Case 4) DM case of 18 year old female

18-year-old women
The patient was admitted to the hospital because of general fatigue
and weight loss. She was diagnosed as IDDM(insulin-dependent
diabetes mellitus) and insulin injection and diet therapy was started.
Because her father was also suffered from DM, she knew it, but she was
afraid of insulin injection by herself.
She was used to the injection therapy gradually, and the glucose level
became normal. But the control of glucose was not so good after
experiment home stay .
The patient's father is now admitted to another hospital owing to Liver
cancer and and her mother was very busy for nursing him. So if the
patient returned to her home, she must live mainly with her younger
sister. Therefore she may not be able to cure herself correctly.
But finally she left hospital after the discussion of medical-staff and
her family .
Her character is quick tempered and unyielding.
Now she is out of work, but she was beauty expert apprentice before.
She is smoking, and she was often experienced glue-sniffing before.
Is the patient discharged too early?
Can she continue injection therapy and diet therapy by herself?
What should the doctor or medical staff to do for her?

4 Box Analysis of this case

<Medical Indication>
Diagnosis : insulin-dependent diabetes mellitus.
If the glucose level is under good control, the patient will lead a normal
life. But if the glucose level is under bad control, some complication, such
as diabetic nephropathy, diabetic retinopathy, diabetic coma will arise.
Her glucose level was 400mg/dl in the first medical examination.
After she admitted to the hospital the insulin level became normal (about
100mg/dl) with Diet therapy and Insulin Injection.

Goal of medical treatment : to get her glucose level under control.
Medical treatment is effective.

<Patient's Preference>
The patient is 18-year-old women, so she can judge everything.
Because her father was also suffered from DM, she knew it, but she was
afraid of Insulin Injection. She could not accept this disease, and she
felt anxiety about her job, marriage, and pregnancy in the future.
She wanted to leave hospital early, because she wanted to feel free.

She must continue treatment during all her life.
There is some prejudice to DM patients , so it is hard for her to get the job,
marriage, and pregnancy.  But some people with DM can control the
disease, and live their life as they want to be.
Her QOL should be decided by her self.

<Contextual Features>
Her father is now admitted in the hospital owing to his Liver cancer.
Her mother was mainly took care of her father, and could not take care of
this patient. So if she leaves the hospital to her home, she should
continue the diet therapy and Insulin Injection by herself.
But she didn't lead a well-regulated life. She was addicted to alcohol.
Her home's economic condition is not easy because of his father's disease.
Her house is far from the hospital.

Dr. Thomas R. McCormick
(206)616-1820-ethics & 616-3023-counseling
Box 357120 UW School of Medicine
Seattle, WA 98195-7120

Thanks for the case of the 18 y.o. diabetic woman.
1. At the age of 18, people often are very different in terms of the
levels of responsibility they are able or willing to assume.  This woman
seems to be somewhat immature, either unable or unwilling to assume
responsibility for the careful management of her diet and insulin regimen.
We know of 16 and 17 year olds who have been very responsible in managing
their diabetes.  On the other hand, during adolescence, some teen agers
are in a process of rebelling against authority---and the medical
authority, often combined with their parents authority, may appear very
powerful, and paradoxically, she may be in rebellion against authority.
OR, she may also be "regressing" into a "helpless" "dependent"posture as
though she is a young child and needs her parents to manage her diabetes
for her.  I think both possibilities need to be explored psychologically.

2. Goal of medical treatment:
a. First, to get her glucose levels under control
b. Second, to TEACH her the responsibility of self care
c. To observe and inquire if there are behavioral steps related to
the insulin injections that are problematic, and finding a way to solve
these, developing a strategy, perhaps with psychological consult.
Good luck in this case.

Reply to McCormick by the student
Thank you very much for your advice.
I think that patient's effort, his family's support and medical staff's
back up are important. I agree with your advice.
But, in my country, social worker or psychologist are very few.
In your country, how do yo do mental care for these kind of patients?
Please teach me concretely.

