Those Darn Diabetics

Difficult diabetics present some of the biggest challenges in health care today. Many docs and nurses dislike this population and view them as "problem children." What they don't realize is that patients need time to process their feelings about the diagnosis, and when they don't get that time, they can easily see the professionals as the enemy. Nurses Announcements Archive Article

Those Darn Diabetics

Those Darn Diabetics!

Do you ever wish difficult type 2 diabetics weren't your headache? Your wish has been granted. They aren't your problem anymore.

You read that right. They are not your problem. They are your patients who have a particular problem. Such a distinction may seem fussy, but it actually represents a pivot point for changing old attitudes and responses toward people who are used to feeling like perennial problem children.

Under the established system, as soon as tests confirm the diagnosis of type 2 diabetes, we lead patients to a conveyor belt. Most hop on by themselves. If they don't, we're happy to give them a nudge (or even a shove). Members of the healthcare assembly line then outfit the patients with armloads of widgets, gadgets and instructions.

But what about the ones who don't go peaceably? You've seen them. They test once a day (if that) when the order is for four times. They don't get their prescriptions filled, or if they do, they don't take the meds. They think they're dieting when they settle for a two-scoop cone instead of a banana split. They lie, even when their HA1c levels rat them out. And some of them simply leave and don't come back for years.

We often fuss about having to respect patient autonomy, but with this crowd we're secretly thankful for such a broad and convenient excuse to hide behind. If they choose to be noncompliant, we can't very well arm wrestle them, can we?

If this stubborn bunch were a tiny percentage of all the diagnosed type 2 diabetics out there, we might have a non-amputated leg to stand on. But it's not a small group, by weight or by numbers. And even among the "good" patients, there can be serious gaps and lapses. We can throw in the towel and continue to absolve ourselves of responsibility, or we can take a look at how we as healthcare providers might be influencing--or even provoking--these less than satisfactory outcomes.

For starters, we need to change the amount of time patients are given to process such a life-changing diagnosis. Many patients will want to begin treatment immediately, and by all means, we should help them to do just that. But some will need a couple of weeks, or even a couple of months, to deal with their shock, anger, grief and resistance.

But isn't waiting dangerous?

For all but the handful who wake up in the hospital after a diabetic coma, the risk of delaying has to be measured against the drawbacks of pushing people who simply aren't ready to make momentous changes in their lives in the blink of an eye. Remember, we're talking type 2 diabetes here--a glacier rather than an avalanche. Some of these folks have been diabetic (without their knowledge) for years. Giving them enough time to become invested in their own health care could avert far lengthier periods of "noncompliance" down the road.

Assessing our patients to see if they're eager or reluctant is a crucial step in deciding what comes next. Those in the "teacher's pet" group will need little more than guidance, tools and affirmation as they follow the program laid out for them. But if treated prematurely, the heel-draggers will see guidance as imposition. Tools will feel like shackles. And there probably won't be a whole lot to affirm.

Why? Because they won't have had a chance to willingly board the good ship, "Sugar-free Lollipop."

Think about a cardiac patient who needs serious but non-emergent surgery. If we give him the diagnosis and then whisk him off to the OR a few hours later, without ever asking what he wants and without obtaining his consent, he could very well end up feeling assaulted. Should this resentment carry over into his recovery period, we can expect him to rebel every chance he gets. He'll complain about having to ambulate in the hallways, fuss about the tasteless new diet, and rail at having to take meds--some right now for the pain and others for the rest of his life. And who can blame him?

If unnecessarily rushing a patient into surgery seems absurd, why can't we see the similarities in our treatment of diabetics? We may not use the general anesthesia implied in the above scenario, but after we lay out the bad news, do we give the patient time to think about the information? Do we ask what his goals and priorities are? Do we present our resources and our knowledge as an offer with the clear recognition (both in us and in the patient) that he is free to walk out the door to seek a second opinion or even do nothing at all? Let's be honest--our sense of urgency on the patient's behalf hardly ever allows that to happen.

Speaking of second opinions, surgical patients are often encouraged (and sometimes required by insurance companies) to obtain a validating (or dissenting) assessment. Not so much with diabetes. After all, the numbers don't lie. And the treatment is pretty straightforward. So, why not skip that option and quick-march those rascally diabetics into treatment?

