Reader Question: Diabetic Malingering Part 3

Janet, great correctional nurse, Ada county Jail, Boise

Dr. Kay Haw submitted the following question:

“I would like to know your thoughts on the ability to forcibly provide insulin coverage on a diabetic inmate whose sugars are out of control and is refusing blood sugar checks and insulin administration.”

This is a great question that I should have answered as part of the Diabetic Malingering series found here and here.  The question here is whether an inmate has a right to refuse medical care, even if doing so could result in harm.  In general, inmates retain the right to refuse medical care, as long as they are competent to do so and as long as the refusal is informed (more on that later). However, this right of refusal is not inalienable and  depends on clinical circumstances, such as how much harm the patient faces by the refusal, the reason the patient has for refusing and the patient’s competence.

In the case of refusing insulin, the risk the patient faces depends on whether the patient is a Type 1 diabetic or a type 2 diabetic. A Type 1 diabetic will eventually die without insulin and may lapse into a diabetic keto-acidosis coma in as soon as 3-4 days.  Type 2 diabetics, on the other hand, will not die without insulin.  They still make their own insulin.  They are insulin resistant but not insulin dependent.  Some are prescribed insulin to keep their blood sugars down, but they do not need insulin to survive.

Refusal of Insulin by a Type 2 Diabetic

So let’s first take the simpler case of a Type 2 diabetic who refuses to take insulin.  Since he does not need insulin to survive, and since insulin is not the only treatment option available, the refusal of insulin is analogous to the same patient refusing a diabetic diet.  It may not be in his best interest to refuse insulin (or a diabetic diet) but the patient has the right to refuse these treatments as long as the refusal is an informed refusal.  An informed refusal entails that someone, usually the jail practitioner, informs this patient of the potential harm that might ensue as a result of refusing medical care.  I would talk about the risk of heart attacks, strokes, kidney failure, blindness, foot amputations and every other complication of diabetes I can think of.  Besides warning him of the possible consequences of his refusal, I might just scare him enough to reconsider.  The threat of impotence seems to work particularly well in the scaring department!

After this, assuming that the patient continues to refuse care, I inform him that he can change his mind at any time and document the conversation thoroughly in the medical record.  There are times when you can be brief in your medical documentation but this is not one of them.  You need to document the risks you discussed with the patient, the fact that he refused and that you told him he could change his mind.  That’s the easy case.

Refusal of Insulin by a Type 1 Diabetic

The refusal of insulin by a Type 1 diabetic is a totally different case since type 1 diabetics are dependent on insulin to survive.  Without insulin, they can lapse into a diabetic coma in as little as 3-4 days.  The threat is real and immediate. The first question to ask a Type 1 diabetic who is refusing insulin is whether he understands this and whether he is intending to commit suicide.  In fact, for Type 1 diabetics, the conversation on adverse consequences can be much shorter than for Type 2 diabetics.  All you really have to say is “Without insulin, you will die.  Maybe within days.  Do you understand this?”

If the patient continues to refuse insulin despite this warning, my personal opinion is that, in most cases, this jail inmate should be forcibly restrained and given insulin despite his refusal.

“Wait!” you might be saying.”What about the inmate’s right to an informed refusal of medical care?” Well, there are several  issues here that bear on my decision to override this particular inmate’s right to refuse care.

1. What is the inmate’s motivation for refusing this life-saving medical intervention? There is a difference between a patient who is refusing life-or-death medical care for religious reasons (Like Jehovah’s Witness refusing blood products) versus refusing due to a trivial protest of jail policies or wanting to commit suicide.   I do have not have much respect for a patient who is refusing insulin as a method of manipulation.  And inmates do not have an innate right to manipulate.

2.  Inmates do not have a right to commit suicide.  Just as an inmate does not have the right to kill themselves by refusing oxygen (by wrapping a sheet around their neck), they also don’t have the right to kill themselves by refusing insulin.

3.  The threat to a Type 1 diabetic’s health of refusing insulin is immediate.  Without insulin, they may lapse into a coma within days.  There often is not enough time to adjudicate the question in court.  If, instead of wanting to commit suicide by refusing insulin, an inmate wanted to commit suicide by refusing food and starving to death, there would be plenty of time to get a judges opinion.  Death by starvation takes weeks.  Death by diabetic coma takes days.  I need to act now.

4. The solution to this dilemma is relatively quick and easy.  In order to keep a Type 1 diabetic alive, all we really need to give them is long acting basal insulin, either Levemir or Lantus, once a day.  And patients need only be restrained for literally seconds, just long enough to get a blood sugar and give insulin.  Patients won’t be well controlled with just Lantus, but it will keep them alive long enough to go to court, if necessary. More typically in my experience, after the first forced shot, patients usually change their mind and again accept diabetic care.

5. Finally, incarcerated inmates, to some degree, have lost absolute autonomy to make their own decisions.  Just like an inmate cannot choose what to eat or to wear, they do not have an inalienable right to refuse medical care when in jail.  Jails, prisons and juvenile facilities have some degree of guardianship over incarcerated inmates and also have not only the right, but the responsibility to protect the well being of the inmate as well as the safety and security of the institution.

“I’ll take insulin, but I refuse to allow you to take blood sugars.”

What about the patient who accepts insulin, but refuses to allow blood sugar checks?  Again, in my mind, this boils down to the risk the patient faces by this refusal.  Since a shot of insulin can potentially kill a person whose blood sugar is low, knowledge of the blood sugar is mandatory to be able to give insulin safely.  I would not allow a patient to accept insulin but refuse blood sugar checks.  They must go together.

