Tuesday, September 17, 2013

Time Bomb

Time slips by quietly until you are almost 18 years old. It seems like everyone counts down the days until that big milestone. And when it arrives, you instantly morph from child to (young) adult.

At least in the eyes of the law.

The day a child turns 18 can be bittersweet for pediatric physicians. Graduating a patient from the practice can be difficult to do if a close rapport has been established over many years, or it can be difficult for many other reasons.

Not long ago I treated a patient admitted to the pediatric intensive care unit for diabetic ketoacidosis, but was not familiar with him as he was followed elsewhere for his routine outpatient diabetes care. I looked at the long list of visits that filled his hospital chart and was appalled – in the 4 years since he had been diagnosed with Type 1 Diabetes he had been admitted a handful of times for DKA and had over 10 documented hypoglycemic seizures. There were notes about his ongoing refusal to partake in treatment with psychology or psychiatry despite his family’s pleas and how he would become combative and strong-arm his way out of the hospital. He could not legally sign himself out of the hospital, but his parents were always left with little choice but to sign the discharge papers against medical advice. His relationship with them was so strained over his poorly controlled diabetes that he often lived with friends for weeks on end instead of coming home.

I waited until he was alone in the hospital room to sit down and talk with him. I pointed out the number of admissions he had in 2013 alone, and he corrected me. “It’s actually way more than that, they just haven’t all been at this hospital. I’ve had over 20 hypoglycemic seizures and over 10 admissions for DKA. I feel like I’ve been in the hospital longer than I’ve been out.”

I asked him if he had thoughts of suicide, because his erratic insulin administration (skipping shots and then ultimately overdosing) could very well kill him. He denied suicidality, but his actions spoke louder.

“I just don’t care,” he said as he looked at me. His face was as indifferent as his words.

Looking back down at his chart, I realized he was only a few weeks away from turning 18. This was significant, because in a few short weeks he would have the legal power to refuse all treatment for himself at his will. If he kept going down his current path, he would surely meet a premature death. Our endocrine team discussed the situation with his own endocrinologist and the ICU team. We all agreed that something drastic had to be done while we still had any power over him -- while he was still a minor.

His parents were approached with the idea to admit him to a medical-psychiatric unit and carry through with it even if he fought and argued and refused. They worried about his potential reaction, but knew that his health was dangerously at stake. His parents, desperate for any intervention that would help their son, agreed.

When the patient heard about the plan involving inpatient med-psych treatment, he said no.
When we did not accept that answer, he ripped his IV lines out and headed for the door.
When security blocked him, he tried to fight them off.
When he continued to fight, we had to give him a sedative and transfer him to a unit that rested behind a double set of locking doors.

It felt like a harsh way to handle a person who is almost an adult. But he wasn’t an adult – not yet. After that day, the time leading up to his 18th birthday may have ticked by very slowly for him. But it is our job to ensure that his time keeps ticking at all.


  1. This reminds me of an "Ask Wil" column on DiabetesMine, maybe two months ago. Parents were trying to get a last-ditch effort to get their child under control (I believe it was alcohol abuse, if I'm not mistaken) but the response was the same -- do all you can before the upcoming 18th birthday, because after that you can't do anything.

    I obviously didn't see this unfold, but I wonder if med-psych treatment is overly harsh. The not-caring likely stems from the effects of erratic diabetes control, and that comes from not caring. It's a vicious cycle that keeps building on itself. Of course, this is just my untrained interpretation from a distance.

    I often compare the situation to hanging on to the back of a speeding roller coaster, hands clutching the back rail and legs flailing about. It's a battle from one curve to the next and it's nearly impossible to keep a tight grip with both hands and there's temptation to just let go. But once you manage to pull yourself into a seat with the harness securely locked over your shoulders, it's a much easier ride.

    I fear that admission to such a facility might further upset him and he'll interpret it as "Wow, there's more wrong with me than I thought!" Then again, time's running short and this calls for strong and forceful intervention, so this could be the best -- although difficult -- course of action.

    I only hope that he can find the strength and the reason to pull himself in, so he can see that there's fun to be had on the scary ride.

    1. It surely upset him, but there IS something wrong. It needs to be brought to the surface. The facility is actually on the same hospital floor, just with different personnel and locking doors. It doesn't feel overly psych-ey. And they have individual and group therapy, etc. We've had to send several of our more extreme D-kids there and it is usually a positive experience in the end. I hope he pulls himself out, too :(

  2. How awful... My heart breaks for this boy and his parents.

  3. I'm saddened by this. The difference between a 17-year-old kid and an 18-year-old man (kid?) is so slim. I hope someone can reach him in time.

  4. Aww so sad, I hope he gets the help he needs!