Patient Centred, Team Based Collaborative Care

short-story-thumbsIt was the day I was to meet the extraordinary Betty, a 42 year old woman with two primary school children and a grown up son. Betty had Type 2 Diabetes Mellitus, the diagnosis coming many years earlier, and as I read over the past 2 years of entries in her file a very negative picture was emerging. There were many statements that Betty had refused all attempts to engage in self management, would not go to a diabetes educator, dietician, exercise physiologist, podiatrist or optometrist. Already classified as morbidly obese she was putting on weight, would not self monitor her blood glucose levels (BGL), refused to have blood tests and did not always attend scheduled appointments. That most disempowering term, non compliant, was repeatedly written in Betty’s file.

Oh how I wanted to run away, leave this place and escape this enormous responsibility. Instead, as many times before, I took a slow deep breath recalling my training days and the empathy, the compassion of the nuns who had taught me how to be a good nurse. The memories brought me to a smile and cleared the negativity from my mind. I made a conscious decision to approach Betty with an open mind and to connect with her, one step at a time.

I greeted Betty with a smile and introduced myself. Inviting her to step on the scales, which she did obligingly, I made note of this positive action. The measure was 135kgs but before I announced the reading I asked if her weight was stable? With shoulders and head held high, Betty proudly told me that she had lost 30kgs! I congratulated Betty on her great achievement as she explained how she had managed this by just moving more. But in the last twelve months Betty had put 5kgs back on. I listened attentively as Betty told of her life. She absolutely adored her 2 young children; they were her life, her reason for living. Betty spoke fondly of their schooling and mischievous nature, their laughter and their love. I enquired about her eldest son and noticed a subtle change in her body language, a slumping of the shoulders, loss of eye contact. With gentle probing Betty informed me her son’s partner was pregnant. I sensed something was wrong. We sat in silence for a while then I asked how she felt about this? The tears came streaming down as she disclosed that she was terrified for them because her first pregnancy, at 18 years of age, had resulted in a stillbirth, something that she had never spoken about.

This consultation had gone from happiness to deep sadness in a matter minutes. I had accomplished my goal and connected with Betty, but what now? Had I opened Pandora’s Box? Was she going to be safe to discharge? Were we ever going to talk about Diabetes, which was what the doctor wanted? We spent some time while I listened to Betty telling me about this horrendous event in her life that had impelled her to have her son, who lived in the city. Now she was in a newer relationship with young children and a hard working husband. Betty declined the offer of a counselling referral, saying she may come back to it at a later stage.

I asked permission to measure Betty’s BGL while she continued chatting. Finances were tight for the family and Betty could not afford a new battery for her glucose monitor that was very old. She did not have the money to prioritise her health and could not to see other health providers for this reason. The BGL was 23.8mmol/lt, 3 hours after breakfast which was just a cup of tea. Betty confided that she did not always have her bolus insulin because sometimes she forgot and didn’t always eat. An admission to hospital a year ago resulted from hyperglycaemia and the Endocrinologist had arranged for her to have a free gastric banding in the city. Betty had not followed this up as she didn’t want to leave her young children and her husband could not manage the time off work. She was ashamed of this and did not want to see the specialist again as he would be annoyed with her.

My head was swirling now and I was trying to sort out what could be the most significant problem to address as time was running out for this consultation. So I asked Betty what was her most important health concern. She said that her vision was blurry and this was worrying her. Unbeknown to Betty her response had opened the door for me to bring it all together. I explained how the high BGL was contributing to her blurred vision and if her blood glucose was normalised this could be reversed. This led onto her insulin and we discussed a regime that might be suitable for her as it was only two injections per day. Betty was confident she could commit to this. With this positive insight I pressed on and explained that Betty would need to see the Endocrinologist at the hospital to commence the regime. She did not want to do this due to the shame and importantly, Betty had a needle phobia and was scared of having the blood tests beforehand. How many barriers can one consultation highlight?