What I have written here is my own opinion.  I freely admit that smart people might just disagree with me!  In fact, I might be wrong!  You should discuss this potential situation with your facitily’s legal counsel and administration so you know in advance what you are going to do when the time comes.  And it will happen!  This is not that uncommon of a situation.

What would you do in the case of a Type 1 diabetic who is refusing insulin?  Please comment!

Special Thanks to David Tatarsky, General Counsel to the South Carolina Department of Corrections, for teaching me how to look at this case from a legal perspective.  Of course, if I have made a mistake, it is my mistake, not his!

 

11 thoughts on “Reader Question: Diabetic Malingering Part 3

  1. Al Cichon

    The topic stirs several thoughts
    First – a court order might be useful (may save later liability)
    Second – I would extend this to include diet: we are obliged to preclude harm – so, restricted calorie diet and no commissary
    Third – The inmates who refuse – then want to start again – then refuse ond so on
    I will usually allow one round of this – then based upon the lack of theraputic effectiveness stop the merry-go–round

    Reply
    1. Jeffrey Keller Post author

      Thanks for your thoughtful comments, Al.

      I agree on pursuing a court order if necessary. I would not wait for the court order, however. I would forcibly give the shot and then, if the inmate persists in his refusal, set up a court hearing.

      I usually allow inmates to refuse a diabetic diet and to purchase junk off commissary–up to a point. When to insist on dietary compliance would be a good topic for another day!

      Inmates who change their mind frequently are definitely hard to deal with. In general, an inmate starts out being in charge of their own health. If they abuse this privilege (as you are describing), they can lose that right and I take over the decision making about their health.

      Reply
  2. Ros Walden

    A mental health referral would be in order here, just as it would be if the inmate states he is suicidal. Documentation from MH may resolve the refusals and/or uncover new information, but it will also help to CYA.

    Reply
    1. Jeffrey Keller Post author

      I agree, Ros! I should have said as much. An inmate who is trying to die by refusing insulin should be treated as any other suicidal inmate is treated: Mental health, suicide precautions including mock if necessary, housing, etc.

      Thanks for catching this!

      Reply
  3. Cheralee

    We had an inmate who has been on dialysis since 12 years of age. While in our facility he became angry that staff did not allow him to do as he chose at dialysis (visit with other patients, free access to food, watch TV) and decided to refuse dialysis. He continued to refuse dialysis for about two more treatments becoming more swollen and HTN each day. We talked repeatedly several times a day about dialysis refusal and death which he verbalized understanding. He was eventually sentenced to prison. What are your suggestions in a case such as this?

    Reply
    1. Jeffrey Keller Post author

      I also had an inmate who refused dialysis. Unlike giving an inmate insulin against her will, It would be very hard to dialyze someone against their will. Maybe even impossible. It doesn’t even matter if you have a court order; if the patient really does not want to be dialyzed, you probably could not do it. So the next best thing is to do everything you can do–have the inmate seen by mental health, notify the nephrologist, and notify your attorney. And document all of your efforts!

      Reply
  4. David Tatarsky

    Another thing I recommend to my medical folks when they come to me with issues like this is to look for anyone who may have the ability to communicate with this particular inmate. Assuming confidentiality is NOT an issue, I often recommend the chaplain. In one case, we even contacted an inmate’s mother (we already had a release from the inmate allowing us to speak with her) and asked her to speak with her son.

    Many states have an Adult Health Care Consent Act which contains provisions for emergency situations. The important thing is to have support (document !!!!) from your medical personnel about the serious potential results of the inmate’s refusal.

    My colleagues may disagree, but I would rather defend the case brought by the inmate complaining that we provided proper care (over his objection) than the case brought by the inmate’s estate complaining that we didn’t provide proper care.

    Reply
    1. Jeffrey Keller Post author

      Thanks again David! Excellent points all. I like your last comment so well, I’m going to post it again:

      “I would rather defend the case brought by the inmate complaining that we provided proper care (over his objection) than the case brought by the inmate’s estate complaining that we didn’t provide proper care.”

      Reply
  5. Dianne Ellington

    In our case it is different, the innate is on a work release program, His meals are never close to a balanced meal, they do not supply his meds, he has to bring his own,. He trust s no one with his meds so he takes them right before his return to jail nightly. Last night his blood sugar dropped to the point that he was shaking. Over 30 minutes later they supplied him with bread, peanut butter and a apple. This morning, his blood sugar was good at 6 am 129. He is supposed to be released at 8am, this is also when he takes his insulin they were late releasing him this morning, by 50 minutes his sugar was 273. Just do not understand this!

    Reply
    1. Jeffrey Keller MD Post author

      HI Dianne! I assume that this is a Type 1 diabetic, not Type 2? Type ones are very sensitive to the balance of insulin–carbohydrates. He should know how to count carbs so to not overdose or underdose his insulin. But it sounds like he does not do a very good job! If he is dosing himself when he is outside of your control, there is not much you can do but fix his mistake with food, as you did. Otherwise, it is up to him to manage his own disease!

      JeffK

      Reply
  6. Jade

    I am late but would you consider using a dexcom on the type 1’s? It is a CGM and the alerts get sent to a reciever, for those who refuse BSL checks (easy to put on can leave on for 7 days) theres an insulin pump called omnipod as well its tubeless (no strangulation hazard) and is controlled through a pdm that can be kept with a nurse (the reciever for dexcom can also be kept by the nurse) i am diabetic and use this system and it works well

    Omnipod needs to be changed every 3 days and dexcom every 7 days (you could do every 6 days to make it easiet) it would cut down on a lot of poking and prodding and it would mean the results would be sent to the nurse straight away (every 5 minutes it checks glucose)

    Reply

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