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.
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.
I'm a community health nurse. I deal with drivers with health problems 1:1 and on a global, statewide basis. Our state's #1 health problem behind the wheel is diabetes. When I talk to the drivers after they have gone into a ditch or another car after a hypoglycemic event, the answer is almost always, "but it wasn't me, it was the diabetes".
I cancel driver's licenses every day over uncontrolled diabetes issues. It is amazing to me how effective license loss is as a tool to get people to own the illness and get on track. Many people call me and say thanks because they just wanted to deny the illness until it cost them their license. For most, loss of a license was far more real that loss of vision/kidney/heart.
I'm not saying this is the way to go but I thought a different POV would add to the conversation.
I cancel driver's licenses every day over uncontrolled diabetes issues. It is amazing to me how effective license loss is as a tool to get people to own the illness and get on track. Many people call me and say thanks because they just wanted to deny the illness until it cost them their license. For most, loss of a license was far more real that loss of vision/kidney/heart.
RN BSN 2009
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