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Is there a time when the pump should be taken away?

Discussion in 'Parents of Teens' started by misscaitp, Dec 22, 2012.

  1. misscaitp

    misscaitp Approved members

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    I tend to have two views on this subject. And I'm just wondering about the perspective of others.

    The first one being, and seems to have made sense during my rough periods, that if I will not complete task such as testing and bolusing on the pump why would I do it on shots. Just because the pump simplifies all the processes that it would take having shots (calculating and actually drawing up the insulin). So with that perspective it makes no sense to remove the pump. And it leads to the question, what are you going to do if the person doesn't comply with shots?

    But then I start to think about the other diabetics that I knew in high school and realize that there are certain grounds on which a pump is not in the best interest. Mainly, if the PWD is not testing and the pump malfunctions/bad site how would the PWD ever know before it reached the point of vomiting, large ketones, DKA, and ER visits? Maybe after seeing peers go into DKA because of carelessness regarding to diabetes task, once on the pump, I have formed this perspective.

    But is there a time where you would support an endo's or CDE's threat to remove them from a pump? What behavior would warrant such a decision?
     
  2. Sarah Maddie's Mom

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    In my experience, 7+ years pumping, pumps don't "malfunction". Do sites get left in too long? sure but that's the users fault not the pumps.

    I can see NO value whatsoever in "taking a pump away" because the pumper has poor control. Poor control means that the basal rates are wrong, that the carb ratio is off, that the user isn't bolusing or is underbolusing for carbs. Not one of those things will be fixed by going back on injections. So, no... I don't ever, ever see the pump as some sort of prize that should be taken away and whenever I hear this suggested I assume that the person suggesting it is a moron.
     
  3. Kimby

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    I can't imagine ever taking Andrew's pump away. What I think the thought is though, is that there is a "depot effect" with Lantus and there is less chance of DKA in someone taking Lantus than solely on short-acting insulin. We have had sites go bad, and Andrew will get ketones within hours. He didn't run ketones ever on shots, but that may have been just because we switched to a pump at the end of his first year. Maybe a compromise might be to reduce basals, give a supervised Lantus shot for the missing basal, and continue using the pump?
     
  4. sarahspins

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    I'm glad you've never experienced it but I went through a stretch for about 6 months where I couldn't get a single site to last more than 24 hours due to allergy issues - they would get very irritated quickly (itchy, VERY swollen) and I would get insulin leaking back out the site along the cannula. I know a lot of people "say" it isn't possible but let me assure you that it can and does happen. My CDE and endo had never seen it as bad as it was with me. They even sent me to an allergist who in his infinite wisdom recommended I no longer use analog insulins (advice my endo and I chose to ignore, FWIW, though I did try pumping regular and even U-500 for a while to see if the reduced volume of insulin would help, and it didn't, since ultimately it turned out that I just can't use any teflon sets any more).

    My control over that time was terrible, and not because of lack of bolusing or because my basals were wrong, but because the boluses often just didn't do anything and I was constantly correcting highs because of the leaking insulin. Even going untethered to eliminate the very real risk of DKA due to lack of basal, I struggled to have reliable post-meal numbers. I did go back on MDI for a while just to get things under control because it was easier than dreading when my site would fail again. It took a lot of trial and error switching insulins and infusion sets to figure out what would work. I wasn't forced back to MDI by my doctor, it was my choice - there was not a single point where my doctor suggested I give up on my pump or that I shouldn't keep trying, I was just fed up and MDI was more reliable at the time. I still take a break from my pump now and then when I am having repeated site issues (which can range from them just not sticking to patterns of questionable numbers - sometimes it's just nice to take a break and know for sure the insulin is getting in)... but it's my choice and I like that I have that choice.
     
  5. Sarah Maddie's Mom

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    Sarah, that sounds awful! But I don't know that I'd call what you experienced a , "pump malfunction".
     
  6. kiwikid

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    I can see that if a child isn't bolusing through a school day, that it might be nice to have an insulin that supposedly peaks around lunchtime. Rachel is going through a stage where she Isn't doing tasks she should and if I could simplify her day by letting her just eat and carry on it might be useful? Not as good a control maybe but better than nothing? I wouldn't take away the pump as a punishment though - more as a solution..
     
  7. nanhsot

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    No. My son's endo threatened that and quite simply we never went back. a) *I* own the pump, not the endo. She can threaten to quit writing the rx for supplies but that one really got my blood boiling.
    b) A pump is no better or worse for creating compliance. Short of forcibly giving shots (which I can't imagine doing on my 200+# teen!), how is it a better compliance issue to be on shot? If they can't be bothered to punch a few buttons what will make them more willing to draw up insulin and give a shot?

    Anyway, short answer is no, long answer is the delivery system is not at fault when you are dealing with non compliance. When my kids were little I didn't "punish" per se, I let natural consequences occur. Same deal here. Not handling their boluses or testing means mom has to take over for a while.

    If I were worried about ketones I would lower the basal delivery in the pump and add lantus to the mix.

    Depending on age of kid would alter how I'd approach it, with my teen I would work with him to figure out why compliance was an issue. My son's endo threatened to take away his pump because he doesn't like to enter his BG or carbs into it, he just enters the insulin needed after he figures it in his head. His A1C is good and he has no compliance issue so it was a stupid threat, more about her ego than anything IMO. We fired her. Threatening teens is not a way to gain their trust.
     
  8. TheFormerLantusFiend

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    If I had a child I didn't trust to administer insulin, and who was pushing buttons and bolusing kind of randomly and/or on purpose to induce a low, that'd be pretty clear grounds to say no to the pump. I can imagine this happening primarily with a mentally ill child (I have a brother with mental illness that I can very easily imagine would do this).

    If I was responsible for a person whose behavior on a pump would lead to a high DKA risk, I would assume that the same behavior would lead to a high DKA risk with shots. I would be more inclined to add a shot of an intermediate or long acting insulin, and not take the pump away, if the person particularly liked using a pump. I would also see this as a pretty good reason to step in to assist with a lot of the diabetes management.

    To be honest, I think the bigger issue is with adults, and I very much sympathize with endos or other doctors who won't write letters of medical necessity for pumps when their patients have been "using" the pump in such a way that they are getting no better blood sugars than they would be on shots. Pumps are expensive. If you're paying for it out of pocket, great, then clearly you really see a value to pumping and I don't see any reason why anybody should be able to stop you.
    If you are not paying out of pocket, and wouldn't be willing to pay out of pocket if you had exactly that much additional income, then I don't think you should be asking insurance to pay for your pumping (I have the same feelings on all medical treatments that are more expensive than alternatives, btw).
    If I was a doctor with a patient who had this expensive tool and was very clearly not using it, I would feel dishonest writing a letter of medical necessity to an insurance company claiming that this patient really was going to benefit from a pump.
    If you are paying out of pocket or your insurance doesn't require a letter of medical necessity because they really believe in pumping, then I don't see the same ethical issue for the doctor.
     
  9. misscaitp

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    I was also thinking of the ethical and liability issue the doctor may face when "threatening". Also I agree with the safety issue and mental illness.

    Maybe part of the issue is that often the "threat" is issued, but there is no explanation on the part of the endo or CDE of why they feel removal of the pump would be necessary and what would change through being on shots.
     

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