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[IP] Re: ADVANCE DIRECTIVE
Due to numerous requests, I will post the advance directive that was printed
in Diabetes Forcast. Ruth posted it but I don't remember the date.
The following was written by Edward Etkind, MD, Associate clinical professor
of medicine at Yale, published in Diabetes Forcast in July 1994.
To: Emergency Room Staff
This patient uses an insulin pump. The insulin pump delivers insulin in a
way that more closely mimics insulin release by a normally functioning
pancreas than does one or two injections a day. I matches the patient's
insulin needs as determined by history, blood glucose levels, food to be
eaten, and expected exercise. Normally, the patient checks his or her blood
glucose levels with a home glucose meter and adjusts insulin to maintain as
near normal blood glucose levels as possible.
Insulin is given in tow ways via the insulin pump:
- Basal rate: a continuous insulin infusion, the amount of insulin the
patient requires to maintain a normal metabolic state when not eating.
- Bolus: the insulin infused with each meal and snack. The patient is
taught to adjust this depending on blood glucose levels, food to be eaten,
and expected exercise.
1) Leave pump in place. Continue basal rate, even if the patient is unable
2) Allow the patient to test his or her own blood glucose levels with a
glucose meter and adjust bolus as he or she has been taught. Bolus will be
adjusted as follows:
under 70 one unit less
than usual dose
71-150 usual dose
151-200 +1 unit
201-250 + 2 units
251-300 + 4 units,
and change tubing
3) If patient is ketotic, it probably means that the pump is not functioning
properly or is blocked. Have the patient change the tubing and needle and
reinsert. Have the patient check his or her blood glucose levels every 2
hours and give bolus doses as above.
4) As noted previously, continue the basal rate if the patient is unable to
eat. Blood glucose levels should be checked, by a patient if possible, every
4 hours, and boluses adjusted as above.
- Do not discontinue pump without giving insulin by another means.
Otherwise, the patient will have no insulin and will develop ketoacidosis.
If the pump is discontinued, the patient will immediately need Regualr
- Blood glucose measurements used to determine bolus adjustments must be
current, It's much safer to make adjustments from the patient's readings than
to wait for blood glucose results from the lab. This patient has been
trained to do this, and routinely does it four times a day, so it is second
- The exceptions to this rule are: if there is a doubt about the patient's
ability perform intelligently or if there is concern about the accuracy of
the glucose meter.
- If the patient has an infection or is under stress, blood glucose levels
may go up. Continuing the basal dose and covering high blood glucose levels
with boluses is a reasonably save way of doing things.
Doctor's Phone Number_____________________
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Customer service phone number is:
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