant" is in itself a judgment of sorts. Someone in another thread said she preferred to use the word "non-participating" as it acknowledges that the patient really DOES have a choice, whether that sits well with us or not. This isn't just touchy-feely sentimental sludge. People care about showing up in the equation as more than just an evaluation of how well they are cooperating. Diabetics can end up feeling like what matters most to health care staff is how many gold stars they earn instead of their overall quality of life.

The primary goal should be connection first, then adaptation.

I know that time is precious, but redundant education that falls on deaf ears takes time, too. Often, diabetics know the what and the why. "I should control my blood sugar so I can live longer and avoid complications." What they sometimes lack is the how. "How do I interact with my family and still try to maintain some kind of healthy eating?" "How do I get through a day when eating has been such a high point all my life? What do I put in its place?" "How do I separate the emotional satisfaction of eating from the physical needs?" This is where many practitioners miss the boat. Yes, a percentage of "non-compliance" stems from lack of information, but I'd be willing to bet that far more comes from having no clue how to make that information matter on a personal level and lacking the ability to find practical ways to live. Even when such facts are presented, there is sometimes little regard for readiness to hear. It's like answering questions that haven't yet been asked. Without an apparent use, the knowledge is discarded or filed away for a future that never quite arrives.

A typical defense mechanism is for diabetic patients to engage caregivers in a tug-of-war. One reason is that it's often an unconscious expression of anger about an ongoing loss of control. Another is that if you can prevail in such a contest, it can substitute for the victory you wish you had elsewhere. In other words, if you can't win over your blood sugar, at least you can show that darn nurse that you're in charge of what you eat.

As clinicians, we often come in with tug-of-war ropes of our own. It can be infuriating to see someone have repeated admissions for conditions which are somewhat controllable when it seems like they won't lift a finger to change their life-threatening ways. It's like watching someone smack themselves in the head with a hammer and then moan and whine about having a headache. Hard to keep from saying, "Well, if you'd just quit hurting yourself, you might quit hurting." An understandable reaction, but ineffective for both sides.

The trick is to recognize the patient's autonomy and then actually use it to their advantage. You can't EVER make the choices that belong to your patient for them. What you can do is get them talking about how THEY make their choices and what they are thinking. For many, that would be a first--to have someone asking them for their thoughts instead of dumping more information on them or scolding them.

It would also be a first for many to put their own thoughts into words. And some of them might be surprised at their true motivation or lack thereof. Once you know what matters to them--their currency--you can meet them where they are and try to find something that will satisfy the emotional/psychological appetite while stiking a balance with their limitations.

For example, you could meet the big male patient mentioned above--the one whose family brought in all kinds of food--by connecting with him at a time when the others aren't around. Get him talking about his brothers and the food and the feelings. Then, having entered into that warm and delicious picture, you can bring up the concerns about blood sugar and the rest. You can ask if he is interested in finding balance between his wants and his needs and tell him you might have a couple of ideas if he is.

If he says no, leave the door open to further discussion by saying that you'll be happy to talk again if he changes his mind. He might be testing you to see if you really are that rare medical bird who can see past the diagnosis to the real person and respect his choices even when you disagree. Could be the beginning of trust.

If he seems interested, get him talking. What is it about the contraband food that matters most to him? The food itself? The camaraderie with his family? The feeling of having some comfort and control in a not-too-friendly place? Try brainstorming with him ways that the two of you could work together to minimize the damage. They bring in a pizza. Would he be willing to eat the toppings and leave most of the crust? Or have you put a single piece on a plate and refrigerate the rest, to be given a slice at a time over the next two days? Chinese food. How about skipping the rice and the egg rolls and concentrating on the meat and veggies? KFC. Okay, more of a challenge, but suggest he divide the meal, start with the coleslaw, remove half the skin and skip the roll. Better yet, ask him how HE thinks he could alter the meal to make it less carbnoxious.

This model where the two of you are allies fighting on the same side against a problematic situation is so much more effective than the one where you lock horns with one another. It also might be the first time that this person has had an example of how to break away from the "all-or-nothing" approach where if you take one bite, you might as well eat the whole thing.

If he's open to it, you can speak with his family members and enlist them in the "project." So many people view their offerings of food as a way to say, "Hey, you're still one of us and we still love you." They need to learn how to enlarge their repertoire and understand that they can deliver this same message by scaling back and adapting their offerings. Don't bring in a bucket of KFC. Bring two pieces of chicken and some coleslaw. Get some barbecue meat without the bun. Chicken and pea pods instead of sweet and sour. A box of sugar-free fudge pops rather than premium ice cream.

