Thursday, October 11, 2007

Clinical Conundrum

The scenario is not easy: a hearing-impaired, cognitively-impaired patient with a history of undocumented head injury is newly diagnosed with diabetes. He now has no local family, the last family member having moved out of state three months ago. Due to the lack of documentation and the fact that the patient has only been in the U.S. for several years, I have no access to any medical records which will allow him eligibility for the Department of Mental Health, the Department of Mental Retardation, or the state head injury program. He is able to basically care for himself and does not need personal care. The only services I have been able to cobble together is a homemaker for three hours per week. He has no car, no friend with a car, and lives relatively far from the nearest supermarket. He also has a very limited income.

How do I teach someone with such a low educational level and cognitive deficits how to change his diet and lifestyle in the face of a new diagnosis of diabetes? How do I educate an individual who is functionally illiterate to read ingredient and nutrition labels on groceries before purchasing them? Like many inner-city residents, he generally shops at small, local grocery stores which carry a limited selection of foods at considerably higher prices. The nearest supermarket is a significant distance, and my patient cannot carry two heavy bags of groceries very far. As food costs rise with the price of fuel, his limited resources are squeezed, and his food stamp benefit has not risen---and will not rise---to accommodate the increased prices at the supermarket. Unfortunately, food pantries generally distribute canned and packaged foods high in sodium, added sugar and carbohydrates---just what a new diabetic does not need in his diet as he tries to make new choices.

Speaking of choices, what are mine? Let him flounder in a food desert? Commit to taking him to the grocery store each month when his check arrives? Push for further neuropsychological and cognitive testing with the bleak hope of increasing his chances for admission to a head injury program? The options are limited and the task is Herculean.

These are the types of scenarios over which the earnest nurse loses sleep.

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