Type 2 diabetes

“If it was serious wouldn’t I need injections?”

Alan is a 58-year-old bus driver in a small company. He has always had relatively good health. He hates going to the doctor, as he thinks it costs far too much and ‘you always get better eventually anyway’. Recently he has noticed that he seems to be thirsty more than usual, he drinks a lot more fluids than usual. He is going to the toilet to urinate a lot more often. He feels tired more often than usual, but has put that down to getting older.

Alan reports eating three meals a day, with the largest being his evening meal after work. But sometimes he skips lunch due to traffic delays. He does not ‘watch what he eats’ and has never been on a diet. He has a BMI of 33, although he thinks he has lost quite a bit of weight lately. His waist circumference is 41 inches. He often reports simply going to MacDonald’s for chips and burgers for dinner, especially after he has been drinking. He reports drinking about 12 pints of beer a week, mostly at the weekends. He does not exercise regularly as he thinks he gets enough exercise in work, and the weather is ‘not suitable for too much walking’.

Recently, his eyesight has not been as good as before – his vision is a little blurry sometimes, but he put this down to tiredness. He is thinking of getting glasses. His family doctor (general practitioner) is concerned about Alan’s symptoms, and decides to run some tests. Results are as follows:

Blood pressure = 145/95; HbA1C = 13.4%; Fasting plasma glucose (FPG) test = 7.1mmol/l; Total cholesterol = 6.7 mmol/l

Based on these results, Alan’s doctor recommends major lifestyle changes for Alan, as relevant to Type 2 diabetes. The doctor also prescribes medication which, along with the lifestyle changes, should keep the diabetes under control and preclude the need for insulin injections.

Social circumstances
Alan has been married for over 25 years. He and his wife both smoke, ‘around 10 a day, but more when we’re out’. His wife was recently diagnosed with anxiety and depression and is taking medication for this. Sometimes Alan feels ‘down’, so much so that sometimes he calls in sick to work, but he has never sought any treatment for this. He had always wanted to retire at 60, but now he is not so sure. He reports having a good social life.

Ethical considerations
Alan hates the thought of taking medication, but thinks it might be ok for a few weeks so he can ‘get rid of the problem’. He thinks that medication is bad for you in the long run and is thinking about using alternative therapies. He does not see the point in checking his glucose three times a day, and intends to do this only in the evenings. His family doctor asks both he and his wife to attend for an appointment and asks his wife to help Alan with his glucose monitoring. Alan resents this and feels that he is being treated like a child. The doctor advises them both to give up smoking, but Alan doesn’t think this has anything to do with diabetes. Alan does not believe he has diabetes, as none of his family have had the condition. Isn’t diabetes something you have to take injections for? He feels very scared when he is told about the potential complications of diabetes, and is particularly fearful at the thought of going blind. Alan thinks that a few weeks of medication should cure what he has, and hopes that after this he can stop taking it.
The following questions are to guide your literature searching and team discussions only. The project report should be written in essay format and should address each section (Social, Ethical etc) in a coherent way but not in a question and answer format of the points included here.

Problem specification:
• What are the clinical presentations and diagnostic criteria for type 2 diabetes?
• How is type 2 diabetes detected? What are the risks for those who have above normal blood glucose levels, but do not fit the criteria for type 2 diabetes?
• What are the most important things that Alan should do, and why? What education interventions are needed to achieve these goals? How often does Alan need to assess his blood glucose?
• How would you deal with Alan’s opinions of diabetes and how it is treated? How could you allay Alan’s fears of going blind? What are the most important things for Alan to understand, and why?
• Would you refer Alan to healthcare professionals other than his family doctor – who, and how often?
• Does Alan ‘feeling down sometimes’ have any implications for your joint management plan?
• Does type 2 diabetes confer increased risk of other diseases in the future?
• How should Alan’s progress be monitored? How often should Alan visit his doctor? How do you think Alan will take this advice? What should Alan do if he notices a raised blood glucose level?
• What are the symptoms of hypoglycaemia and hyperglycaemia? Differentiate between mild and severe.

Societal context:
• Approximately how many people are diagnosed with type 2 diabetes each year in this country? How many patients currently have type 2 diabetes in this country? How does this compare to one other country (choose a country)?
• Does living with a wife who has mixed anxiety-depression alter your concerns about him as a patient? Do you think that having a good social life is relevant for Alan in this instance? Does this have any implications for Alan’s smoking?

Healthcare context and patient safety:
• What is the current best practice in treating and managing type 2diabetes?
• The implications of not managing diabetes can be severe for the patient.From a patient safety point of view, how can the doctor ensure appropriate management of Alan’s condition?
• How does poor management of type 2 diabetes impact on the health services?
• What is the cost of type 2 diabetes to the health services?

Ethics:
• It is clear that Alan does not fully understand his condition. What is the implication of this for Alan and for his doctor?
• Comment on the implications of involving Alan’s wife in the management of his condition.
• It could be argued that Alan’s condition is largely self-inflicted. Should treatment be influenced by the cause of the condition?
• Is it likely that Alan will be non-adherent to medication? Are there any ethical issues with prescribing medication to someone who may not adhere to it?

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