Create a vision of participation that seems doable. Spark imaginations that were formerly used to circumvent restrictions. Teach the "buy down" principle of taking a desire--chocolate covered donuts--and seeing if there is something less carbolicious that would still be satisfying--peanut butter on toast.

Try to find the opportunity to show the patient the difference in his blood sugars. And let him know that he doesn't ever have feel that he's cheating--he's merely making choices. Once that old bugaboo is lifted, it changes the dynamics of the "game" entirely.

The lady with the candy might see sweets as a kind of self-administered TLC. You'd have to ask her. Apply the same principles with her. Is she really hungry or is she lonely or bored or unsatisfied in some other way? Try to find out if having the bag of candy means one piece an hour (not all that horrible if they're small) or the whole thing within one hour. If she's willing, put your heads together to come up with something safer. Sugar-free Jello and three minutes of your time. A diet soda. A two-minute foot rub. A phone call to a friend.

Again, I know time is at a premium, but a couple of minutes spent effectively can be more efficient than the usually unproductive dance.

Even more important is the concept that there is no such thing as cheating. There are choices. Throw the tug of war rope out the window and let the patients start understanding that the real struggle is inside themselves. As long as we get in the way, they can't really internalize this essential concept. In our efforts to do good, we can actually rob the patients of the very autonomy that could save them.

I know this is long, but "diabetic compliance" is such an ongoing power struggle and is so poorly understood from the emotional/psychological standpoint. Highly educated folks with good intentions pour all kinds of effort into teaching and caring for this population only to leave out the sense of connection that can make the rest of it work.

Here's a nugget of truth that is sad but at the same time can give you a real advantage: many diabetics are lonely, starved for respect, used to being found substandard in some way, and resigned to feeling invisible except for their disease. Find a way to meet them where they are AND acknowledge their autonomy, and you will find patients who are ready to consider alternatives, even if they can only take small, hesitant steps in the beginning.

You really can make a difference for these folks. This knowledge can make a difference for you, too.

[clemmm78, RN]

wow Miranda. You have really made me think about how I used to approach patients like that. thank you so much.

[kat911]

:yeah: RN/Writer said so well and so clearly!

I have to comment about nurses who try to take away the snacks of these types of patients, they feel justified in taking the offending food because it is not allowed. Usually nothing happens when a nurse does that, other than making the patient or family mad, but beware that is called theft. You cannot take something from a patient unless as I said earlier they are a danger to self or others. Excluding illegal substances which we turn over to the police. Another pet peeve of mine, I have to deal with the ticked off patient or family.

[SassyRedhead]

I understand and respect what Miranda has to say. In fact, we've had MANY attempts at therapeutic conversations. All were met with resistance.

I respect pts autonomy, I really do. But legally, I am concerned about where my actions in this circumstance could lead if I just say "the heck with it, I know she's probably downing bags of candy at home." I feel as I am being held to a higher responsibility in this circumstance, I don't have a choice NOT to follow a Dr's direct order since it was appropriate. We did attempt to work with the doc to change the order, without success. It's not a choice born of arrogance or control, it's one of my responsibility to the pt.

BTW, later in her stay, one of my coworkers did give her the candy because of her constant behavior. IMO that undermined the rest of the nurses and set up a staff splitting scenario.

[kat911]

Sassyredhead-You cannot control what a "competent" patient will do or not do. Remember no matter how correct a physician order is the patient has a right to accept that order or reject it, do some of it or do it sometimes only. It is always the patients decision. We cannot force competent patients to behave or take meds they do not want. Doing so or attempting to do so can be considered Battery. It sounds like you are trying to do what the doc wants, reasonalbly, but you cannot force or IMHO "bully" the patient into following doctor orders (some nurses try). Keep discussing the reasons for the order with the patient and hope he/she will come around. Otherwise all you can do is document, document, document. If the candy was taken away from the patient in this case she could accuse the staff of theft. That doesn't mean you can't ask the family to remove the candy or not bring in anymore or ask the patient if you can put it someplace "safe" like RN/Writer suggested and then doling out the goodies in a more responsible manner. I know it's frustrating dealing with noncompliance patients but unfortuantely you can't save people from themselves.