Living in a rural area has many benefits, including knowing most health professionals, and I had recently attended an update on diabetes by the Endocrinologist from the hospital who had discussed the said insulin regime. I had boldly asked a couple of questions and thought the specialist would talk to me over the phone so I confidently told Betty I would arrange an appointment without her having to do the blood tests. She smiled and agreed. I asked if she would measure her BGL before, after each meal, and at bedtime until she saw the specialist, if I was able to organise a new monitor for her at no cost. Again Betty smiled and agreed. I was intrigued at how positive Betty was with my suggestions, considering the notes in her file.

So the question now was, do I push on or take these achievements as enough for the day? Go for it I told myself, just do it! Sticking with the high BGL I discussed the effects of this on the nerve endings and how this could eventually lead to immobility or amputation and the impact this would have on her children. Betty told me how she wore shoes everyday because her feet had a burning feeling and this was preventing her from moving as much as she wanted. Being a contemporary nurse, I was aware that our Medicare Local had an excellent diabetes program that included free podiatry, but the gateway to this was an appointment with the dietician. Explaining the importance of podiatry and that a local appointment could be arranged at no cost to Betty I again saw her smile and agree. Left with the often hard sell of a dietician referral I pressed on informing Betty that we had a dietician who visited the practice and how changes to her insulin regime would necessitate changes to her nutrition. Betty was at first a little sceptical so I made it clear that dieticians no longer prescribed strict diets rather, they worked with the patient to develop eating plans that suited the client’s needs and tastes. I watched in anticipation as Betty thought this through and then she agreed on one condition, if I would be at the practice at the same time as the appointment. My answer was yes of course, lucky it was one of my work days, but I did inform her that I would be seeing other patients. Betty agreed with this arrangement.

Feeling a touch exhausted I asked Betty if she had anything else she would like to talk about and to my complete surprise she asked about having her eyes checked! I just wanted to jump out of my chair to give her a hug and tell her what a wonderful, intelligent woman she was. Instead, I congratulated her on this insight and discussed how this would be best after her BGL had normalised, in about a month.

So this consultation with the remarkable Betty had come to an end. I thanked her for coming and again passed on my praise for her achievements. I then walked with her to reception to arrange the podiatry and dietician appointments. Betty asked if she could see me again in another week and we arranged an appointment for when the blood glucose monitor would be available.

I now had so much paperwork and so many phone calls to make but importantly I needed to speak to the doctor. Sending a message noted as urgent, I asked if the doctor could kindly see me before consulting with Betty. Sadly, this did not occur and even though I had completed my notes before Betty’s consult with the doctor, all went horribly wrong. The doctor refused to give Betty a referral to the specialist unless she would have the blood tests. When Betty declined, the entry in her file noted that she continued to be non compliant.

Again, this consultation had gone from happiness to sadness in a matter of minutes. Returning to reception, Betty cancelled her appointments except the one with me. She informed the staff that she would not see that doctor again and declined to make an appointment with a different doctor. During the next few days I completed the miles of paperwork and referrals, made numerous phone calls, one of which was to the Endocrinologist who agreed to see Betty without the blood tests. I carefully choose another doctor, a compassionate and empathetic one, who agreed to see Betty and would join the next consult with her in my room. I contacted Betty and listened to her distress, apologising for what she had experienced and encouraged her to return.

The monitor arrived and Betty came back the next week. We recapped our previous appointment and when the doctor joined us I informed him how Betty had lost 30kg. He congratulated her on this wonderful achievement and discussed options for ongoing care. The consultation ended with Betty agreeing to all of the referrals. Another connection ensued, this time between Betty and the doctor, and she now had a primary health care team. Over the next few months Betty’s BGL normalised on the new insulin regime, her vision cleared and optometry review revealed no retinopathy. The burning in her feet had subsided and she was moving more again, leading to further weight loss. Betty did eventually have the blood tests as arranged by the specialist at no cost to her and with, in his expert opinion, the best phlebotomist he had ever known. It still brings me to a smile thinking about that. Oh and I almost forgot, Betty is now the proud grandmother of a beautiful, healthy baby boy.

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