What do you think would happen if we went at a slightly slower pace? What if we did encourage a second opinion or at least a second appointment a month or so after the initial diagnosis so that the patient could work through the bad news and figure out what he wants? What if we sent him home with factual, non-emotional information about the systemic nature of the disease and explanations of the different treatment choices? We know that patients (and their family members) Google every ache and sniffle, so why not provide a list of trustworthy websites to help them see the big picture. We could even give him a couple of down-to-earth questionnaires to help him organize his priorities, identify areas of struggle, and zero in on where he wants to direct his energy.

When we jump the gun and bypass the patient's the need to internalize this knowledge, we communicate that we don't trust him with his own life. But if we give him solid information and offer our resources as consultants, we ditch the typical tug-of-war rope and make ourselves available to collaborate against a common foe.

If we demonstrate this much respect--nothing more than a potential surgical patient is routinely accorded--we'll appear more like allies rather than enemies to be lied to and avoided. The glucometer, the meds, the exercise and even the diet will look like ammunition to fight a disease rather than punishments from the mean medical folks.

Once we're willing to see our patients as people who need our help with their problem, they won't be our problem anymore.

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Specializes in LTC, assisted living, med-surg, psych.
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Specializes in ER.

I can't see likening rushing a patient into non emergent surgery as assault. They either do or do not sign the consent form.

As for the diabetics, I am a citizen, a taxpayer, a consumer of the health care delivery system in this country, a patient advocate and a healer.

I believe in good boundaries.

Delaying care, treatment or targeted interventions for diabetes should result in a lack of coverage for your condition. Health care is expensive and we all need to be responsible consumers. Thinking about it while you eat a pint of ice cream isn't fair to the rest of us and it likely confuses the patients if they think we find it somehow acceptable to delay care.

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Specializes in Nephrology.

When I was diagnosed with Type 2, my doctor looked at me and said "Well, now to figure out how to control this. Have you given any thought to what you'd like to do?" (We had the chat about 2 weeks earlier about "This looks like....") He offered to refer me for diabetes education, but said that if I'd rather not go, respecting who I was and what I do, he'd be okay with that. But I went and learned a lot. In my current job many of our pts develop Type 2, whenever possible I try to sit down with them and talk about how they feel about this, tell what their choices are, let them know they aren't alone in this, and we as a clinic try to ease them into this gently. Unless they are in a dire situation, we never hit them with everything right away. We are pros at the "call me if you have questions, otherwise we'll catch up in a few weeks and check to see how you are". That doesn't mean we don't have those who just want to ignore, and for those we try to leave the door open for whenever they decide they are interested in learning more. Seems to work out fairly well most of the time...

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i can't see likening rushing a patient into non emergent surgery as assault. they either do or do not sign the consent form.

the article mentioned rushing someone into non-emergent surgery without his consent. we often rush to treat newly diagnosed diabetics without assessing their state of mind. we assume that we have consent and then go barreling ahead with treatment the patient may not be ready for. again, i'm primarily speaking about type 2 diabetics, a population who may have many years of trearment ahead of them. taking that extra time to get started may be the difference between someone who becomes invested in their own care or someone who resists treatment until they lose a foot. btw, rushing someone into non-emergent surgery without their consent does meet the legal definition of assault.

as for the diabetics, i am a citizen, a taxpayer, a consumer of the health care delivery system in this country, a patient advocate and a healer.

i believe in good boundaries.

delaying care, treatment or targeted interventions for diabetes should result in a lack of coverage for your condition. health care is expensive and we all need to be responsible consumers. thinking about it while you eat a pint of ice cream isn't fair to the rest of us and it likely confuses the patients if they think we find it somehow acceptable to delay care.

delaying initial treatment is not something everyone will need to do. but for those who do need it, nothing else will do. i would love to see someone do a study on the difference between the "old school" paternalistic approach where a doctor orders a patient to do things and the newer methods that involve respect, non-emotional education, an open door policy and patient-driven goals.

i'm not talking about throwing out the rules--only tailoring them to the individuals who have to live with them. and listening a lot more than we do now to what the patients are telling us. maybe if we listen more to them they'll listen more to us.

