A lesson in how to support and teach difficult patients.
Ricardo, a 35-year-old man, newly diagnosed with type 1 diabetes, was hospitalized for diabetic ketoacidosis (DKA).
Once he was stabilized, he wanted to go home. He refused to learn how to self-administer insulin. However, he was told he would not be discharged until he self-administered insulin, at least one time. I was the hospital diabetes educator who was called in to meet with him. I taught him about type 1 diabetes and his need for insulin. He told me he would be fine without his insulin; all he had to do was pray, and he would do fine. I was not about to argue with him, nor was I going to agree with his idea that he did not need insulin. I firmly told him he would need to take insulin for his health. I also taught him there might be a period when his glucose levels might seem to be at the average level (honeymoon period), but that does not mean he wouldn‘t need to take insulin for the rest of his life. He did perform a demonstration of insulin self-administration, and he “taught back“ to me what he‘d learned about type 1 diabetes. At the end of the session, he told me once again he would not be taking insulin once he got home.
Being the “seasoned“ diabetes educator I am, I knew better than to argue or agree with him. I also thought that was not the time to recommend a psych consult to help him cope with his new diagnosis. Although this type of referral can be beneficial for many, telling him he needed to see a psychiatrist, psychologist, or social worker might be the very words that would cause him to check out against medical advice and never get the teaching he needed. I also informed the staff that, in time, I thought he would learn. “He’ll go back into DKA, be admitted, and he’ll get it. In time he will do what he needs to do when he realizes it himself.”
He was discharged with insulin and the supplies he needed to manage his diabetes.
About a month later, he was on my mind. I called him. He told me he had been praying, did not take insulin, but did check his blood sugar once in a while. He had noticed his blood sugar was starting to rise again and that he didn’t seem to have the energy he used to. I told him that this was all due to his type 1 diabetes and not taking insulin. If he wanted to get better, he would need to take insulin. He finally agreed to resume his insulin, check his glucose levels, and follow up with me for further diabetes education. Ricardo averted another episode of DKA.
- It’s difficult for anyone to accept that they have a chronic condition. We all have our way of accepting and coping.
- It’s not up to me to judge or argue with my patients. It’s my job to assess the situation, know when to and when not to refer on, and teach survival skills to people newly diagnosed with diabetes.
- Don’t give up on patients when they are “out of sight.” If they are on my mind, I reach out to them — there’s usually a reason.
Joy Pape, MSN FNP-C CDE WOCN FAADE
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See related article on difficult patients and managing rejection of insulin.