suspended for doing the right thing...

Published

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 :no:

I think you have a distorted view of 'doing the right thing' for your patient. Do you have a specific MD order limiting this child's intake? Because most diabetics now do NOT have diet restrictions and simply count carbs and take the required amount of insulin for correction.

I believe the parents were right to be upset, and you were wrong to remove the child from a classroom celebration.

Working with a diabetic unit, I agree on this

Up Vote Up Vote ×
Specializes in Oncology.

I have type 1 diabetes. Current recommendations for type 1 management are to "carb count" and cover with insulin, providing a normal, unrestricted diet and allowing the child to participate in activites, including class parties, as their peers do. There is no "diabetic diet" for type 1 kids. Diet did not cause their disease, and diet is not going to fix it. This isn't just willy-nilly shooting up insulin in vague amounts. This is a scientific and calculated approach. A carb ratio is employed where a certain amount of carbohydrates is covered with 1 unit of insulin and this amount is scaled up and down according to carb intake, most commonly via an insulin pump. This is likely what the parents do with the BLESSING and GUIDANCE of the child's endocrinologist. Hopefully you have specific written instructions spelling out all of their doses. This is not mediocre care. This is mimicking the action of a healthy pancreas. The reason the parents did not send a "diabetic friendly" snack is because they did not have to. All snacks are just as friendly to a diabetic as a non diabetic and an apple is going to raise the blood sugar just the same as a brownie.

Who are you to deny the child the experience of celebrating with his classmates if the parents and doctor allow it? Further, what was the point of involving the principal and teacher to support your decision? What is their medical training?

Up Vote Up Vote ×
Specializes in orthopedic/trauma, Informatics, diabetes.

thank you blondy-you are much more eloquent than I am.

Farmernurse I go through your mindset every single day of my life with my child. he has behavioral issues as well. I am scared to death for him every day that he will end up with what I see every day. I feel what you feel, but I have to say in this situation, to listen to blondy.

I think you are too close. I worked HH and I got too close and it hurt me to see things. I had to walk away so I could keep perspective. they are our pts, not our family.

Up Vote Up Vote ×
Specializes in Oncology.
@meanmaryjean-so you would not take into account that the blood sugar was already elevated, and that, per MD orders, insulin is only to be given after the client eats, which would cause a severe spike in blood sugar before the insulin had a chance to kick in? Furthermore, because of extenuating circumstances around client's mental status, had I caved and said yes to said sugary treat the client would not have been satisfied with a smaller portion in order to help keep the spike down, but would have "razed cane" until they had the same amount (approx 30g cho) as everyone else. Isn't that considered to be neglect at best, and abuse by-proxy at worst?

You said in the first post the child was already getting insulin because their blood sugar was high. Now you're saying they are only to get insulin when eating? Which is it?

A 30gm snack is reasonable. If you give 2 units of insulin (assuming the child's ratio is 1:15) and another non-diabetic child's pancreas makes extra insulin it's the same thing.

Up Vote Up Vote ×
Specializes in ICU, LTACH, Internal Medicine.

Sorry for the question, but:

- what exactly are you treating - this child, or this child's blood sugar, everything else be d***ed?

I spent a whole lot of my school days crying in the corner because everybody knew that a mere skin contact of some sweets would kill me in minutes. I knew it too, it did not make things any bit easier. Trust me, it is so hard to be a "special kid", and the last thing you care of while being one is how good are intentions of all those adults around you.

DM is, thanks God, not like allergy. Next time, please let the kiddo be a child for a moment, not your patient!

Up Vote Up Vote ×
Specializes in NICU, PICU, Transport, L&D, Hospice.
Regardless of whether you were actually right or wrong, it would be best to find another case, now, while you have a say in the matter.

I couldn't agree more.

The professional trust has been broken in this nurse/family arrangement. As well there seems to be a conflict in philosophy of care.

I still find it sad that this resulted in a loss of work and pay as an immediate management response.

1
Up Vote Up Vote ×
Specializes in ED.

"These are the parents that are ruining school for everyone else. Now this school is going to basically outlaw sugar for everyone because one parent gets upset that their child cannot have it while everyone else can. Most parents who have diabetic children make homemade treats so that the child won't feel left out. It's a shame that you're taking the hit for this."

My child's elementary school has already done just this.

Up Vote Up Vote ×
Specializes in Oncology.
@JulesA: I conferred with both my supervising RN and the school principal before moving forward with removal of said treat. The parents have been educated repeatedly over the course of many moons regarding proper nutritional choices and were asked to bring in healthy alternatives.

What about conferring with, oh, I don't know? The parents! Ultimately they have the say in what is being done for their child. If you feel they are grossly mismanaging his care, contact the treating physician with your concerns.