Tomoko Matsuo
(Ph.D.student in University Heidelberg.Germany,
Ph.D.student in Kyusyu university, Legal Philosophy)

Patient education
According to the principal information, the patient hasn't accepted
or won't accept her healthy situation. But is she too mature to it?
I think not, but she needs more educational commitment. There are
some IDDM patients-groups, and the doctor could ask some successful
patients with the similar situation with her and who could keep in
company with her, to go to her and talk with her. Not only from
medical stuff, but also under the interaction among patients
themselves and reciprocal supports can be counted.
For this kind of patients a long term educational caring and support
is necessary.
On the other hand, a public health nurse can be involved. In Japan
there is little communication between hospitals and public health
care centers, it is regrettable. After patient leaves hospital, we
could do nothing when the person doesn't come to hospital again.
Especially when the point comes to chronic and long term
educational care needed disease, it would be better if someone out of
family who live near him or her gives advice and has contact with her.

Personally I think she needs some reliable medical stuffs with
whom she can talk about her anxiety and problems. To keep medical
treatments rightly it is more effective and easier when the relation
between patient and medical stuff is smooth and near. The patients
are inclined to obey the instruction of the medical stuff because
they trust it during they have don't have enough actual feeling about
their health problem. Here we can say patient autonomy is based on
the trust between them in a sense.

Summary of this case discussion by the student

The Patients suffered from IDDM are usually young.
It is important for them to get his glucose levels under good control by
diet therapy and Insulin Injection not to make complications (such as
retinopathy, nephropathy, neuropathy, and in case of Pregnancy, gestational
toxicosis will easy to arise, etc.).
Even if the patient can control his or her glucose levels under good control,
it is difficult for her or him to get the job or marriage because of the prejudice
to this disease.
So to teach them the importance of self care and to observe and inquire if
there are behavioral problem, and finding a way to solve the problem,
by developing a team approach not only by the doctor but also by other medical
staffs, such as nurse, public health nurse and psychiatrist.
But it is still not so popular in Japan making a team approach to DM patient.
There are some self help groups of young DM patients are made in some
places. They made a good support for these kind of patients.

In this case, after the patient left hospital,she continued to go to hospital
regularly and her glucose levels was under control at that time.
But 6 months after she left hospital, she left home and started to live  with
her boy friend and stopped to go to hospital.
I hope she will return to the hospital or local medical doctor for regular
check of her condition.

Comment and Summary
by Masashi Shirahama(Mituse Health Insurance Clinic)

It is not only a ethical case but also a patient management case.
Medical knowledge is not enough to treat these kind of patients.
The children's DM is mainly treated by the parents,
The generation of young adult patient such as this patient have many problems.
They cannot understand the future complication if their glucose level were under
bad control. They want to live free instead of diet therapy nor Insulin Injection.
There is also prejudice to IDDM from the society. It is not easy to get job or
marriage for IDDM patient. Some DM patient get the job not to say they have

How to deal with these kind of patients I want to write some comment depend
on the case discussion with my student and some Japanese comment.

1) DM is a disease not treated by the medical staff but by the patient with the
help of the medical staff. But it is not so easy for the patient to understand
that the patient is the main treater.(I think most of the chronic disease is also
treated by the patient. Medical staff play a role of a coach or adviser.)
2) Doctors need to look not only the glucose data but also the patient's life.
Listen to the patient's life plan. And tell her she can do most of the thing,
such as job, marriage, making her own baby, if she can keep the diet therapy
and Insulin Injection with the advice of medical doctor.
3) In this case the hospital is far from the patient's home and difficult to go
regular visit. If the local family doctor have good relationship with the patient
and have time to speak about the patient's fear of the disease or her life, he/she
will be a good supporter of the patient.
4) Medical doctor cannot help all of the problem of this kind of patient.
Other medical staff, nurse, public health nurse, psychiatrist will play a important
role. But it is not so popular these kind of team approach in Japan. There is few
psychiatrist who make regular consultation in hospital. But psychological and
social support help the patient to treat the disease by herself.
5) Patient self help group is also a important support system. But it is also not so
popular in rural area. But in rural area prejudice to this kind of patient is still
strong. DM is not rare disease in Japan (1/10 people are candidate of DM), so
Teaching the Information of DM to common people is more needed.
Diet therapy for DM patient is good for all of the people to prevent obesity or stroke.

Howard Brody
Department of Family Practice and Center for Ethics and Humanities
in the Life Sciences, Michigan State University,East Lansing, MI USA.

I appreciate the many thoughtful comments on this case, and
agree that the psychological and patient management issues are central.
Dr. Shirahama is correct that the physician does not really "manage"
diabetes and most chronic illnesses; the patient does.

