VOL. 18 NO. 3 Summer 2000
Case Study: A 46-Year-Old Man With a 15-Year History of Type 1 Diabetes Who Died of Diabetic Ketoacidosis
Deborah Thomas-Dobersen, RD, MS, CDE, and Michael J. Dobersen, MD, PhD
This 46-year-old Hispanic man with a 15-year history of type 1 diabetes was found unresponsive by his wife of 18 years. He was pronounced dead by paramedics despite resuscitative efforts.
His wife provided a history of the days leading up to his death. On Friday (Day 1), he ate dinner out at an unfamiliar restaurant. He became ill that evening with vomiting. Although she ate the same food, his wife did not become ill. He omitted his bedtime injection of insulin because he had not kept down any food. He continued vomiting Saturday (Day 2) and Sunday (Day 3), again omitting all insulin injections because he had not kept down any food.
During this time, his wife encouraged him to see, or at least to call, his physician, but he declined. He did not measure his blood glucose level because he had left his meter at work. He did not measure urine ketones because he had never been instructed to do so. His wife discovered him unresponsive on Monday morning (Day 4). His wife stated that they had learned about diabetes when he was initially diagnosed, but had not had any diabetes education since.
At autopsy, his vitreous glucose level was 627 mg/dl and vitreous ketone level was 37 mg/dl. (Vitreous humor is used for postmortem determinations of glucose, ketones, and other analytes, and the results correlate with premortem levels.) He was also found to have severe three-vessel coronary artery atherosclerosis and early diabetic nephropathy. Based on these findings, his death was attributed to diabetic ketoacidosis (DKA).
The primary care physician (PCP) who had followed this patient for 6 years provided a history of a noncompliant patient who had chronic poor control as evidenced by a recent HbA1c level of 14.9% (normal <6.3%). The patient's most recent insulin dose was 18 U of NPH and 4 U of regular insulin in the morning and 22 U of NPH at bedtime. His height was 5'10" and weight was 185 lb. Therefore, his insulin dose was ~0.52 U/kg body wt/day. He had been referred to an ophthalmologist but not to an endocrinologist or diabetes educator.
The PCP provided medical records that failed to document assessment of or provision of diabetes self-management education. There was no flow sheet. The patient had had 18 office visits over the past 6 years, but only two HbA1c levels (12 and 14.9%) were recorded, and there were no recorded tests for microalbuminuria. Most of the recorded physician visits centered around his problems at work, osteoarthritis from a motorcycle accident, and notations describing an absence of insulin reactions.
The deceased was a member of a large national health maintenance organization that provides PCPs with a yearly capitation rate for their members. Costs of education and referrals to specialists are applied directly to the capitation rate.
- Why does illness often result in DKA unless appropriately man-aged?
- What is the recommended education for sick-day management for people with diabetes?
- What is the "standard of care" for teaching self-management to people with diabetes?
- What tools are available to PCPs to provide diabetes education for their patients?
- What is the liability of the PCP or insurance company when lack of education contributes to a death?
Infection, illness, or major stress may induce an increase in counterregulatory hormones including glucagon, catecholamines, cortisol, and growth hormone. These hormones, especially in the setting of relative or absolute insulin deficiency, worsen the metabolic derangements characteristic of DKA by providing alternative fuel sources through lipolysis, glycogenolysis, and ketogenesis.1 These effects include the following:
- hyperglycemia, osmotic diuresis, and dehydration caused by hyperglycemia, and
- anion gap acidosis secondary to increased production of free fatty acids, leading to increased production and decreased utilization of both acetoacetic acid and 3--hydroxybutyric acid.
Among the most common causes of DKA is incorrect self-management during illness.1 Unless educated in self-management, patients who are unable to eat or drink or to keep food down often omit insulin in fear of hypoglycemia. Unbeknownst to these patients, factors other than food are elevating the blood glucose level and making insulin less effective and acidosis more likely. In this particular patient, the chronic poor glycemic control made insulin omission more alarming and its metabolic consequences probably more critical.
Educating people with type 1 diabetes about self-management around illness is most appropriate when taught before an illness occurs. Including a spouse, parents, or supportive others may prove critical to preventing hospitalization (and death) from DKA. Understanding the need for more frequent monitoring of blood glucose and ketones is crucial and must be taught in the context of the special effect of illness on diabetes control. Individually wrapped Ketostix that do not expire are a must for people with type 1 diabetes to have at home.
In patients with type 2 diabetes, education about diabetes self-management around illness is also crucial. Presumably, sufficient endogenous insulin is able to prevent lipolysis and ketogenesis, but will not prevent hyperglycemia when a patient is ill.
