Compliance

(I merged the stories of two non-compliant patients into one for convenience of story-telling. )

Mrs Chan is a 75-year-old lady, with a history of diabetes mellitus for eight years and developed nephropathy recently. Oral hypoglycemic drug failed to control her condition and the HbA1c level raised to 8.5% in the latest check up. The level stayed well above 8 throughout the years despite several increment in insulin dose. She claimed to be compliant to the injection.

In one follow-up the physician have a spot check of blood glucose by H'stix and it turned out to be 33.1 mmol/L. This necessitate an urgent admission since she was at the edge of developing hyperosmolar nonketotic coma. Normally she would have been put on sliding scale of insulin, however, the physician deliberately ordered regular insulin injection this time, in the same dose as prescribed for her home injection.

You know what, when the same dose of insulin was injected by the nurse but not Mrs Chan herself, her glucose level returned drastically to 6.9 mmol/L within six hours. If she had really injected the same dose of insulin for the past three months, her HbA1c should be around 6-7% only. (NEJM 310 (6):341–6.)

Everyone is innocent until proven otherwise. Is it due to drawing the wrong dose into the syringe, or due to her poor injection technique? She was referred to the diabetic nursing specialist for inspection of skills, and she was able to demonstrate a nice injection successfully.

The doctor further probed if she was really skipping the insulin, and she strongly denied it. She also refuted his argument by showing a "homework" of home H'stix blood glucose monitoring - all the values were well below 7 mmol/L.

The painstaking doctor consulted the chemical pathologist, if there is any condition that HbA1c can be falsely high. The reply was, "If the patient is not suffering from any haemolytic anaemia recently or having any haemoglobinopathy like sickle cell disease, there shouldn't be any errors."

She is a mother of two. I bet she must have taught her children to be honest. I also bet when we were young, we must have lied to our parents and teachers to conceal our fault or laziness, etc. Yes, we know that she is actually lying. But what can we do? I agree that this is a kind of rejuvenation, are you convinced?