Ok, so I'm a school contract nurse through a home health agency working with a very young diabetic patient. The school is great, couldn't be more supportive of my role and continuously praise my efforts at keeping the client's blood sugar levels within range. That being said, the parents are much less than cooperative, downright non-compliant mostly. They have the "feed whatever whenever and cover with insulin" mentality, and cannot seem to understand why I won't jump on board with their dangerous, and if I'm honest, abusive behavior. After a particular incident occurred recently in which the client's blood sugar was well above the MD's range for the client, I refused to give the client a sugary, carb-filled treat with the client's classmates. I discussed the situation with my supervising RN as well as the school principal and we all agreed that adding fuel to the fire was a big no-no for BS levels, regardless of the fact that everyone else was going to have the treat. The client's parents were informed well ahead of the event that the class would have said sugary treat and could have brought in a diabetic-friendly alternative but did not do so. Furthermore, the parents called my employer after I clocked out to inform them that they were furious with me denying their child the sugary treat since everyone else had it (I took my client onto the playground so nobody ate in front of client) and since BS was high and I had to treat with insulin anyways why couldn't I just give the kid the treat?! Well, after much griping, my RN mgr decided to call me and determined it would be best if I were to take the next day off-without pay!!!- to let everyone cool down. So, what can I do about this whole situation? Keep my mouth shut and poison the kid next time like they wanted me to do so I don't get suspended without pay? ~feeling like a flamin' bag o' poo after being stomped on a few times right now
I also want to point out that even "Type 2s" are NOT always doing carb restrictions, rather, some providers, at least in my area, are advocating the prevention of DKA, and want to ensure adequate insulin is available for the pts body to have a target BG; they are moving towards carb exchange as well.
Remember, not every diabetic is as the textbooks show, and it helps to know what the specialist plan is, and well as what works for the pt and family; we can't lose sight of :
1. Individualized care
2. Self-determination
3. Constant communication
4. Science and EBP is fluid in the health care arena.
I think that's where we are falling down in communication.
Those of us advocating for following physician's orders are not saying we force anything on the child or a patient. Obviously, they have the right to refuse.
But someone can't tell us to do something that goes against the physician order.
That's all many of us are saying.
I'm not giving you more or less insulin than the orders state. I'm not going to change the carb count/insulin ratio based on anything other than what the physician writes.
(When I worked in the ER, I didn't give the drug seeker the Dilaudid they screamed for but I did offer the Toradol that the physician noted on his orders. A patient can refuse but I certainly didn't hold them down and give them Toradol).
I agree with you 100 percent. I became a nurse 30 years ago. Back then it was expected that nurses make decisions for their patients keeping their best intrests in mind. But times have changed. Its all about giving the patient and the family whatever they want. In my experience you can try to educate them but most people are noncompliant. . Its sad I know but there is nothing you can do about it. Either you just blindly do whatever the parents want or find another job.
Trying to understand, the macro ratios of the diet doesn't really have a significant impact on outcomes with T1 as long as corrected with adequate insulin?
Yes, and no. We aren't correcting, we are preemptively striking. We give the insulin to match the carbs based around a ratio that is determined by the endocrinologist, the pt, and blood glucose logs.
So the most crucial part of our treatment is the I:C (insulin to carb). The I:C, if correct, and given at the correct time, should keep us from spiking. If we don't spike, we have better overall and long term outcomes.
The macros matter, because we need a balanced diet just like the next person. Plus we need a healthy diet a little bit more than the next guy, because the diseases associated with a poor diet (heart disease ect ect) we tend to be more prone to, and they tend to hit us harder.
This thread has taught me that I know a decent amount about metabolic syndrome with hyperinsulinemia and resulting insulin resistance, and non insulin dependent DM II. However, I need a refresher about type 1 DM.
I need to get 20 hours of CEs by the end of August. Guess I know where to direct my focus!
Thanks to the OP and everyone who has contributed.
I don't understand how nurses can be so misinformed about this. A patient's, or their POA's, refusal of a physician's order is what we are legally required to abide by. Continue to implement a Physician's order that has been refused is grounds for loss of license and potentially criminal charges.