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I can remember reading about this attitude. Called risk management....the patient is given the option of how much risk to manage at a time.....can they tweak their diet? next step might be a little exercise. then another tweak in the diet....etc trying to lead, not pull nor shove.

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Specializes in ER.
delaying initial treatment is not something everyone will need to do. but for those who do need it, nothing else will do. i would love to see someone do a study on the difference between the "old school" paternalistic approach where a doctor orders a patient to do things and the newer methods that involve respect, non-emotional education, an open door policy and patient-driven goals.

i'm not talking about throwing out the rules--only tailoring them to the individuals who have to live with them. and listening a lot more than we do now to what the patients are telling us. maybe if we listen more to them they'll listen more to us.

and i agree just as long as the rest of us do not have to continue to pay for those patients to delay care.

for example, stating, "i understand that while you may not be ready to make significant changes in your life today, please understand that of you present yourself to the emergency room with extremely elevated sugars that require treatment and perhaps admission, your care will not be covered under medicaid/medicare/your insurance plan. you will receive a significant bill instead. furthermore, if a delay in treatment can be linked to the loss of vision or extremity pain or amputation, you will need to pay for these treatments out of pocket and before treatment because you have chosen to delay care."

please know that i am all for patients making informed decisions. in fact as a nurse, i pride myself on reminding patients that they are active participants in their own care and have the right to have care provided in a manner consistent with their own desires but that doesn't mean there aren't any consequences to making your own decision to delay care.

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Specializes in Med Surg.

So we use financial blackmail to coerce pts into doing exactly what we say, how we say, when we say, and where we say? Given the cost of healthcare that isn't giving the patient freedom of choice. Sounds more like bullying than anything else. What is wrong with giving a person who has just been given a life changing diagnosis a little time to come to grips with the situation, do a little research, maybe get a second opinion, and maybe accept things rather than expecting them to make immediate on the spot changes that not only affect thier lives but their family's as well.

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I think that many of the attitudes of dislike and being considered "problem children" come from the knowledge that type 2 DM is usually a preventable disease, and that even once you have it that it can be controlled, but that many patients are where they are because of non-compliance. It's hard to overcome those feelings, but we try to give the same care to everyone regardless.

I also don't think that a proven record of non-compliance (once a diagnosis is made and treatment is offered) resulting in non-coverage by insurance for further treatment is being unreasonable. There are limited funds to go around for health care these days. I've seen many people where I work in the hospital refuse treatments or leave AMA and in a way I feel sorry for them but yet in a way I don't.

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I think that many of the attitudes of dislike and being considered "problem children" come from the knowledge that type 2 DM is usually a preventable disease, and that even once you have it that it can be controlled, but that many patients are where they are because of non-compliance. It's hard to overcome those feelings, but we try to give the same care to everyone regardless.

I also don't think that a proven record of non-compliance (once a diagnosis is made and treatment is offered) resulting in non-coverage by insurance for further treatment is being unreasonable. There are limited funds to go around for health care these days. I've seen many people where I work in the hospital refuse treatments or leave AMA and in a way I feel sorry for them but yet in a way I don't.

But what if our approach and our judgmental attitudes are taking a bad situation and making it worse? What if we could make changes in the way we educate new diabetics that would increase their willingness to become more invested in their own health? What if we found out that our best and most well-intentioned efforts were actually contributing heavily to the negative behaviors of our patients? Shouldn't we want to know what we're doing that's such a turn-off and change it if we can? Or is it enough to say, "Oh well, you're making bad choices, so, no more care for you!"

Participating in self care is not an all-or-nothing proposition. It's a contiuum. A little is better than nothing. And a little more is better than just a little. And a little more than that is better still. Most people are not receptive to huge changes at one time. Unwilling change causes stress and a lot of unwilling change causes a lot of stress. Even the most highly motivated individuals can only take on so much at one time. If we are willing to meet people where they are and pick something that seems doable, they can build one small success on top of another.

If we hit them with the whole shebang and they become overwhelmed, what good does that do?

Meeting people where they are (in the hopes of taking them someplace better) isn't caving in or enabling. It's being willing to listen to them and earn their trust so that some good things can happen.

If you woke up with a chronic health problem tomorrow would you want to see someone who gave you a list of things to do and told you to just do it all or you'd be ineligible for further care? Or would you rather see someone who gave you information and then listened to your reactions and helped you work through your choices to find things you thought you could realistically start with and progress from there?

