DIABETIC DEATH
Case: A Deputy/Investigator from the Ada County Coroner’s office responded to the ICU of a local hospital concerning a 37-year-old male that had expired after being found down, unconscious, apneic (absence or cessation of breathing) and pulseless (without pulse) at his residence. Paramedics responded to his residence and started CPR as well as the usual ACLS (advanced care life support) protocol, which included medications epinephrine and atropine. When he presented at the Emergency Room he had minimal neurological activity. The subject had diagnosed Type 1 Diabetes - had been treated with insulin therapy for many years. He had a significant history of End Stage Renal Disease secondary to Diabetic Nephropathy (Kidney disease caused by diabetes) that was being managed by Hemodialysis (A method of removing waste materials or poisons from the blood. This process is used on patients whose kidneys are failing.) Additional history included ASCVD (arteriosclerotic cardiovascular disease), Hypertension (A condition of elevated blood pressure that can lead to kidney disease, heart disease and stroke.) He had been hospitalized on several occassions for treatment of an ulcer on his foot and toe that would not heal.
Significant for this case was Diabetic Ketoacidosis (Condition that results in untreated diabetes from the body's attempt to burn fat for fuel when carbohydrates cannot be utilized. Ketones, the byproduct of fat metabolism, enter the bloodstream and make the blood more acidic than the body's tissues.) According to the subject’s physician and medical records, the patient was not compliant with taking his medication - specifically insulin therapy. He was well known to hospital personnel from his multiple admissions and a pattern of severe medical noncompliance and poor self-care. He was placed on a ventilator and admitted to the ICU for observation for the first 24 hours. This observation would include neurological function – if no change or recovery was noted, the patient would be withdrawn from life support.
Following the 24-hour observation period, the patient’s condition was evaluated and he was found to have suffered an anoxic brain injury. Because of the grave prognosis, the family was consulted and the decision was made for the patient to be removed from the ventilator and placed on comfort care only, with a DNR (do not resuscitate) code status. The patient died within a few hours.
It is important to note that uncontrolled diabetes causes damage to many tissues of the body including the kidneys. Kidney damage caused by diabetes most often involves thickening and hardening of the internal kidney structures. Strict blood glucose control may delay the progression of kidney disease in type 1 and type 2 diabetics. A significant number of type 1 diabetes patients seen by this office are many times not compliant with taking medication as prescribed.
What is Diabetes?
Diabetes is a group of diseases marked by high levels of blood glucose, also called blood sugar, resulting from defects in insulin production, insulin action, or both. Diabetes can lead to serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complications.
Types of Diabetes
Type 1 diabetes was previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes. Type 1 diabetes develops when the body’s immune system destroys pancreatic beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose. To survive, people with type 1 diabetes must have insulin delivered by injection or a pump. This form of diabetes usually strikes children and young adults, although disease onset can occur at any age. In adults, type 1 diabetes accounts for 5 to 10 percent of all diagnosed cases of diabetes. Risk factors for type 1 diabetes may be autoimmune, genetic, or environmental. No known way to prevent type 1 diabetes exists. Several clinical trials for the prevention of type 1 diabetes are currently in progress or are being planned.
Type 2 diabetes was previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes. In adults, type 2 diabetes accounts for about 90 to 95 percent of all diagnosed cases of diabetes. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce it. Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Native Hawaiians or other Pacific Islanders are at particularly high risk for type 2 diabetes and its complications. Type 2 diabetes in children and adolescents, although still rare, is being diagnosed more frequently among American Indians, African Americans, Hispanic/Latino Americans, and Asians/Pacific Islanders.
Gestational diabetes is a form of glucose intolerance diagnosed during pregnancy. Gestational diabetes occurs more frequently among African Americans, Hispanic/Latino Americans, and American Indians. It is also more common among obese women and women with a family history of diabetes. During pregnancy, gestational diabetes requires treatment to normalize maternal blood glucose levels to avoid complications in the infant. Immediately after pregnancy, 5 to 10 percent of women with gestational diabetes are found to have diabetes, usually type 2. Women who have had gestational diabetes have a 40 to 60 percent chance of developing diabetes in the next 5 to 10 years.
Other types of diabetes result from specific genetic conditions, such as maturity-onset diabetes of youth; surgery; medications; infections; pancreatic disease; and other illnesses. Such types of diabetes account for 1 to 5 percent of all diagnosed cases.