Here's my dilemma: if a child with a food allergy cannot have the same sugary treat and their parents don't provide an alternative then the school simply would omit said treat, correct? Yet, if a diabetic child has insulin handy go head and give it to them and just cover, regardless of the fact that said treat will do damage to their body the same way that a food allergy will do damage to the other child's body.

Rationale for this: both conditions require medical intervention to keep the child from imminent harm, ie the food allergy needs epinephrine and the diabetic needs insulin so where is the difference?[/QUOte]

There is no alternative that allows a child with a food allergy to safely consume foods they are allergic to. Insulin is what allows a type 1 diabetic to live at all, and to eat. Epinephrine is a rescue medication given in an emergency situation. Insulin is a maintenance medication required several times a day. High blood sugars are not imminently life threatening. Clearly you have to understand this is not a fair comparison? No young child with type 1 is going to have perfect blood sugars constantly.

Up Vote Up Vote ×
Specializes in Oncology.
mmc51264: unfortunately one of my siblings is type 1 and so i do know first hand what growing up diabetic is like, and i also know that different foods/carbs are broken down in the body differently. Also, this child has a hoarder mentality stemming from long before T1D Dx and I do advocate quite vocally at every "event" that there be either SF alternative or fewer carbs provided, not just for the client but for all children at this school b/c there is A LOT of sugary treats there. The A1C at Dx of the elementary-aged child was just over normal and happened to be Dx by accident during a regular checkup, but at the 6-month checkup the A1C was at 10, so yeah, this is a day-in, day-out struggle to educate the parents while at the same time try to prevent long-term damage to the child's body. And, we have documented behavioral and emotional changes related to large spikes in the kid's BS, including an episode where the kid busted their head open running into something while BS was elevated, and episodes of "drunkenness"-esque behavior from extremely high (450+) BS's.

Immediately after diagnosis of type 1 diabetes it is common for the pancreas to still make some insulin. This is referred to as the "honeymoon period." Blood sugars run lowish during this time and insulin needs are low. As this period ends, insulin needs often increase dramatically and blood sugars become much higher. As a result, it's common to see poorly controlled blood sugars in the first few A1c's after diagnosis. If this family is not even a year into dealing with this it's VERY unfair to be judging them so.

Up Vote Up Vote ×
Specializes in Psychiatry, Community, Nurse Manager, hospice.

I don't have advice for you, but I just really want to thank you for doing the right thing and taking care of the child!

It sucks that they want to suspend you over this! It makes me mad! Please keep doing the right thing anyway.

Up Vote Up Vote ×
Specializes in Nurse Leader specializing in Labor & Delivery.
I don't have advice for you, but I just really want to thank you for doing the right thing and taking care of the child!

It sucks that they want to suspend you over this! It makes me mad! Please keep doing the right thing anyway.

Based on current recommendations, it doesn't sound like she was doing the right thing, though.

Up Vote Up Vote ×
I have type 1 diabetes. Current recommendations for type 1 management are to "carb count" and cover with insulin, providing a normal, unrestricted diet and allowing the child to participate in activites, including class parties, as their peers do. There is no "diabetic diet" for type 1 kids. Diet did not cause their disease, and diet is not going to fix it. This isn't just willy-nilly shooting up insulin in vague amounts. This is a scientific and calculated approach. A carb ratio is employed where a certain amount of carbohydrates is covered with 1 unit of insulin and this amount is scaled up and down according to carb intake, most commonly via an insulin pump. This is likely what the parents do with the BLESSING and GUIDANCE of the child's endocrinologist. Hopefully you have specific written instructions spelling out all of their doses. This is not mediocre care. This is mimicking the action of a healthy pancreas. The reason the parents did not send a "diabetic friendly" snack is because they did not have to. All snacks are just as friendly to a diabetic as a non diabetic and an apple is going to raise the blood sugar just the same as a brownie.

Who are you to deny the child the experience of celebrating with his classmates if the parents and doctor allow it? Further, what was the point of involving the principal and teacher to support your decision? What is their medical training?

I totally agree with this.

I have not one, but two children that have type 1 diabetes! I am constantly astonished how ignorant most nurses are about type 1 diabetes. I would have been livid as a parent if you had withheld a treat. Do a search on the relationship of depression and eating disorders in type 1 diabetics? This type of withholding behavior contributes to further problems than just one little treat's damage might do. If properly dosed for with insulin there should be no issue. Instead of withholding a treat I might call the parents and see if they can talk to their doctor about how to bolus extra insulin for treats if you are truly concerned. While at the moment you may feel like withholding is helping this child, trust me when I say it is not. You really must look at the whole person and the whole picture on this.

Up Vote Up Vote ×
+ Join the Discussion