I find it very difficult to imagine how I would approach this
patient as her local primary care physician, assuming that as in Japan I
did not have a good team at my disposal and perhaps had to do a good
deal of the counselling myself.  (This might be true also in certain
parts of the US and for certain socioeconomic groups.)  The problem is
that some 18-year-olds are like young adults and some are like
adolescents.  I find it helpful to think about these two categories of
patient somewhat differently.

If I sensed a more mature, adult sort of patient I would be
inclined to be very frank about identifying what I saw as the problems
in compliance, asking the patient what her own goals were for
management, and then if we could agree on some goals, asking her how I
could best help her meet her goals.  I would try to put more
responsibility on her to tell me how to help her, rather than rush in
right away with advice.

If I sensed a more immature adolescent, I would try much harder
at first to gain trust and form a relationship.  This might be a slow
process and it might involve showing tolerance for "acting out" behavior
in which the adolescent tested me by "disobeying orders" to see if I
would then reject her, or if I would continue to try to maintain the
relationship.  Once I had gained her trust and showed that I was on her
side, I would next address the feelings she had about diabetes and
alcohol, and especially how this related to her social support system of
her peers, assuming that peer approval is extremely important for
adolescents.  Finally, after learning all of this, I would start to make
recommendations where I saw progress most possible, to get her daily
activities more in line with medical goals in ways that minimized
conflicts with her peer support network.  As people have said, a major
goal is to persuade her that she can best carry out the things in life
she wants for herself by keeping her glucose under control, while
rebelling against controlling the glucose will ultimately make her
unable to achieve what she wants.  "Control" is usually a major
psychological conflict for diabetic adolescents at various levels, and
they may try to be "more in control" in ways that actually make them
less in control in the long run.

For either the adolescent or the young adult with IDDM, support
groups and chat groups on the Internet may be extremely valuable sources
of advice and emotional support and people of that age are especially
likely to have facility in using the Internet.

Stuart Sprague, PhD
Associate Professor of Family Medicine
AnMed Family Practice Center
Anderson, SC USA.

Case 4 -18 year old with IDDM
   Adolescence is a difficult period for all cultures.  Adolescents with chronic
medical conditions are especially difficult for physicians.  Ideally, we would
like to engage the patients' wills to choose actions which will be in their best
interests.  Unfortunately, this approach does not always succeed.  I believe
that the minimum which careful physicians owe such patients are
explanations which give the patients the best information about what they
can expect from their chronic illness and what their actions will do to their
bodies, in the near future and for the long term.  Physicians are not
responsible for all the decisions of their patients.  They are responsible for
doing all they can to foster a helpful relationship based on trust and full
disclosure of the facts.  Trust will always be a bit different for each patient.
  One of the skills physicians need to develop during their training is the
ability to empathize and to communicate effectively with patients of all ages
and family backgrounds.
  In this case I believe that the physician should take enough time to tell her
in very clear terms what the effects of her disease are likely to be and the
various ways in which her actions can improve or worsen the condition.  Also,
the physician should take account of the difficult family circumstances into
which she will return.  Offering her a referral to a counselor who will work
with her over a longer term would be an important asset to her treatment. In our
family practice clinic, we have family counselors who work with patients and
their families.  This is becoming a more prominent feature of family practice as
a discipline.  These counselors can spend more time with the patients.  Over
a long term they can also help the patients deal with failure and attempts to
recover and return to the prescribed regimen.  This is not a substitute for the
physician taking similar steps, but it is a way of complementing and
reinforcing what the physician has said and done for the patient.
  It is difficult to say whether the patient was released too soon in this case.
More information would be needed, and a clinical judgment like that is best
made after direct contact with the patient.  It is also difficult to say without
talking directly to her whether she is capable of maintaining the diet and
therapy by herself.  Most 18 year olds are capable of understanding the
instructions and the consequences of failing to do it appropriately.  One thing
to check for is whether the financial support is available to provide all the
supplies and the right kind of food for her diet. Sometimes patients are willing
to follow instructions but are reluctant to admit to the doctor that they cannot
afford the therapy recommended.  In any case, a referral to a counselor
would be appropriate, and finances may be an issue in whether that
recommendation is followed.

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