Case Study: A 46-Year-Old Man With a 15-Year History of Type 1 Diabetes Who Died of Diabetic Ketoacidosis
His wife provided a history of the days leading up to his death. On Friday (Day 1), he ate dinner out at an unfamiliar restaurant. He became ill that evening with vomiting. Although she ate the same food, his wife did not become ill. He omitted his bedtime injection of insulin because he had not kept down any food. He continued vomiting Saturday (Day 2) and Sunday (Day 3), again omitting all insulin injections because he had not kept down any food.
During this time, his wife encouraged him to see, or at least to call, his physician, but he declined. He did not measure his blood glucose level because he had left his meter at work. He did not measure urine ketones because he had never been instructed to do so. His wife discovered him unresponsive on Monday morning (Day 4). His wife stated that they had learned about diabetes when he was initially diagnosed, but had not had any diabetes education since.
At autopsy, his vitreous glucose level was 627 mg/dl and vitreous ketone level was 37 mg/dl. (Vitreous humor is used for postmortem determinations of glucose, ketones, and other analytes, and the results correlate with premortem levels.) He was also found to have severe three-vessel coronary artery atherosclerosis and early diabetic nephropathy. Based on these findings, his death was attributed to diabetic ketoacidosis (DKA).
The primary care physician (PCP) who had followed this patient for 6 years provided a history of a noncompliant patient who had chronic poor control as evidenced by a recent HbA1c level of 14.9% (normal <6.3%). The patient's most recent insulin dose was 18 U of NPH and 4 U of regular insulin in the morning and 22 U of NPH at bedtime. His height was 5'10" and weight was 185 lb. Therefore, his insulin dose was ~0.52 U/kg body wt/day. He had been referred to an ophthalmologist but not to an endocrinologist or diabetes educator.
The PCP provided medical records that failed to document assessment of or provision of diabetes self-management education. There was no flow sheet. The patient had had 18 office visits over the past 6 years, but only two HbA1c levels (12 and 14.9%) were recorded, and there were no recorded tests for microalbuminuria. Most of the recorded physician visits centered around his problems at work, osteoarthritis from a motorcycle accident, and notations describing an absence of insulin reactions.
The deceased was a member of a large national health maintenance organization that provides PCPs with a yearly capitation rate for their members. Costs of education and referrals to specialists are applied directly to the capitation rate.
Among the most common causes of DKA is incorrect self-management during illness.1 Unless educated in self-management, patients who are unable to eat or drink or to keep food down often omit insulin in fear of hypoglycemia. Unbeknownst to these patients, factors other than food are elevating the blood glucose level and making insulin less effective and acidosis more likely. In this particular patient, the chronic poor glycemic control made insulin omission more alarming and its metabolic consequences probably more critical.
Educating people with type 1 diabetes about self-management around illness is most appropriate when taught before an illness occurs. Including a spouse, parents, or supportive others may prove critical to preventing hospitalization (and death) from DKA. Understanding the need for more frequent monitoring of blood glucose and ketones is crucial and must be taught in the context of the special effect of illness on diabetes control. Individually wrapped Ketostix that do not expire are a must for people with type 1 diabetes to have at home.
In patients with type 2 diabetes, education about diabetes self-management around illness is also crucial. Presumably, sufficient endogenous insulin is able to prevent lipolysis and ketogenesis, but will not prevent hyperglycemia when a patient is ill.
