How Health Care Providers Can Discuss Insulin Delivery Options with People Living with Type 2 Diabetes
As clinicians, we are aware that the people with diabetes (PWD) we care for often experience extended periods of hyperglycemia and diabetes-associated complications, which can negatively affect quality of life and potentially reduce life expectancy.1 Yet, despite these detrimental outcomes, PWD can often be hesitant to discuss and consider insulin therapy, insulin delivery options or diabetes technology.
For some PWD, lifestyle changes, such as healthy meal planning, may have already proven to be a great challenge. The possibility of other treatment for diabetes, such as insulin therapy, may trigger a sense of denial about more intensive levels of therapy. They may not see a need to make a change despite their not achieving A1C or other glycemic management goals. For clinicians, however, delayed discussions around intensifying treatment may be due to strained communication with PWD around their health goals. These patient and clinician obstacles together can create a state of therapeutic or clinical inertia2.
An individual’s resistance to considering insulin use and/or insulin delivery options may be initially addressed by identifying their concerns with insulin therapy. Common concerns include weight gain, fear due to misinformation about insulin, embarrassment of intensifying treatment, type 2 diabetes-related stigma or technology.3 After identifying the concerns of PWD, employ an effective communication technique, such as the OARS communication method4, to address these barriers.
Get the Conversations Started: The OARS Method of Communication
The OARS method, (Open-ended questions, Affirmations, Reflective Listening, Summary), is an evidence-based tool used by clinicians to help build rapport with a person seeking medical guidance to ensure effective communication. OARS can facilitate discussions around insulin therapy as well as selecting insulin delivery devices. OARS should be used in conjunction with providing essential information regarding treatment options while considering the health literacy, motivation and goals of the person seeking medical guidance.
Let’s illustrate the principles of OARS with a hypothetical patient named John. While John is not a real case study, in my experience working with PWD, John’s concerns are rooted in the realities of what PWD experience when therapy needs to be intensified.
John is a 55-year-old patient who started on multiple daily injections of insulin, (MDI), but taking his shots four times each day is not fitting into his life. John has not been taking his insulin as prescribed when he is not home and is not savvy about carb counting.
Begin with open-ended questions. Ask questions that cannot be answered in one-word responses and encourage John to share his thoughts. Facilitate the opportunity for him to do most of the talking and lead the conversation.
Since John previously expressed that it is challenging to take his insulin via MDI, this would be a great opportunity to ask John his thoughts regarding meeting with a CDCES to learn about insulin pump therapy as well as pump options which are approved for use for people with type 2 diabetes. “John, what are your thoughts on meeting with a certified diabetes care and education specialist to discuss additional possibilities of insulin delivery?” Referral to a CDCES would also be helpful for you, the clinician, who might not have the time to thoroughly discuss approved insulin pump therapy options for people with type 2 diabetes.
Affirmations. Affirmations are statements made to validate and respect the patient’s feelings regarding diabetes treatment options.
After discussing the basics of pump therapy or referring John to a CDCES to discuss those options, show empathy and let him know you are actively listening and doing your best to understand how he feels without being condescending or judgmental. Build a rapport, be aware of your verbal statements and body language, and acknowledge his concerns, even if you have a different point of view5. “John, you’ve made a great effort in meeting with Mary, the CDCES, to discuss insulin pump therapy, and it’s great that you shared the difficulties you were having with MDI. I appreciate you sharing your concerns about the inconvenience of using MDI and that you are thinking about using an insulin pump.”
Reflective Listening. Reflective listening involves rephrasing a person’s statements while encouraging more in-depth discussion of concerns. Now is the time to reinforce the need for change and to consider additional treatment options. “John, it sounds like you’re worried about forgetting to give yourself daily injections” or “John, you sound embarrassed about figuring out how to take insulin shots when you are not home and that you are interested in trying the insulin pump you discussed with Mary.”
Summarize. Once John has concluded expressing his concerns, summarize or recap the conversation. As the clinician, summarize John’s opinions in a realistic manner and focus on the key decision options for diabetes management. Make sure that there is a clear understanding of the collaborative discussion around those statements that show a desire to change. Summarizing includes a review of what was discussed to make sure everyone agrees. “John, let me check that I understand what you’ve told me so far about how you plan to switch from MDI to an insulin pump as part of your diabetes management plan.”
John’s decision to try an insulin pump was influenced by the way the information was shared by a CDCES and caring physician, nurse practitioner or another prescriber. Mutual respect for the decision-making process using the OARS approach will likely improve glycemic management, reduce complications and improve his quality of life. By simply reframing the way an option is discussed can impact the ability of a PWD to consider insulin pump therapy as a viable choice for their care.
The author was compensated for this article.
References
- Centers for Disease Control and Prevention: People with Diabetes can Live Longer by Meeting their Treatment Goals, Reviewed June, 2022.
- Pantalone, K. et al, Clinical Intertia in Type 2 Diabetes Management: Evidence From a Large, Real-World Data Set. Diabetes care 2018, 41 (7): e113-e114
- National Library of Medicine, Alidrisi et al Barriers of Doctors and Patients in Starting Insulin for Type 2 Diabetes Mellitus 2021 sep, 13 (9) e18263
- Miller, R, Motivational Interviewing Third Edition, Helping People Change, 2012.
- Centers for Disease Control and Preventions: Diabetes Stigma: Learn About It, Recognize It, Reduce it. November, 2022.
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