Uncooperative Diabetic Question

[KKEGS, MSN, RN]

Alright nurses! Help me figure this one out! Having issues with this student and family on multiple fronts.

4th grade boy with type I diabetes. Diagnosed 1 year ago. Has the Dexcom G5 CGM and an Omnipod pump. Usually very responsible with it. In the fall I attended his parent/teacher conference because parents had some concerns that his 504 wasn't being followed. They were specifically concerned that he wasn't being escorted to the health office by an adult when he was feeling or alarming that he was low. Turned out that he was not being walked to the office but was observed down the hallway while he walked to the office. Also parents were concerned that he was missing too much time by going to the health office to do finger pokes and treat his highs and lows. We came up with a plan that everyone seemed happy and comfortable with.

Fast forward 5 months. Here I am thinking everything is going along just fine when, about 2 weeks ago, I get an angry phone call from this student's father. Dad has just found out that yet another nurse (our 3rd one this year) has quit and he is angry about the turnover and the fact that every time a new nurse starts they get multiple phone calls a day while the new nurse is figuring out this student's routine and treatment. I acknowledged his frustration, expressed my concern also and my goal of keeping their son safe at school, yada, yada, yada and then directed him to my boss, the Director of SPED to voice his concerns.

I get more phone calls throughout the week about the parents' concerns that this student's treatment plan isn't being followed and that we don't trust their son to put in his own numbers and that we aren't allowing him to be independent. Their son is telling them one thing and I was able to confirm via our charting and speaking with the health office nurse and his classroom teacher that what the student is telling his parents simply isn't true.

Now we have a series of subs in the health office as we conduct interviews to find a permanent replacement. I have given them a heads up about this family and have advised them to contact me first if they have any questions and we can try to troubleshoot and only call the parents if necessary because they seem to get so angry about being contacted.

Today's sub contacted me because he is being quite defiant and uncooperative. He gets annoyed that we ask what his BG is and how many units the pump is giving him, how many carbs he's eating, etc. He seems to think (and maybe his parents do also?) that he shouldn't need to tell us any of this information. All we do is write it down and let him go on his merry way. But we are responsible for his safety and shouldn't we know this information each day?!?

Anyway his spring parent/teacher conference is tomorrow and I am attending again along with his counselor/case manager (he's currently being evaluated for SPED which I think may be part of parents' bad attitude) and his classroom teachers.

Basically I guess my question is how do I go about informing his parents about how uncooperative he is being (sometimes he is downright rude!), our need to know his daily numbers, and that he isn't being truthful with them without ruffling their feathers even more? Right now they really seem to think that we are the bad guys.

[caliotter3]

Bite the bullet and be straight up with them. Any attempt to downplay anything may result in further misunderstanding.

[Cattz, ADN]

Wow. I would be matter of fact and upfront about your concerns. (But that is how I handle difficult situations like that). Can you produce any evidence- through charting, or whatever means- to show the parents that he isn't being truthful with them? Maybe getting the dr. involved- Is he/she ok with him being as independent as he is wanting to be?

[KKEGS, MSN, RN]

I know we've had students in the past who wanted to be completely independent but they were high schoolers! That seems to me like too much responsibility for a 4th grader but I suppose I could present that scenario to the parents like we have in the past. We basically ask for a signed letter or order from a doctor saying that the student can be completely independent and that we will only step in if an emergency situation arose like the need for glucagon.

[JenTheSchoolRN, BSN, RN]

Bite the bullet and be straight up with them. Any attempt to downplay anything may result in further misunderstanding.

This.

I had a very uncooperative diabetic HS student for a few years. I would attend this student's IEP and 504 meetings (student had both) and state the facts. And I made the student cry every. single. time. (The student's reason for an IEP was a definite challenge when it came to compliance and this was noted.)

Luckily for me, the parents were understanding of the student's non compliance and equally frustrated. This student could not be trusted to be compliant and that was hard to balance as well as I would physically need to call this student every single day for BG checks and insulin dosing as this student would say they did it and never ever do (evidence in BG trends and history on glucometer as student was not on pump due to non compliance on pump.)

These parents may also be frustrated with the student's health status. I'd ask how his sugar is checked at home and see if that routine matches/is close to how they would like to be conducted at school. Are his CGM numbers and numbers he's reporting close? Or does the nurse he works with not have access to his CGM data?

