One of the hardest barriers to treat diabetes is the fear of starting insulin on patients. Not only do you have patient barriers but you may also have provider barriers. Her will discuss mainly patient barriers to starting insulin.
Addressing insulin fears
Patients come into the visit with many pre-conceived ideas about medications but especially insulin. The first step is to try to find out why they don’t want insulin, is it fear of needles or is it fear of insulin itself?
Is it fear of needles or fear of insulin?
Determining the root cause of patients’ fears or ambivalence toward insulin therapy can allow for more specific discussion, intervention and resolution.
Fear of needles:
Fear of pain or discomfort
- Compare the sensation to the current experience.
- Perform a mock injection with saline and an insulin syringe, and share your personal experience (if any) with subcutaneous injections. If appropriate, go through the exercise with the patient in the office with saline
Fear of exposures
- Review low risk for infection, explain the sterility of products and educate on safe injection techniques
Fear of insulin:
• Associating need for insulin with personal failure
Have frequent discussions and provide reassurances that the progression of diabetes and need for insulin is normal, and not a reflection of personal failure.
• Worry about side effects, costs, interference with life/routine, whether insulin will work or “fail”, and others
Early conversations can elucidate concerns, and allows time for patient-centered discussions and interventions to address worries and fears.
Include family members and other team members to address specific needs.
• Former experience with a friend or loved-one, e.g. “My uncle started insulin and then he needed to have his leg amputated.”
Review importance of balancing personalized goals of therapy with quality of life and show commitment to shared-decision making.
As part of early education, patients should be introduced to the possibility of insulin for treatment. Weather is because their disease state has progressed or they are sick and in the hospital or they have symptoms suggestive of insulin deficiency (weight loss, polyuria/polydipsia)
Fear of Hypoglycemia
Many times they feel anxious and feel like they may even die. When patients develop this fear, they will often skip their insulin doses or even reduce doses to avoid low blood sugars. In the same way they may not want to restart insulin if they had a bad hypoglycemic episode.
Many patients once they have experienced hypoglycemia will become very afraid of the feeling they get during low blood sugars.
Reassure patients that this time you will start the dosing low and go slow, review what to do if they get a low blood sugars
Talking Points For When You Start Insulin
- When insulin is indicated, explain why and how it will be helpful. Reinforce that the need for insulin does not represent a personal failure.
- Keep the conversation(s) dynamic and patient-centered. Use open-ended questions and reflective listening to learn the patient’s expectations, impressions, and fears about insulin. Tailor the conversation to their needs.
- Share your opinion as their provider, and show that you find value in the patient’s perspective.
- Involve the patient’s caregivers and all members of the patient’s care team in the conversation(s) (nurses, medical assistance, support staff, etc).
“Many patients have told me that once they get the hang of it, injecting the insulin is actually easier and less painful than checking your blood sugar with the fingerstick. I even tried it myself!”
Many times Provider barriers can also become a problem. Providers can delay starting insulin for fear of complications like severe hypoglycemia, lack of time for teaching or close follow-up, unsure how to start or adjust insulin, and complexity of newer insulins. This is where Pharmacists can have a role to help educate not only the patients but also the providers. Pharmacists can also help adjust insulin doses and monitor patients closely to avoid complications or side effects.
