Why We Shouldn't Overlook Psychosocial Issues In Patients With Diabetes
Recognizing And Addressing Patient Fears And Anxieties
Following admission to the hospital, patients with diabetes are often transferred to a skilled nursing facility where they might remain for weeks or sometimes months. Remaining at these institutions is never a substitute for their home environment yet rarely are the patients’ psychosocial issues ever considered by the physicians who continue to treat them. The lack of sensitivity on the part of the treating physicians as well as the intrinsic feelings of emotional abandonment on the part of the patient may contribute to a deepening depression, frustration, anger and, finally, withdraw from medical treatment.3
An amputation may be as devastating to the patient with diabetes as it is for his or her family.4 As surgeons who deal with these issues on a daily and objective basis, we can see the benefits of a judicious ablation, knowing that it will permit the patient to resume his or her life in the community. For many patients facing the possibility of an amputation at any level, their perception is far more subjective. One needs to reassure these individuals that the physical loss of part of their extremity is necessary and explain the potential benefits from such an intervention. Surgeons should consider having the patient evaluated and counseled by behavioral health professionals before their amputation. Out of all the team members, it is often psychiatrists and social workers who are underutilized.
Preventing complications associated with diabetes is always preferable to treatment. Newly diagnosed diabetics should not only be educated about dietary adjustments, self-monitoring of blood glucose and exercise, but also should be specifically counseled by their primary care physicians on the potential for depression. Physicians should address depression shortly after the diagnosis of diabetes and they should recommend emotional support for the patient and their families far more often than they do.
Diabetic foot infection is one of the major reasons for hospital admissions. To the health care provider, it is likely to represent just another admission, one that may result in a trip to the operating room and possible amputation. As surgeons involved with busy inpatient services, it is easy for us to forget the patient’s stress and anxiety associated with such an admission. It is less the potential loss of a leg but rather the way in which it is revealed to the patient that will ultimately determine the patient’s acceptance of events.
Even though it is sometimes out of our reach to help save a foot or limb, providing a source of emotional support for patients with diabetes is essential at the beginning of their treatment. Healthcare providers are often astonished by the fact that their diabetic patients refuse to consent to an amputation until the foot is grossly infected and has become frankly septic. Their resistance is often falsely supported by the absence of pain as well as their concerns about living alone as an amputee, their ability to continue to provide for themselves and their families, and other concerns they might not be able to articulate.
Clearly, the multidisciplinary team approach is the best way of handling the needs of patients with diabetes. Early interventions, such as yearly eye and foot examinations, maintainance of tight glycemic control, urinalysis and screening for microalbuminemia, testing for hyperlipidemia and hypertension, exercise, smoking cessation, application of a healthy diet and weight loss are all essential elements for reducing the complications of diabetes. However, we also should not overlook the importance of an early assessment of the patients’ understanding of their disorder and their ability to cope with the disorder.
Dr. Zgonis is an Adjunct Assistant Professor of Surgery at the College of Podiatric Medicine and Surgery at Des Moines University in Des Moines, Iowa. He is the Associate Director of the PGY-5 Fellowship in Reconstructive Foot And Ankle Surgery at New Britain General Hospital in New Britain, Ct. Dr. Zgonis is an Associate of the American College of Foot and Ankle Surgeons.