Practice dilemma - An elderly diabetic refuses to use insulin

Hilda, an elderly patient with diabetes, is poorly controlled on oral hypoglycaemics.

She lives alone, her diet is variable and she is refusing to change to insulin. Although I have explained to her the risks, she remains adamant that she wishes to continue with her current medication. She is becoming more forgetful. I believe she has mild dementia and fear there is little I can do to prevent inevitable complications.

A GP's view: Dr Raj Thakkar is a GP in Wooburn Green, Buckinghamshire
Exploring Hilda's concerns is important in this scenario. Her fears may be laid easily to rest by exploring and addressing each concern in turn, with tailored education and robust support.

Fears often revolve around stigma or about physically administering the insulin. Perhaps she does not appreciate that modern insulin pens simply require the user to 'dial-up' the dose.

Other patients are often a great resource and comfort in these situations.

She may agree to insulin if the drug is administered by district nurses.

Insulin may be perceived as the final stage of the illness, the beginning of the end. Investing time and investigating why she is reluctant to use insulin may prove insightful.

If Hilda has dementia, however, she may not have been able to retain all of the information you gave her to make an informed decision. If this is the case, should she be changed to a new medication that has significant associated risks?

Is she safe to be on her own at all? Have there been any occurrences where she has misused her current medication?

A pragmatic approach should be taken in this situation. Decide if the objective is quality of life and ensuring she is safe or whether she should be medicalised at all costs.

Would she want her family involved in the decision? Does she have an advanced directive? Perhaps it is more appropriate to investigate the cognitive decline before altering her diabetic mediation. After all, she may have a treatable cause, such as hypothyroidism.

A mini mental test score and consideration of medication for dementia could potentially improve her quality of life far more than focusing on insulin.

A medico-legal opinion: Dr Bryony Hooper is a medico-legal advisor for the Medical Protection Society
This is a tricky but not uncommon situation, in which an elderly patient is refusing to accept advice aimed at improving her health.

Patients have the right to make their own decisions about their healthcare, if they are competent to do so. Given the mild dementia, you should assess Hilda's competence to make a decision about her diabetic medication.

Under the Mental Capacity Act, adult patients are assumed to have capacity unless it is established that they do not. To lack capacity the patient must have an impairment of the mind - dementia would be considered such an impairment.

You then need to establish whether Hilda understands the decision to be made and its consequences, and is able to understand and weigh up the relevant information, such as the potential complications of poorly controlled diabetes.

If not, she lacks capacity to make that decision. Capacity should always relate to a specific decision, and can vary over time and with the nature of the decision.

If you decide that Hilda lacks capacity, you should act in her best interests. You should still try to involve her in any decision, as well as taking into account the views of others who know her well and anyone who holds an enduring or lasting power of attorney.

If Hilda has capacity, you will need to work with her to consider how her treatment can be optimised. Could her compliance with oral therapy be improved? Would a second opinion from a specialist help? Would it be safe to switch to insulin given her forgetfulness?

Family and friends may be able to help you and Hilda reach a better understanding about her treatment.

In this case, it may be that the management will not be greatly altered by your decision on capacity - imposing a treatment that Hilda does not agree with seems unlikely to be in her best interests, and a negotiated way forward may be the only realistic option.

A patient's view: Rosemary Humphreys, member of the RCGP patient partnership group
The GP seems to have done his or her best to persuade Hilda to change to insulin but perhaps it is worth one more attempt in Hilda's home environment rather than at the surgery.

The GP could emphasise the benefits rather than the risks and try to make Hilda see how much better she would feel if her diabetes were better controlled.

We are not told why Hilda does not want to change to insulin. Maybe it is because she is worried about having to inject herself, which for most people is a daunting prospect and perhaps even more so for an older person living alone.

If possible, a diabetes nurse at the practice could talk to Hilda and show her what the new procedure would entail. If Hilda does change treatment, consider if community nurse support could be offered for the first few days of the new regime until Hilda feels more comfortable with the routine.

If this fails the GP could ask Hilda if it would help if they talked together with a relative present. It may be reassuring for her to talk a patient who is already on insulin.

Perhaps Hilda's diabetes is poorly controlled because she is not taking her oral hypoglycaemics appropriately (especially given the suspected mild dementia).

If she remains adamant about not changing to insulin, it might help if her medication was provided on a monitored dosage system and a relative or carer checked whether it was being taken.

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