How do you manage an insulin pump in a patient with suicidal intentions?

Management of Insulin Pump in Suicidal Patient

In a hospitalized patient with suicidal intentions, the insulin pump must be immediately discontinued and the patient transitioned to intravenous insulin infusion or subcutaneous basal-bolus insulin therapy, as inability to self-manage diabetes and impaired decision-making capacity are absolute contraindications to continued pump use. 1

Immediate Discontinuation Protocol

The pump should be removed immediately upon recognition of suicidal ideation, as the patient no longer meets safety criteria for independent pump management. 1

Key Contraindications Present in Suicidal Patients:

• Patient's inability to correctly use appropriate pump settings 1
• Inability to self-manage diabetes safely 1
• Impaired decision-making capacity that poses safety risk 1
• Healthcare decision to discontinue for patient safety 1

The Lancet Diabetes and Endocrinology explicitly states that pumps must be discontinued when patients cannot safely self-manage or when healthcare decisions dictate removal for safety reasons. 1 In the context of suicidal ideation, the pump becomes a potential means of self-harm through intentional insulin overdose or manipulation of settings. 2, 3

Transition Strategy

Option 1: Intravenous Insulin (Preferred for Acute Safety Concerns)

Start IV insulin infusion at least 30 minutes before disconnecting the pump to prevent dangerous gaps in insulin coverage. 1, 4

• Calculate initial IV insulin rate based on the patient's 24-hour total basal dose from pump settings 1, 4
• Monitor blood glucose hourly initially, then every 2-4 hours once stable 4
• Target glucose range of 100-180 mg/dL 5
• Continue IV insulin until patient is psychiatrically stable and eating regularly 5

Option 2: Subcutaneous Basal-Bolus Insulin

If the patient is medically stable and eating, transition to subcutaneous insulin using the pump's 24-hour basal dose as the foundation. 1

• Calculate long-acting insulin dose: Use the total 24-hour basal dose from pump settings 1
• Administer as glargine (Lantus) or detemir (Levemir) in 2 divided doses 12 hours apart 1
• Example: If total daily basal dose is 22 units, give 11 units every 12 hours 1
• Discontinue pump 2 hours after first basal insulin injection to allow subcutaneous depot formation 1
• Calculate meal-time insulin using the patient's insulin-to-carbohydrate ratio from pump settings 1

Critical Safety Measures

Secure the Pump and Supplies

All pump supplies, insulin vials, syringes, and diabetes equipment must be removed from the patient's room and secured by nursing staff. 1

• The pump device itself should be stored in a locked medication room 1
• All insulin administration must be supervised and documented by nursing staff 2, 3
• Consider one-to-one observation if suicide risk is high 2, 3

Monitor for Intentional Insulin Manipulation

Be vigilant for signs of intentional insulin overdose, including unexplained prolonged hypoglycemia or glucose instability. 2

• Check insulin-to-C-peptide ratio if unexplained hypoglycemia occurs to detect exogenous insulin administration 2
• Monitor for hypokalemia, hypomagnesemia, and hypophosphatemia, which are common with insulin overdose 2
• Ensure psychiatric evaluation occurs within 24 hours of pump discontinuation 2

Common Pitfalls to Avoid

Never allow a gap between pump discontinuation and alternative insulin coverage—this creates risk for both hyperglycemia/DKA and potential for self-harm through insulin withholding. 1, 4

• Do not return pump control to patient until psychiatric clearance is obtained and safety plan is established 1
• Do not rely on patient self-reporting of pump settings—verify all settings directly from pump memory 1
• Do not assume the patient will request insulin when needed—maintain scheduled insulin administration 2, 3

Psychiatric Coordination

Immediate psychiatric consultation is mandatory, as insulin-related suicide attempts (both overdose and intentional withholding) are well-documented in the literature. 2, 3

• Depression screening should be performed on all patients with diabetes requiring pump discontinuation 2
• Document clear safety plan before any consideration of pump reinitiation 2, 3
• Coordinate with psychiatry regarding timing of pump return, if appropriate 2, 3

Documentation Requirements

Document the specific reason for pump discontinuation (suicidal ideation/safety concern) and obtain signed agreement from patient acknowledging the transition, if patient is cooperative. 1

• Record all pump settings before discontinuation for future reference 1
• Document psychiatric evaluation and safety assessment 2
• Create clear plan for pump reinitiation criteria, if applicable 1

The evidence strongly supports that professional societies advocate for pump continuation only with signed patient agreement and demonstrated ability to self-manage safely. 1 Suicidal ideation fundamentally violates these safety prerequisites, making discontinuation not just appropriate but medically necessary.