VOLUME 9 NUMBER 4 • NOVEMBER 2012
185
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REPORT
mia risk; and patients hate severe hypo-
glycaemia.’
Most patients however do not reach
optimal targets. Only a small minority
achieve protective HbA
1
c
levels, with as
many as 80% exposed to long-term compli-
cations. ‘Type 1 diabetes requires a lifelong
effort. It never gets better. Patients never
get time off. Who can sustain the effort
required? For most patients, intensive insu-
lin management is just too difficult, and the
technology isn’t good enough. Relative to
the body’s natural insulin response to food
intake, injected insulin kicks in too late and
hangs around too long.’
As a result patients tend to ‘choose’
their own HbA
1
c
level, one that reflects
their lifestyle and psychology. This wide
spectrum in glycaemic control probably
reflects the normal spectrum of psychologi-
cal make-up in the population. However, it
causes healthcare professionals immense
frustration.
Prof Dayan underscored that when con-
fronted with these patients whose HbA
1
c
levels are consistently above 10%, health-
care professionals are stepping into what
is largely an ‘evidence-free zone’, as these
patients are rarely included in clinical trials
and lie outside almost all guidelines.
Prof Dayan describes these patients as
having ‘extreme diabetes’. ‘You’ll therefore
be relying on your wits and taking risks
when you manage them’, he said.
There are different phases of risk, rang-
ing from complication-free, through early
complications, severe complications, auto-
nomic neuropathy, to cardiovascular dis-
ease. Diabetic keto-acidosis and severe
sepsis need to be taken into account
throughout the continuum. ‘Some patients
have a Damascus moment in respect of
taking ownership and control of their dia-
betes, but it happens at different stages for
different patients. You need to be there for
that moment.’
He outlined the following management
principles:
Understand the person.
•
Understand their drivers.
•
Stay with them and keep communi-
•
cating. Remember this is a long-term
therapeutic relationship, maybe 20–30
years. It’s important to control your
own frustrations.
Be creative. There is no track to follow,
•
so use your own sense, understanding
and clinical skills to consider creative
alternatives outside the guidelines. This
is an opportunity to apply your deepest
understanding of the pathophysiology
of microvascular complications and the
patient/carer relationship.
It’s never too late. Until they actually
•
die, you can improve their quality of
life. Don’t give up trying.
Underpinning all of this should be uncondi-
tional positive regard (UPR) for the patient.
‘
Never forget that they have other prob-
lems and issues in their lives. It’s important
to believe that they’re doing their best,
and not to criticise them. They know when
they’re doing badly, criticism only makes
things worse and adds to their stress.’
It is necessary to ascertain the truth in
respect of insulin compliance, testing fre-
quency and attitudes to diabetes. ‘You only
get one chance, which means that your
approach here is critical. Sometimes, 20 years
after diagnosis, you’ll find patients who still
haven’t accepted their diabetes and remain
furious. Use UPR to ascertain each individual
patient’s drivers for change.’
Prof Dayan feels one should deal with
the greatest and most accessible risk first.
He warns that the onset of complications
can be explosive and often they come all at
once. ‘It’s also important to address what’s
major for the patient, even if it seems
minor to you and appears to miss the point.
Always be aware too that these are people
on the edge and that some of them are in
grave danger of falling off.’
The Ascending Star lecture:
Through the looking glass
Sr Madelein Young, Diabetes specialist
nurse, Centre for Diabetes, Witbank
Empathy and reflec-
tion are critical when
managing patients
with diabetes, and
healthcare profes-
sionals have lim-
ited time in which
to interact and get
them thinking and
learning about their
condition. ‘Patients
spend 1% of their
time with us and
the other 99% managing their diabetes on
their own’, cautioned Sr Young.
Learning can be seen as both an
active and a reflective process. It is often
subconscious. Reflection is a form of
mental processing, the vehicle for problem
solving, allowing one to identify patterns
and develop higher-order thinking skills,
which lead to holistic growth. Experiential
learning is an on-going cyclical process,
acquired through life and work experience.
It allows the incorporation of new knowl-
edge and enables the recollection and uti-
lisation of the information in the future.
‘
Many different life experiences can be
useful in diabetes’, she said.
All three of these play a part in effec-
tive communication and interaction with
patients, as every single day both patient
and healthcare professional are in different
stages of change. ‘It’s therefore important
to know that your patient is well and in
which stage they are regarding specific sit-
uations. Patients need to be valued for who
they are; they need acceptance, love and
understanding. We are not their superiors.
Many healthcare professionals adopt an
“
I’m right, you’re wrong” approach, which
does not allow for constructive engage-
ment. Our patients need to understand
fully what’s going on with their health, so
we have to impart knowledge with empa-
thy and gain their trust and respect.’
There are various stages of learning that
deepen gradually. These are:
noticing
•
making sense
•
making meaning
•
working with meaning
•
transformative learning.
•
‘
We need to reflect constantly on how we
interact. As healthcare professionals, we
often recite to patients what they need to
know and do, forcing education on them.
Then we turn around and tell them they’re
not good enough when things don’t go our
way, becoming angry, irritated and frus-
trated. We need to remember always to
treat them with respect and give them time
to process and assimilate the information.’
Reflection allows that time, enabling one
to think in more detail about complex issues
that have no immediately obvious solution.
It allows for the identification and question-
ing of underlying beliefs and values, better
understanding of patients’ strengths and
weaknesses, acknowledgment of fears,
the challenging of assumptions and the
identification of areas for improvement. ‘By
being reflective, we build up expertise in
practice’, continued Sr Young.
‘
Reflection provides the right conditions
for learning – so teach your patients to do it
too. And, importantly, ask their permission.
Give them the opportunity to voice their
opinions and don’t just make decisions for
them. Never forget that you’re dealing with
Sr Madelein Young
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