We might need something similar to a 12-step program for diabetics for constant encouragement. Anyone who thinks instantly adhering to a diabetic plan (diet, exercise, finger sticks, meds, etc.) is a "just do it!" proposition doesn't get it.

And hearing people suggest threatening folks with withdrawing care absolutely floors me. Maybe there's time to speak of that after we undo some of the damage we in the business have done over the years.

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Specializes in Critical Care.

I think the point you are making would be radical to some. I don't agree with those people, I do agree with YOU. IMHO, essentially what you're proposing is offering the patients the psycho-social support we all learned about back in school but in today's nursing practice, many of us find we have little time for.

Patients are bombarded by news media about the "obesity epidemic" as well as the "type 2 diabetes epidemic" but with that bombardment comes little in the way of true education. People who develop type 2 diabetes are then criticized, for example in this thread- "you could have prevented this if only......." but we don't think about what cost emotionally this diagnosis means for them. We throw a bunch of medication at them, tell them they now have to perform painful procedures "x" times a day (for those who may poo-poo this, try poking your fingers with a needle 4 times a day and see how you like it! it ain't fun!), rush them through a diet teaching program to make their heads swim, tell them if they don't do what we say all these nasty things will happen! How can patients possibly process all this information, deal with all the education they must undergo, and then face the stigma of being called "one of THOSE people". No wonder complicance is such a huge issue.

I was diagnosed with Type 2 diabetes over a year ago. I'm a nurse, a good one but didn't realize this was happening. NO ONE in my family has ever had diabetes. Yes, I am obese...my sister who was much larger than me never developed diabetes, neither did my mom or paternal grandmother, all women who struggled with weight issues. How did I GET SO LUCKY as to get a gene that decided I needed to get this illness? I struggled for a long time with denial, this couldn't be happening to me. Tried different meds, let my PCP manage things but when my A1C remained high, I finally accepted this diagnosis and sought out an endocronologist. My diabetes is now undercontrol with an average A1C of 6.8. Do I use diligence in monitoring my daily glucose levels? Not as well as I should. Do I follow the diet and take my meds? Religiously. For some reason, poking my finger puts me in a place of anxiety. I accept I'm a diabetic, I accept I need to manage this disease and I am doing my best.

But let me be honest: I already have issues regarding my weight, now this pushes me further into a mental arena that makes life even more difficult. Self-esteem is a problem as is PTSD from an issue from a few years ago. You know what hurts most? The looks I get from others about my now being "one of those people". Because I'm fat, it is now considered acceptable to judge me because I now have this illness. How I"m a drain on the healthcare system, how I could have prevented all of this, how I"m a bad person. Yes, there are consequences for not managing my disease properly but instead of judging me, why not offer a hand to help?

Your blog reminds us all that if we wonder why our patients are non-compliant, we need to look to make sure we are TRULY supporting them. Have we truly given them our best or just shoved a bunch of papers at them and said "good luck"...when they stumbled did we offer them a hand up or just give them the emotional equivalent of a "smack-down"? I have dealt with my share of non-compliant patients (my primary patient population is heart failure patients) and yes, some of them drive me crazy when they don't do as they should...but I will never give up on them. I will try to support them the best I can as much as they will allow me to. It may require some deep breathing on my part but I still try. Just some thoughts.

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These cercumstances make me feel kind of torn.

The stubborn side of me wants to ask, well if you were poisoned, how terrible would you have to feel before you got help?. Why wait one more seconds to start making the changes you need to get better? I mean for sure most people find out because they have been feeling horrible and trying to find they answers as to why. Everyone is responsible for their actions and crying while eating a donuts and feeling sorry for ones self inst going to help.

However I'm a health nut myself and I realize I have to get into my brain, health isn't always a top priority for some people and making the changes to their lives would mean for them to literally feel like they are no longer living or can no longer be happy.

Although its frustrating to deal with and as much as we feel they deserve a good lecture or a kick in the pants, I suppose there are ways to work on the problem in order to get PT to work with it as well. Sometimes drying our hands of the matter till they decide they are ready, is the best we can do. Your time will be better spent on workable situations instead of wasting energy on immovable forces :D

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