Diabetes management challenges for uninsured working adults

.....nurse assigned to care for this patient, I would strongly advocate on behalf of the patient's autonomy. The clash between patient autonomy and the healthcare system and its representatives like nurses can only be resolved by being honest in this situation. The patient is under a high degree of stress, not only because of his health condition and the fear that brings out in him, but due to other stressful life events including his financial situation. He was also supposed to get married immediately before the bypass surgery was scheduled, and this is bound to add to his level of stress. The primary issue here is providing what the patient needs to keep him safe during the procedure, and if he insists on using his own pump, which he has successfully used for the thirty years he has lived with the disease of diabetes, then he should use his own pump. There is no need for the nurses on duty to be concerned about this issue, or to coerce the patient into purchasing a new pump that he not only cannot afford, but does not want. Perhaps the new pump would not be effective in his case, anyway. The nurse manager is in the wrong, and I would tell her as much, while advocating on behalf of the patient. When confronted with the ethical issue of patient autonomy, many nurses perceive that they respect patients more than patients perceive they are being respected by nurses (Rahmani, 2010). Sometimes nurses forget that what is convenient for them (such as using the pump the nurse manager was familiar with already) is not best practice for the patient.

The standard post-op orders are not a rigid rule. They are guidelines, designed to be flexible to allow for any extenuating circumstances or issues like this. Unless the nurse can definitively prove that post-op, the patient's pump will be insufficient for keeping his blood insulin levels at equilibrium, then the nurse manager has no business telling the patient to buy a new pump. The patient's safety needs to be assessed more in relation to the stress of the bypass surgery, which is a totally separate issue. If the patient does need to adjust the settings on his pump temporarily, then there are better ways of framing the issue other than coercion and paternalism. The patient has been managing his disease for a long time, leading to personal familiarity with his biological signals. He has what nurses sometimes refer to as embodied knowing, which the nurse manager does not possess. The significance of the diabetes for the patient is a lot different from his perception of the heart attack, which he was not expecting. The nurses should focus on the heart issues the patient is currently experiencing, and ensure that he becomes a co-collaborator in his own care rather than a passive recipient of whatever care the nurses want him to have. I might even suggest that the patient ask his mother to remain at his side, because she is a nurse and could provide the multiple levels of care he needs at this time. If that were not possible, I would locate a nurse specialist who was familiar with the specific type of insulin pump the patient has and likes.

If patient safety and his wishes were in provable and immediate conflict, the best way to approach it is by explaining the issue in detail. The patient is already well-informed about what diabetes is, and what it can mean for the body under recovery from surgery. Explaining the biological issues and the issues surrounding his need for extra insulin might help him feel empowered with information, instead of being treated like a disobedient child as the nurses in this situation seem to be doing. If I were the patient's brother or father, I would not see the situation any differently. I would passionately argue that the staff needs to respect the autonomy of the patient, and politely but firmly decline their orders. The family might not know about their rights in the situation, which is why as a nurse I believe it is important for healthcare facilities to have pamphlets on hand about patient advocacy and autonomy. When family members need to speak up and support their relatives, they need an advocate to speak on their behalf.

References

Rahmani, A., et al. (2010). Respecting to patients' autonomy in viewpoint of nurses and patients in medical-surgical wards. Iranian Journal of Nursing and Midwifery Research 15(1): 14-19.