People with type 2 diabetes are at risk for hyperglycemic hyperosmolar nonketotic syndrome (HNKS), a life-threatening condition when illness is not treated and blood glucose is not controlled. HNKS is marked by the absence of ketosis and acidosis but is manifested by blood glucose levels between 600 and 2,000 mg/dl. Patients with type 2 diabetes who have poor fluid intake are more likely to get HNKS. When unable to keep down oral hypoglycemic medication because of an intercurrent illness, these patients may need supplementary regular insulin injections to control their blood glucose.2
The accompanying Patient Information page shows frequently taught guidelines for people with diabetes (type 1 or 2) to follow when ill.1,3,4 Children or infants with type 1 diabetes present a special challenge. Sick-day education reinforced before an illness occurs and an on-call diabetes educator or physician prevent many hospitalizations for DKA. Special guidelines for this age-group may be helpful.5
The American Diabetes Association (ADA) position statement "Standards of Medical Care for Patients with Diabetes Mellitus" is published each year in a supplement to the journal Diabetes Care and is also available on the ADA website (www.diabetes.org/diabetescare). It states that "diabetes is a chronic disease that requires continuing medical care and education to prevent acute complications and to reduce the risk of long-term complications."6
Four topics pertinent to this case are stressed in the Standards of Care. First, a comprehensive assessment of self-management knowledge should be performed, and areas of weakness should be identified. Second, instruction on the prevention and treatment of acute complications (DKA and hypoglycemia) is a part of medical management. Third, if resources (i.e., time) are insufficient to carry out these goals of educating patients and their families in self-management, referral to a diabetes care team for consultation or comanagement is recommended. Fourth, a flow sheet is recommended to keep track of medical tests as well as assessment, provision, and reinforcement of educational needs for self-management.
Although many PCPs may not have time to provide diabetes education, there are available tools that can help. The National Diabetes Education Program, a joint project of the National Institute for Diabetes and Digestive and Kidney Diseases and the Centers for Disease Control and Prevention, provides educational handouts for patients with diabetes to be used in PCP offices (1-800-438-5383; http://ndep.nih.gov/). However, it is clear that handouts are not as effective alone as they are when combined with physician or diabetes educator teaching.
The ADA's Diabetes Forecast magazine is an excellent vehicle for keeping patients educated and informed and comes with a minimal membership fee. In addition, many books and newsletters are written for people with diabetes. Certified diabetes educators can usually be found in hospital-based settings and can comanage or provide the educational component for self-management.
How can outcomes like this be prevented? Clearly, a lack of education, a component of medical management, led to this patient's death. In this case, the health management organization offers capitated care, which means that physicians either provide the education themselves or in their office or pay for the education to be provided elsewhere. It is possible that this manner of payment provided a disincentive to offering education. The omission of the necessary education probably constitutes medical negligence, and, if proven to have been a direct cause of death, the family has a legal cause of action against the medical provider and the insurance company.
In Colorado, the state health department records the number of deaths from DKA but does not explore the contributing factors. How many poor outcomes can be attributed to the lack of provision of education? We simply do not know.
When physicians agree to go at risk for patients with diabetes, do they realize that they also agree to provide self-management educationa difficult task when most physicians do not have the time and are not compensated for such activities? To us, this case reflects one of the major disadvantages of the capitation system.
1American Diabetes Association. Diabetic ketoacidosis. In Medical Management of Insulin-Dependent (Type 1) Diabetes. 2nd ed. Alexandria, Va., American Diabetes Association, 1994, p. 76-77.
2American Association of Diabetes Educators: A Core Curriculum for Diabetes Education. 2nd ed. Chicago, American Association of Diabetes Educators, 1996, p. 164.
3Davidson MB: Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Los Angeles, W.B. Saunders, p. 71.
4Lowe E, Arsham G: Diabetes: A Guide to Living Well. Minneapolis, Minn., Chronimed Publishing, 1997, p.339-41.
5Chase HP: Understanding Insulin-Dependent Diabetes. 9th ed. Denver, Colo., The Children's Diabetes Foundation Guild, 1999, chapter 15. (A copy can be purchased by sending $15 to: The Guild of the Children's Diabetes Foundation, 777 Grant St., Suite 302, Denver, CO 80203, or by calling 1-800-695-2873.)
6American Diabetes Association: Standards of medical care for patients with diabetes mellitus (Position Statement). Diabetes Care 23 (Suppl 1):S32-42, 2000.
Deborah Thomas-Dobersen, RD, MS, CDE, is in private practice, and Michael J. Dobersen, MD, PhD, is a forensic pathologist at the Arapahoe County Coroner's Office, in Littleton, Colo.
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