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Where has the Hippocratic Oath Gone to? Read this!

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13 December 2005

Where has the Hippocratic Oath Gone to? Read this!

Red State Moron is obviously an Obstetrician. Read this post from 10th December....(click on title above to see link)

I have sympathy about Red State Moron's ethical dilemma about the "non-compliant" diabetic woman who is 24 months pregnant. I think the concerns are valid. But I am also sympathetic to the woman with diabetes. Where is her Physician (GP), Diabetologist or Endocrinologist? Why is she out there drowning on her own? What is her medical history? Why isn't "Red Moron" collaborating with other specialists?

She refuses to engage with her diabetes management. She refuses to see a therapist, and all our attempts to connect with her are also refused.

Something is clearly wrong. Normally it is difficult to be rational with a A1c of 12 - has this been considered? Along with the obvious issues of patient denial, I think the healthcare system has failed her completely.

Additionally, there is something off about the comments made to this post. Are these really medical professionals? Did I miss something in the Hippocratic oath?

Not to teach medicine to other people.
To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them.
To avoid violating the morals of my community.
To keep confidential what I learn about my patients.
To keep the good of the patient as the highest priority.
To avoid attempting to do things that other specialists can do better.


There seems to be something numb and diseased about this chat the doctors(?) are having. I love the comparison of the cocaine addict to the diabetic --- that is priceless! Scroll down a bit to read this:

Interesting, and difficult dilemma. to play the devil's advocate, what would be your options if you had clear evidence a patient was, say, a daily cocaine abuser and 24 weeks along? The risks to the baby, while in specifics may be different, are the same in the long haul. I don't envy you in this situation; good luck.
Written by Aggravated DocSurg

or
When my patients refuses to follow my advice, the important thing for me is to document her refusal. Apart from that, she is an autonomous human being and is by law (at least in my country) entitled to do whatever she wants. As for doing a C-section on a diabetic in 24th week of pregnancy after the kind of intrauterine environment you have described; I would not do that. There are worse things than dying.
Written by My Opera

Can someone call a doctor...?

7 Comments:

Anonymous Tom said...

Elizabeth;
A couple of comments. Yes, I am an obstetrician. I am also a subspecialist in Maternal-Fetal medicine. I, too, am very sympathetic to this young woman with diabetes. That is way I am trying to engage her in the care of her diabetes. There are many other physicians, nurses, diabetic educators, and social workers involved with her case. Many resources are being tried. I disagree that her elevated hemoglobin A1c makes her not rational. Yes, she is in denial, but how are we failing her? Please be specific. Generalities do not help. She is not being "compared" to a woman using cocaine. I encourage you to read the post again. There is a law in my state that allows for the hospitalization of a pregnant woman against her will if she is using illicit drugs or alcohol, and refuses help. Clearly persistent hyperglycemia can result in adverse outcome for the fetus/baby, including still birth. Unlike most physicians, I have responsibility to both the pregnant woman and her unborn baby/fetus. As the fetus can now survive outside the uterus, the clinical question is whether or not I proceed with delivery (at this gestational age not really a good option), expectant management (and risk still birth), or hospitalization against her will. Perhaps you can provide some insight (as a patient yourself with diabetes) as to what I may do to help this young woman who is placing herself, and her fetus/unborn baby at risk. I hope I have addresses your questions and concerns.

10:18 PM  
Blogger Elizabeth Snouffer said...

Good to hear from you.
The issue I had was to many of the doctors whose feedback to your dilemma I found questionable. And two of the doctors who commented sited meth addicts and a hypothetical cocaine addict as analogous to your dilemma with the noncompliant diabetic...
Moving onward...This is not an easy case, no doubt.
With very little to go on the profile of your patient, (ie, education, economic background, age), it is difficult for me to know what I can offer. But here are a few suggestions:
1. Build trust. Ask her what is most difficult about taking insulin? For example, ask her what is worse - taking her finger sticks or injections? Just listen, and ask questions without judging, then work back from there. Perhaps there are ways to negotiate her activities. One small change may lead her along a continuum that may lead to other behaviour changes.
2.Perhaps she never had the chance to express her feelings about diabetes (being diagnosed at such an early age); she may need to express that grief. Pregnancy is another life-altering stage and while it isn't an ideal time to confront loss of an earlier period, there may not be a choice.
3. Perhaps she has never experienced anything positive with health care providers and her diabetes management. Is her experience with her pregnancy similiar? It can all become just a self-fulfilling phophecy. Failure is just expected. Is there one thing that she is doing that is remotely successful? Re-inforce something. Perhaps her trust in just one person is all she may need before she is able to allow/accept/commit to the changes you are suggesting.
4. Scare tactics don't work. Threatening her with the death of her baby probably won't work either in that she may have heard those threats before with her own illness. It is so insidious and reckless, but she is rebeling. The rebellion is not against you, but something to do with herself, and my guess is that it may be very deep.
Lastly, an HbA1c of 12 can make a person belligerent, irrationale and just plain difficult - but confirm this with your diabetes specialist on staff.
These are just my thoughts. Please keep in touch and let me know how it all goes.

11:48 PM  
Anonymous tom said...

Thank you for your thoughts and suggestions. I will share these ideas with the other physicians and staff. And I will stay in touch. Thank you again.

2:32 AM  
Blogger Aggravated DocSurg said...

I'm happy to be quoted, but actually my quote was the former, not the latter, of the last two excerpts from Dr. Wigton's site. My point was that this patient presents a difficult ethical and medical dilemma -- her actions presently harm not only herself, but her unborn child. The "cocaine abuser" scenario is thrown into the mix only to illustrate the dangers she poses to her child.

3:13 AM  
Blogger Elizabeth Snouffer said...

Dear Aggravated Docsurg,
I fixed that.
Thanks.
Elizabeth

10:30 AM  
Anonymous AmyT said...

Hi Elizabeth,
I just discovered your blog, and it is very thoughtful and thought-provoking.

Have you found me yet at www.diabetesmine.com?

It seems we have a lot in common. I too have over a decade experience in professional communications work, also married with children.

I'm adding you to my blogroll, and would be very pleased if you would do the same. Would you also post an email address, so readers can get in touch with you "off-line"?

Thanks & welcome to the blogosphere!
- AmyT

10:36 AM  
Blogger Megan said...

The way doctors deal with diabetes amazes me sometimes. I really dislike my endocrinologist. I wish there were doctors that cared more about the person than the disease, and didn't blame us everytime something went wrong.

4:31 AM  

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