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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 
to eat.

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:

        Glucose             Bolus

        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.

Patient's Name___________________________
Doctor's Name____________________________ 
Doctor's Address__________________________
Doctor's Phone Number_____________________
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