People with type 2 diabetes are at risk for hyperglycemic hyperosmolar nonketotic syndrome (HNKS), a life-threatening condition when illness is not treated and blood glucose is not controlled. HNKS is marked by the absence of ketosis and acidosis but is manifested by blood glucose levels between 600 and 2,000 mg/dl. Patients with type 2 diabetes who have poor fluid intake are more likely to get HNKS. When unable to keep down oral hypoglycemic medication because of an intercurrent illness, these patients may need supplementary regular insulin injections to control their blood glucose.2
The accompanying Patient Information page shows frequently taught guidelines for people with diabetes (type 1 or 2) to follow when ill.1,3,4 Children or infants with type 1 diabetes present a special challenge. Sick-day education reinforced before an illness occurs and an on-call diabetes educator or physician prevent many hospitalizations for DKA. Special guidelines for this age-group may be helpful.5
The American Diabetes Association (ADA) position statement "Standards of Medical Care for Patients with Diabetes Mellitus" is published each year in a supplement to the journal Diabetes Care and is also available on the ADA website (www.diabetes.org/diabetescare). It states that "diabetes is a chronic disease that requires continuing medical care and education to prevent acute complications and to reduce the risk of long-term complications."6
Four topics pertinent to this case are stressed in the Standards of Care. First, a comprehensive assessment of self-management knowledge should be performed, and areas of weakness should be identified. Second, instruction on the prevention and treatment of acute complications (DKA and hypoglycemia) is a part of medical management. Third, if resources (i.e., time) are insufficient to carry out these goals of educating patients and their families in self-management, referral to a diabetes care team for consultation or comanagement is recommended. Fourth, a flow sheet is recommended to keep track of medical tests as well as assessment, provision, and reinforcement of educational needs for self-management.
Although many PCPs may not have time to provide diabetes education, there are available tools that can help. The National Diabetes Education Program, a joint project of the National Institute for Diabetes and Digestive and Kidney Diseases and the Centers for Disease Control and Prevention, provides educational handouts for patients with diabetes to be used in PCP offices (1-800-438-5383; http://ndep.nih.gov/). However, it is clear that handouts are not as effective alone as they are when combined with physician or diabetes educator teaching.
The ADA's Diabetes Forecast magazine is an excellent vehicle for keeping patients educated and informed and comes with a minimal membership fee. In addition, many books and newsletters are written for people with diabetes. Certified diabetes educators can usually be found in hospital-based settings and can comanage or provide the educational component for self-management.
How can outcomes like this be prevented? Clearly, a lack of education, a component of medical management, led to this patient's death. In this case, the health management organization offers capitated care, which means that physicians either provide the education themselves or in their office or pay for the education to be provided elsewhere. It is possible that this manner of payment provided a disincentive to offering education. The omission of the necessary education probably constitutes medical negligence, and, if proven to have been a direct cause of death, the family has a legal cause of action against the medical provider and the insurance company.
In Colorado, the state health department records the number of deaths from DKA but does not explore the contributing factors. How many poor outcomes can be attributed to the lack of provision of education? We simply do not know.
When physicians agree to go at risk for patients with diabetes, do they realize that they also agree to provide self-management educationa difficult task when most physicians do not have the time and are not compensated for such activities? To us, this case reflects one of the major disadvantages of the capitation system.
- Patients with diabetes must be educated about the importance of appropriate sick-day management as a part of their medical management.
- Among the most common causes of DKA is the withholding of insulin when ill with the mistaken belief that hypoglycemia will result.
1American Diabetes Association. Diabetic ketoacidosis. In Medical Management of Insulin-Dependent (Type 1) Diabetes. 2nd ed. Alexandria, Va., American Diabetes Association, 1994, p. 76-77.
2American Association of Diabetes Educators: A Core Curriculum for Diabetes Education. 2nd ed. Chicago, American Association of Diabetes Educators, 1996, p. 164.
3Davidson MB: Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Los Angeles, W.B. Saunders, p. 71.
4Lowe E, Arsham G: Diabetes: A Guide to Living Well. Minneapolis, Minn., Chronimed Publishing, 1997, p.339-41.
5Chase HP: Understanding Insulin-Dependent Diabetes. 9th ed. Denver, Colo., The Children's Diabetes Foundation Guild, 1999, chapter 15. (A copy can be purchased by sending $15 to: The Guild of the Children's Diabetes Foundation, 777 Grant St., Suite 302, Denver, CO 80203, or by calling 1-800-695-2873.)
6American Diabetes Association: Standards of medical care for patients with diabetes mellitus (Position Statement). Diabetes Care 23 (Suppl 1):S32-42, 2000.
Deborah Thomas-Dobersen, RD, MS, CDE, is in private practice, and Michael J. Dobersen, MD, PhD, is a forensic pathologist at the Arapahoe County Coroner's Office, in Littleton, Colo.
