Management of Diabetes Mellitus (DM) as a Palliative Approach to Care.
Special Considerations at End of Life
- Common symptoms at EOL, such as poor appetite, reduced intake and nausea/vomiting may increase risk of hypoglycemia.
- Metabolic disturbances, such as cachexia, may make tight blood glucose (BG) control difficult.
- Both diabetic and non-diabetic patients being treated with steroids may experience hyperglycemia as a side effect of treatment.
Revisiting Goals of Care When Life Expectancy is Limited
- Tight control of BG levels aimed at reducing long-term complications of DM are no longer necessary.
- Goals may now include (according to patients’ wishes):
- Less frequent BG monitoring and insulin injections.
- Decreased pill burden.
- Preventing symptoms of hyperglycemia that impact quality of life.
- Preventing episodes of hypoglycemia that expose the patient to risk of coma and hypoglycemia-related death.
Revising Treatment Plan Accordingly
- All treatment decisions should be individualized and in keeping with the patients’ goals of care. Whether the patient has Type 1 or Type 2 DM will guide the treatment plan.
- Newer guidelines suggest that interventions might include:
- Type 1: Consider ongoing insulin treatment at a lower dose if BG levels are high enough to cause symptoms. Individualized Short-Acting insulin sliding scales on a PRN basis may be helpful.
- Type 2: Reducing or stopping hypoglycemic treatments and BG monitoring unless symptomatic hyperglycemia is suspected.
Source: Pallium Canada (2016) The pallium palliative pocketbook.