[tining, BSN, RN]

Wow, just wow. Some people will never be happy.

When a student enters a school that child IS now our responsibility whether the student likes it or not. Should something happen and someone questions the Licensed Professional what would that person say? I don't know what his BS was or how much insulin the pump gave? Won't hold up in court and these parents could be potentially litigious. Especially since they are concerned about his lows and unsure how safely he is getting to the health office.

Explain to the parents "It has come to my attention that LD has not wanted to share his BS or insulin dose with our substitutes, and has been quite vocal with it. As the medically responsible person in this school we need that information if God forbid something would happen. We all share the concern with LD's diabetic management and only want what is safe for LD." They can take the 'quite vocal' part and you won't be saying how rude LD has been.

[ruby_jane, BSN, RN]

I would get the provider involved. If the student's A1C is perfect and he is compliant in all other situations...maybe he can be responsible.

I'm not saying that any of that's true. It's probably not. One of our childrens' hospitals allows the parent to select the level of care the student receives (either some assistance, total care, or independent). The other selects it for them. Know that it's an awkward situation but there are 10-12 weeks of school left, right? Your documentation (including his refusals with the sub nurse) should demonstrate your are doing your level best to keep the kid healthy.

[KKEGS, MSN, RN]

These parents may also be frustrated with the student's health status. I'd ask how his sugar is checked at home and see if that routine matches/is close to how they would like to be conducted at school. Are his CGM numbers and numbers he's reporting close? Or does the nurse he works with not have access to his CGM data?

We do not have access to his CGM. Parents monitor it remotely. They never call the school to tell us if he is trending high or low or even when it isn't working at all which has happened several times over the last couple of weeks. We literally have ZERO communication with his parents and when we do call they get angry.

His Dexcom is the one that is FDA approved for dosing instead of a finger poke. His parents were complaining that the nurses aren't following orders about dosing using number on the Dexcom. Again, after talking to the nurse she said that wasn't true. The day I spoke with her he hadn't done a finger poke at school for nearly 3 weeks.

[NutmeggeRN, BSN]

Bring a release of information form to the meeting so you can contact the MD (if not already in place). Explain the facts of the situtation and ask how s/he wants the nurse in school handle it. Very upfront and non confrontational. Explain to the parents that your only concern is his safety in a medical crisis. as long as you are acting within your scope of practice and doing everything you can, you should be ok.

Good Luck!

[ruby_jane, BSN, RN]

We do not have access to his CGM. Parents monitor it remotely. They never call the school to tell us if he is trending high or low or even when it isn't working at all which has happened several times over the last couple of weeks. We literally have ZERO communication with his parents and when we do call they get angry.

His Dexcom is the one that is FDA approved for dosing instead of a finger poke. His parents were complaining that the nurses aren't following orders about dosing using number on the Dexcom. Again, after talking to the nurse she said that wasn't true. The day I spoke with her he hadn't done a finger poke at school for nearly 3 weeks.

Wow. Whelp...definitely time to get administration involved.

[WineRN]

We do not have access to his CGM. Parents monitor it remotely. They never call the school to tell us if he is trending high or low or even when it isn't working at all which has happened several times over the last couple of weeks. We literally have ZERO communication with his parents and when we do call they get angry.

His Dexcom is the one that is FDA approved for dosing instead of a finger poke. His parents were complaining that the nurses aren't following orders about dosing using number on the Dexcom. Again, after talking to the nurse she said that wasn't true. The day I spoke with her he hadn't done a finger poke at school for nearly 3 weeks.

This is not ok. He is only in 4th grade, he just doesn't have the maturity yet to handle this on his own and his parents sound like they need some education on how diabetes in managed in the school to keep him safe.

[grammy1]

We do not have access to his CGM. Parents monitor it remotely. They never call the school to tell us if he is trending high or low or even when it isn't working at all which has happened several times over the last couple of weeks. We literally have ZERO communication with his parents and when we do call they get angry.

His Dexcom is the one that is FDA approved for dosing instead of a finger poke. His parents were complaining that the nurses aren't following orders about dosing using number on the Dexcom. Again, after talking to the nurse she said that wasn't true. The day I spoke with her he hadn't done a finger poke at school for nearly 3 weeks.

I think it's time for the parents to know that LD isn't being completely truthful with them. Just state the facts.