Who should be allowed to administer insulin to California school children with diabetes? After five years of litigation, it still depends on whom you talk to. In May six new amicus briefs were filed in a legal battle that pits the California Department of Education (CDE), the American Diabetes Association, and now the U.S. Department of Justice, among others, against the American Nurses Association\California (ANA\C) over who can administer insulin to school children with diabetes.

The CDE argues that local education agencies should be authorized to "train a voluntary school district employee to administer insulin to a student with diabetes during school and school-related activities." This would be permitted if the student's individualized education program (an individually tailored education plan required under federal law for every disabled student) or Section 504 plan (a similar plan) allows it and if no person already authorized to do so (such as nurses, parents or guardians, and even an unlicensed voluntary school employee "with appropriate training" in an emergency) is available.

Although the issue may sound simple, it isn't. The American Diabetes Association supports the CDE position because, the association maintains, there aren't enough nurses available in California's schools to administer the insulin and because not allowing unlicensed volunteers to administer insulin deprives the children of their rights under disability laws. Allowing volunteers to give insulin, however, could similarly violate those rights. According to Amy Garcia, chief programs officer at the ANA (which is one of the plaintiffs, along with the ANA\C and the California School Nurses Organization) and former executive director of the National Association of School Nurses, the health care of children is much more complicated than merely giving a shot: "The child must be assessed, future activities anticipated, carbohydrates counted, insulin doses calculated, correction doses added or subtracted, and then the drug must be administered correctly." And each person with diabetes has a unique pattern of symptoms, she says, adding, "Imagine the risks when asking a busy school secretary to also give insulin." Garcia also points out that there's no real shortage of RNs in California; rather, there are inadequate numbers of funded school nurse positions in the state. And she notes that 41 other states have better ratios of students to school nurses than California does. The CDE's proposal also defies the California Nursing Practice Act, says Garcia, which doesn't allow delegation of medication injection to unlicensed personnel in an institutional setting. Two lower court decisions have previously upheld the ANA\C's position. The California Supreme Court will hear the case later this year. -Gail M. Pfeifer, MA, RN, news director