The Patchwork Problem of School Diabetes Care
Whereas in Washington, a child with Type 1 is barred from school, in Maine he is embraced by a school community.
As we discussed in the previous article about the laws surrounding in-school diabetes care, what level of care a child with Type 1 receives during the school day varies wildly by state and district. This was the case for Owen Pollard, a child with Type 1 who was refused diabetes care during the school day in two schools in the Seattle area.
In theory, the Americans With Disabilities Act and other federal civil rights laws focused on providing equal educational opportunity are supposed to protect children with diabetes by barring discrimination based on a medical condition. In practice, it’s a bit more complicated than that.
According to the American Diabetes Association, 29 states and the District of Columbia permit teachers, administrative personnel, and coaches to administer insulin injections and emergency glucagon, if staff are given proper training. However, there is no uniform model law for state legislatures to adopt, as existing laws vary significantly from state to state.
In Maine, where the Pollard family relocated, all public and private schools come under the authority of the state’s education commissioner insofar as administration of medications in a school setting is concerned. Every school board or district is required to appoint a registered professional nurse (RN) who also holds the credentials of a public health nurse, and who by law has the buck-stops-here authority over administration of medication. The nurse has the authority to delegate that job to a licensed practical nurse (LPN) holding equivalent credentials.
Glucagon is considered an emergency life-saving medication, which under Maine law can be administered by a lay person. Glucagon is covered under the same set of state education department rules which address Epipens and asthma inhalers. Maine follows a “Good Samaritan” doctrine, which shields anyone who offers emergency assistance against civil liability.
Insulin administration in school is a little less clear. There is no prohibition against its administration by personnel not holding medical licenses, but neither is it specifically allowed. In practice, for children who cannot test themselves or self-administer insulin, state education department guidelines require that an RN or LPN perform that task, and also administer other injectables, unless an emergency calls for it. There’s a presumption that children develop testing and insulin-taking skills as they grow, and there are tiered expectations laid out for diabetes self-care as children change schools from elementary to middle school to high school.
An accompanying Department of Education rule sets out a training requirement for non-licensed school personnel involved in administering medications. It is rigorous, and includes annual refresher education. The state sets minimum training requirements, provides a model training program to be followed, and the local school board or district is permitted, within the parameters set by state law and regulation, to author its own policy.
The state’s education department has published a comprehensive booklet for schools entitled Maine Guideline for Schools: Tools for Schools Who Have Students with Diabetes (2004). Among its contents is the age-tiered outline of tasks that students are expected to carry out on their own, including glucose self-testing and self-administration of insulin. Parents are expected to submit detailed daily care plans, including testing times, snack times, dosage information, and the like, accompanied by doctor orders, and to supply and resupply prescriptions and materials for diabetes self-care.
There is no provision in the handbook stating that the school will always be responsible for administering insulin, or that it will make a staff member available for that task. What the school will do is make available a person who has undergone the required training to supervise self-testing for blood glucose and urine ketones, and self-administration of insulin. A school is required to set aside an area in which these tasks can be done in private.
The Pollards’ son, Owen, goes to school in one of the most affluent school districts in Maine – Portland. The Portland school he attends has two nurses, and so the biggest daily difficulty he and his parents ran up against back in Washington State, that of not having a nurse available for testing and insulin injections, has been swept away. But as his mom told Insulin Nation in a telephone interview, a diabetes-friendly school is about more than just having the right amount of medical personnel on hand.
“The school community here has been incredibly receptive [with teachers and staff showing] willingness to learn about diabetes and the daily struggles kids like Owen have,” says Dr. Jessica Pollard, a pediatric oncology specialist with the Maine Children’s Cancer Program.
Not every local school board or district in Maine has resources at its disposal to employ nurses or LPNs at the same level as Portland area schools. Not every Maine kid has two practicing physicians as parents, either. Diabetes advocates in several states are working hard to ensure that every child with diabetes can be as lucky as Owen when it comes to in-school diabetes care.
The American Diabetes Association’s “Safe At School” program maintains a multi-jurisdiction digest of laws governing administration of diabetes medication in school. The list is subject to periodic updating and one should confer with a lawyer when considering a challenge to school diabetes care policy.
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