Copyright � 2000American Diabetes Association
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The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. Among the disciplines involved in diabetes education, nursing has played a pivotal role in the diabetes team management concept. This was well illustrated in the Diabetes Control and Complications Trial (DCCT) by the effectiveness of nurse managers in coordinating and delivering diabetes self-management education. These nurse managers not only performed administrative tasks crucial to the outcomes of the DCCT, but also participated directly in patient care.1
The emergence and subsequent growth of advanced practice in nursing during the past 20 years has expanded the direct care component, incorporating aspects of both nursing and medical care while maintaining the teaching and counseling roles. Both the clinical nurse specialist (CNS) and nurse practitioner (NP) models, when applied to chronic disease management, create enhanced patient-provider relationships in which self-care education and counseling is provided within the context of disease state management. Clement2 commented in a review of diabetes self-management education issues that unless ongoing management is part of an education program, knowledge may increase but most clinical outcomes only minimally improve. Advanced practice nurses by the very nature of their scope of practice effectively combine both education and management into their delivery of care.
Operating beyond the role of educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care.
Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses.3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of patients with type 2 diabetes who have a constellation of comorbidities, all of which must be managed for successful disease outcomes.
Many studies have documented the effectiveness of advanced practice nurses in managing common primary care issues.4 NP care has been associated with a high level of satisfaction among health services consumers. In diabetes, the role of advanced practice nurses has significantly contributed to improved outcomes in the management of type 2 diabetes,5 in specialized diabetes foot care programs,6 in the management of diabetes in pregnancy,7 and in the care of pediatric type 1 diabetic patients and their parents.8,9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients.10 Primary management of these patients by NPs led to improved metabolic control regardless of whether weight loss was achieved.
The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes.
A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.
Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.
A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results.
He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.”
A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.
During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).
A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”
The medical documents that A.B. brings to this appointment indicate that his hemoglobin A1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health.11
A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.
A physical examination reveals the following:
Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m2
Fasting capillary glucose: 166 mg/dl
Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg
Pulse: 88 bpm; respirations 20 per minute
Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy
Lungs: clear to auscultation
Heart: Rate and rhythm regular, no murmurs or gallops
Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally
Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle
Results of laboratory tests (drawn 5 days before the office visit) are as follows:
Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)
Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)
Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)
Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)
• Total cholesterol: 162 mg/dl (normal: <200 mg/dl)
• HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)
• LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)
• Triglycerides: 177 mg/dl (normal: <150 mg/dl)
• Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)
AST: 14 IU/l (normal: 0–40 IU/l)
ALT: 19 IU/l (normal: 5–40 IU/l)
Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)
A1C: 8.1% (normal: 4–6%)
Urine microalbumin: 45 mg (normal: <30 mg)
Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:
Uncontrolled type 2 diabetes (A1C >7%)
Obesity (BMI 32.4 kg/m2)
Hyperlipidemia (controlled with atorvastatin)
Peripheral neuropathy (distal and symmetrical by exam)
Hypertension (by previous chart data and exam)
Elevated urine microalbumin level
Self-care management/lifestyle deficits
• Limited exercise
• High carbohydrate intake
• No SMBG program
Poor understanding of diabetes
A.B. presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit.
The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and agreed to start improving dietary control by reducing his portion size by one-third during the week before his dietary consultation. Weight loss would also be an important first step in reducing his blood pressure.
The NP contacted the registered dietitian (RD) by telephone and referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at meals and snacks. She asked that the patient also try to estimate portion sizes.
Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. After further discussion, he realized that a week or more would often pass without any significant form of exercise and that most of his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary.
A.B.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.
A first-line medication for this patient had to be targeted to improving glucose control without contributing to weight gain. Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain.12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain.12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). α-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system. However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%.13 Acarbose may be considered as a second-line therapy for A.B. but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration to dose efficacy.14
After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day. Possible GI side effects and the need to avoid alcohol were of concern to A.B., but he agreed that medication was necessary and that metformin was his best option. The NP advised him to take the medication with food to reduce GI side effects.
The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient.
During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the metformin dose was being titrated. He understood the need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.”
The NP reviewed glycemic goals with the patient and his wife and assisted them in deciding on initial short-term goals for weight loss, exercise, and medication. Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle.
A.B. drew the line at starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure.
Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the prevention of diabetes complications. However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. was obese, weight loss would be beneficial for many of his health issues.
Because he has a sedentary lifestyle, is >35 years old, has hypertension and peripheral neuropathy, and is being treated for hypercholestrolemia, the NP performed an electrocardiogram in the office and referred the patient for an exercise tolerance test.11 In doing this, the NP acknowledged and respected the mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and safety.
In her role as diabetes educator, the NP taught A.B. and his wife the importance of foot care, demonstrating to the patient his inability to feel the light touch of the monofilament. She explained that the loss of protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by poorly fitting footwear worn during exercise.
At the conclusion of the visit, the NP assured A.B. that she would share the plan of care they had developed with his primary care physician, collaborating with him and discussing the findings of any diagnostic tests and procedures. She would also work in partnership with the RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the NP would facilitate the continuity of care and keep vital pathways of communication open.
Advanced practice nurses are ideally suited to play an integral role in the education and medical management of people with diabetes.15 The combination of clinical skills and expertise in teaching and counseling enhances the delivery of care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager.
Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum.
Note of disclosure: Ms. Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes.
- American Diabetes Association