There was no refusal of the order though...the child is too young to consent, and the parents were not contacted. The school refused to allow the nurse to contact the parents, but she consulted with school officials, and they agreed with her decision. So she consulted with everyone she could, and was still disciplined. Seems kind of bass ackwards to me, especially not being able to call parents- I don't know if I'd care for a child if I was forbidden to talk with the parents.
OP, this has been a very educational thread, thank you.
I understood where you were coming from, but then read other diabetic's opinions and thought "of course I'd let them have the cupcake." But you added the fact that you couldn't call the parents, AND there were behavior problems with hyperglycemia. Jeepers, it was a hard decision, and even in this thread we can't come to an agreement.
But remember that you consulted with two other people, including your boss, and they agreed with your decision. If they had doubts they could have called the family. Once they are consulted they should be on the hook just as much as you are- after all, they are experts in the social dynamics of the classroom, right? That's the whole reason you brought them into the decision. Then you got suspended? Ridiculous. They tied your hands, (not able to talk to the parents) and advised you in bad faith. I don't think you did anything wrong. At worst you made an error in judgement, but with good intentions.
Some days you can't win for trying. You can be my nurse anytime.
There was no refusal of the order though...the child is too young to consent, and the parents were not contacted. The school refused to allow the nurse to contact the parents, but she consulted with school officials, and they agreed with her decision. So she consulted with everyone she could, and was still disciplined. Seems kind of bass ackwards to me, especially not being able to call parents- I don't know if I'd care for a child if I was forbidden to talk with the parents.
If the burden of consent was on the patient to refuse an intervention then one could argue that restricting food intake was appropriate, but that's not how it works. The burden is on us to obtain consent, not on the patient to refuse an intervention otherwise we have the right to impose interventions unless specifically refused. We can only impose interventions where there is explicit consent, so no consent = no intervention (except in implied consent/emergent situations).
I agree that not being allowed to discuss consent and various aspects of the plan of care with the decision makers (the parents) should not have been considered acceptable to a nurse in that situation, the nurse should have taken it upon themselves to contact the decision makers or abstained from any interventions where consent could not be reliably established due to interference from the school.
I think that's where we are falling down in communication.
Those of us advocating for following physician's orders are not saying we force anything on the child or a patient. Obviously, they have the right to refuse.
But someone can't tell us to do something that goes against the physician order.
That's all many of us are saying.
I'm not giving you more or less insulin than the orders state. I'm not going to change the carb count/insulin ratio based on anything other than what the physician writes.
(When I worked in the ER, I didn't give the drug seeker the Dilaudid they screamed for but I did offer the Toradol that the physician noted on his orders. A patient can refuse but I certainly didn't hold them down and give them Toradol).
I think there's maybe some confusion about whether or not certain exceptions are being included in broad statements, such as "But someone can't tell us to do something that goes against the physician order. " Without many exceptions and qualifiers, that's not an accurate statement. If a physician orders "0.5mg dilaudid", obviously I can't ignore that and give the patient 1mg dilaudid. But there are actually other situations where you do have to "go against" the physicians order if the patient refuses it. If the physician writes an order that says "NPO" and the patient is capable of refusing then you do actually have to go against an order to keep the patient from eating or drinking.
Muno- If a diabetic in hospital asked me to get them a chocolate milkshake I would refuse, based on their ordered diet. But if their family member brought in a shake I wouldn't remove it from the room. I allow the patient to make their own choices, but I will not be a part of helping them worsen their health. Is that in line with your ideas about consent?
Specializes in Flight, ER, Transport, ICU/Critical Care.
OP - though you are TECHNICALLY & ETHICALLY correct, you are in a losing situation. Unfortunately, the matter has gotten a lot more traction than any "cupcake" issue deserves. Failure to recognize your reality and act in your own best self interest will only serve to hurt you.
Continuing to fight about this will only damage you - not fair, not professionally deserved (but nursing is a "customer-service" business first & foremost). They will not ever officially "take your side" - they can't. Bigger issues will ALWAYS be at play with the company and contract. Keep that in mind. A well worded professional letter of resignation is in order and MOVE ON as soon as you can type it.
This has been a very interesting thread, thank you.
NanikRN
392 Posts
What an informative thread. Its been helpful to me to see all,the differing viewpoints and the info to back those viewpoints.
Kudos to OP for caring and be open enough to reahnout to peers for input on her actions