Ms Smith is a 62-year-old African American with a 6-year history of type 2 diabetes. Her current medication is metformin 1000 mg twice daily and glimepiride 2 mg once daily with breakfast. She has several comorbidities, including hypertension, dyslipidemia, background retinopathy, and decreased sensation in her feet. At her last office visit, her A1C was 9.2% and her BMI was 36. She has a strong family history of type 2 diabetes. Her father died of cardiovascular disease at age 67. Her primary care physician has encouraged lifestyle changes to promote weight loss and increase activity. Ms Smith has 3 children and is on permanent disability from a job-related injury. She has private medical insurance from her previous employer as well as Medicare coverage part B.
Eighteen months earlier, her physician had broached the subject of the need for her to start insulin therapy. Ms Smith has been reluctant to start what she referred to as “the big needle,” citing a fear of syringes and an inability to self-inject; however, she did agree to see the CDE at the local hospital. The physician completed the referral, citing the indication for individual one-on-one instruction due to cognitive impairment.
The following week the CDE saw Ms Smith, who suspected that her physician had instructed the CDE to talk her into giving herself “the shot,” which she reported she was not going to do. The CDE explained that this was not the purpose of the visit and clarified that at this time she simply wanted to do an assessment. However, the CDE was interested in why Ms Smith was so averse to insulin. Ms Smith explained that she already “knew what happened when you went on insulin,” as it had happened to both of her parents. She said, “You just get worse.” Her mother had started insulin at around the same age as Ms Smith is now. Within 1 year she had a below-the-knee amputation and needed laser therapy. She is now confined to a wheelchair, in need of constant care. As soon as her father started insulin, he died of a heart attack. Ms Smith said that she knew that insulin had done this and was never going to take “that big needle.”
The CDE stopped her assessment at that point and explained that although her parents did go through a course that was unfortunately typical of many people who had diabetes at that time, she had an obligation to explain the reality of the situation and how lack of control of blood glucose played a part in undesired outcomes. Ms Smith listened very carefully and decided she would return for another visit.
At the next visit, the CDE showed Ms Smith some of the current devices for treating diabetes, including a blood glucose meter that required less blood, as well as a pen with short, thin needles for injecting insulin. Ms Smith was amazed at how small the needle was and agreed to try it. To demonstrate the relative ease of self-injection, the CDE drew a saline solution into a syringe that was the same size as one of the pen devices. Ms Smith very softly stated that she believed she could do that if the CDE thought it would help her. The CDE supported Ms Smith in her decision, received the order and prescriptions from the physician, and started Ms Smith on insulin therapy.
Ms Smith was able to start group classes the following month. She received education in the 10 content areas of an ADA ERP and was encouraged to call the physician’s office to report her blood sugars to help with the insulin and oral agent adjustment. She returned to her physician the following month, 6 weeks after the start of insulin. Her A1C on follow-up was 8.1%. Her BMI was the same, although she was getting some exercise by taking a walk with her daughter every other day. To ensure that she would not become discouraged, the CDE explained to Ms Smith that although she did not lose weight, her blood sugar was under better control. She was referred to the dietitian for continued support on MNT as recommended by the CDE.