Deaths among People with Diabetes, United States, 2006
- Diabetes was the seventh leading cause of death listed on U.S. death certificates in 2006. This ranking is based on the 72,507 death certificates in 2006 in which diabetes was listed as the underlying cause of death. According to death certificate reports, diabetes contributed to a total of 233,619 deaths in 2005, the latest year for which data on contributing causes of death are available.
- Diabetes is likely to be under reported as a cause of death. Studies have found that only about 35 to 40 percent of decedents with diabetes had it listed anywhere on the death certificate and only about 10 to 15 percent had it listed as the underlying cause of death.
- Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age.
Complications of Diabetes in the United States
Heart Disease and Stroke
- In 2004, heart disease was noted on 68 percent of diabetes-related death certificates among people ages 65 years or older.
- In 2004, stroke was noted on 16 percent of diabetes-related death certificates among people ages 65 years or older.
- Adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes.
- The risk for stroke is two to four times higher among people with diabetes.
High Blood Pressure
- In 2003 to 2004, 75 percent of adults with self-reported diabetes had blood pressure greater than or equal to 130/80 millimeters of mercury (mm Hg) or used prescription medications for hypertension.
Blindness
- Diabetes is the leading cause of new cases of blindness among adults ages 20 to 74 years.
- Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.
Kidney Disease
- Diabetes is the leading cause of kidney failure, accounting for 44 percent of new cases in 2005.
- In 2005, 46,739 people with diabetes began treatment for end-stage kidney disease in the United States and Puerto Rico.
- In 2005, a total of 178,689 people with end-stage kidney disease due to diabetes were living on chronic dialysis or with a kidney transplant in the United States and Puerto Rico.
Nervous System Disease
- About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, erectile dysfunction, or other nerve problems.
- Almost 30 percent of people with diabetes ages 40 years or older have impaired sensation in the feet—for example, at least one area that lacks feeling.
- Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.
Amputations
- More than 60 percent of nontraumatic lower-limb amputations occur in people with diabetes.
- In 2004, about 71,000 nontraumatic lower-limb amputations were performed in people with diabetes.
Dental Disease
- Periodontal, or gum, disease is more common in people with diabetes. Among young adults, those with diabetes have about twice the risk of those without diabetes.
- People with poorly controlled diabetes—A1C greater than 9 percent—were nearly three times more likely to have severe periodontitis than those without diabetes.
- Almost one-third of people with diabetes have severe periodontal disease with loss of attachment of the gums to the teeth measuring 5 millimeters or more.
Complications of Pregnancy
- Poorly controlled diabetes before conception and during the first trimester of pregnancy among women with type 1 diabetes can cause major birth defects in 5 to 10 percent of pregnancies and spontaneous abortions in 15 to 20 percent of pregnancies.
- Poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to both mother and child.
Other Complications
- Uncontrolled diabetes often leads to biochemical imbalances that can cause acute life-threatening events, such as diabetic ketoacidosis and hyperosmolar, or nonketotic, coma.
- People with diabetes are more susceptible to many other illnesses and, once they acquire these illnesses, often have worse prognoses. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes.
People with diabetes ages 60 years or older are two to three times more likely to report an inability to walk a quarter of a mile, climb stairs, do housework, or use a mobility aid compared with people without diabetes in the same age group.
Prevention of type-2 diabetes
Your best chance of prevention of type-2 diabetes is avoid obesity and to do regular exercise. You should avoid foods that cause high rises in blood sugar and should eat a healthy diet
Missy Scrivner has been a transcriptionist for the Ada County Coroner's Office. She is 2010 Mrs. Treasure Valley International. Her platform is Women and Diabetes.
As Mrs. Treasure Valley International, I am committed to helping those women at risk of and affected by diabetes look at their diabetes in a whole new light. It is a known fact that if you teach a woman to take better care of herself, even with simple things such as a new hair-do, a manicure/pedicure, massage, facial, etc., she will feel better about herself and, in turn, take better care of her health and the health of her family. For more information about women with diabetes, please visit www.divabetic.org
Women are the healthcare decision makers for their family and possess the ability to positively impact the well being of their families by encouraging better lifestyle choices. This is very important for people living with diabetes or for families with a history of diabetes who can incorporate healthier habits to reduce the risk of developing serious diabetes-related complications such as blindness, heart and blood vessel disease (heart disease is the #1 complication of diabetes in women), stroke, kidney failure, amputations, nerve damage, and even death. The burden of diabetes on a woman’s health puts her at higher risk for certain complications, as compared to men with diabetes. Diabetes if the 5th leading cause of death in the United States, and among the top 10 leading causes of death among women. (Source: CDC, ADA)