After consultation with my Endocrinologist, I have chosen to use an insulin pump to help treat my diabetes. I understand that the pump offers certain advantages to me in terms of flexibility of lifestyle and tighter control of my blood sugar levels, if used in accordance with my Endocrinologist’s instructions. I also understand that tighter control may help me in preventing the complications associated with diabetes. For these reasons and other, I have chosen the pump over other forms of treatment.
Although the pump has certain advantages, I recognize that the pump is an electromechanical device that, like all other mechanical devices, may fail. The catheter may fail and I would have to take my insulin by syringe injection. It is still up to me to closely monitor my blood sugar levels to ensure that I am receiving the right amount of insulin. I am committed to doing this because my health demands it.
Should my blood sugar levels rise and I be unable to normalize them, I will consult my health care team immediately. I recognize that such an even may be caused by illness, stress, pump malfunction, or other factors. I understand I may be more at risk for diabetes ketoacidosis when using and insulin pump. Therefore, it is my responsibility to involve my health care team in helping me deal with unexplained high blood sugar levels as soon as possible. I also understand that it is my responsibility to consult with my health care team to manage recurring episodes of low blood sugar levels.
Follow up with the Insulin Pump therapy team as scheduled as well as communicate insulin pump management records regularly.
Must follow insulin pump program protocols: Management of Unexplained High Blood Sugar on Insulin Pump, Causes and Treatment of hypoglycemia with eth Pump sick Day guidelines, Exercise and the Insulin Pump Guidelines for Driving and Rules for the Road.
My Insulin Pump will be stopped by my Diabetes Doctor if I do not do the above or as clinically indicated.
Patient Signature (patient) _____________________________________ / Date ____
Patient Signature (Parent/Guardian) _____________________________ / Date _____
Insulin Pump Educator Signature_______________________________ / Date _____