Diabetic Emergency with an Advance Directive
You are called to a small apartment at 11:00. A 72-year-old man with long-standing diabetes is confused and sweating. His neighbour found him on the floor and called. He is awake but does not answer questions appropriately and does not recognize his neighbour. His skin is cool and clammy. Capillary glucose reads 2.4 mmol/L. Respirations are 18, pulse 96 and regular, blood pressure 138/84, SpO2 97% on room air. He is able to swallow and protect his airway. On the fridge is a signed document dated four months ago stating he does not want 'heroic measures' and does not want to be hospitalized. His daughter is listed as substitute decision-maker and is 20 minutes away. He lives alone and manages his own insulin.
1. Interpret the document and decide whether to treat and transport, explaining your reasoning.
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The document is a general advance statement, not a specific refusal of treatment for this event. It says he does not want 'heroic measures' and does not want hospitalization, but it is vague, it was signed four months ago, and it does not name hypoglycemia or authorize withholding of a simple reversible treatment. More importantly, he is currently confused from hypoglycemia, so he cannot make or confirm a decision right now. A substituted decision-maker is listed, but waiting 20 minutes while a treatable cause of confusion persists is not in his interest.
Decision: treat the hypoglycemia and plan transport. Hypoglycemia is a reversible, immediately life-threatening condition, and oral glucose is a low-burden intervention consistent with his stated wish to avoid heroic measures. Withholding sugar would not respect autonomy; it would let a temporary metabolic state make the decision for him. Give oral glucose per protocol because he can swallow and protect his airway, then reassess glucose and mental status. If he returns to a clear baseline and refuses transport, document his capacity and refusal carefully, contact the daughter, and follow your service's refusal policy. If he remains confused or the glucose does not correct, transport. Do not treat the document as a do-not-resuscitate order unless it meets your jurisdiction's specific criteria, and even then it would not prevent oral glucose.
2. He improves to a glucose of 5.1 mmol/L and now refuses transport. What must you assess and document before accepting refusal?
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First confirm capacity. He should be oriented to person, place, time, and situation, able to understand the risks of refusing, and able to communicate a consistent choice. Ask him to explain in his own words what happened, what could happen if he refuses, and what he would do if symptoms return. Confusion from hypoglycemia can persist subtly, so repeat the glucose check and reassess mental status.
Assess the risk: he lives alone, manages his own insulin, and had a severe episode that left him on the floor. Ask what he ate, when he last took insulin, whether he has had previous low sugars, and whether he has a glucose meter and fast-acting sugar at home. Consider whether a medication error or illness triggered the event. Explain the risk of recurrence and the warning signs.
Document: the initial and repeat glucose, his mental status before and after treatment, the treatment given, his exact words refusing transport, the risks explained, that capacity was assessed, the daughter's involvement and response, and any safety plan. Offer alternatives such as a follow-up call, contacting his daughter, or a welfare check. Follow your service's refusal policy, which may require a medical oversight consult or a signed refusal form. If capacity is doubtful or the risk is unacceptable, escalate rather than accept the refusal.