Tayside Diabetes MCN Handbook
Management of diabetes in the end stages of life

Background

 

The purpose of this web page is to provide people with diabetes, carers and health professionals with information and points to consider for diabetes management in palliative care and end stages of life to reduce the risk of uncomfortable and distressing symptoms of high blood glucose levels and those of hypoglycaemia.

 

Diabetes management during terminal illness may be complex from a physiological, clinical, practical and ethical perspective. There is no agreed, evidence based guideline for end of life diabetes care and care should be designed to take cognisance of quality of life and the length of time the person is expected to live.

 

Those in the early stages of palliative care should maintain their routine diabetes care. Those entering the later stages of their illness may need to have their diabetes management and medications adjusted to reduce the risk of hypoglycaemia but avoid symptomatic hyperglycaemia.

 

Principles of High Quality Diabetes Care at the End of Life (Diabetes UK, 2018)

  • Ensure that effective symptom control is provided during the dying stage
  • Tailor glucose-lowering therapy and minimise diabetes-related adverse treatment effects
  • Avoid metabolic de-compensation and diabetes-related emergencies:
  • Frequent and unnecessary hypoglycaemia
  • Diabetic ketoacidosis
  • Hyperosmolar hyperglycaemic state
  • Persistent symptomatic hyperglycaemia
  • Avoid foot complications and pressure sores in frail, bed-bound individuals with diabetes
  • Avoid symptomatic clinical dehydration
  • Provide an appropriate level of intervention according to stage of illness, symptom profile, and respect for dignity
  • Support and maintain the empowerment of the individuals (in their diabetes self-management) and carer for as long as possible

 

Assessment

A number of physiological factors may influence glycaemic control during terminal illness. These can include anorexia, cachexia, malabsorption, renal and hepatic impairment; and treatments for conditions such as cancer.

 

Nutrition

It is more important for the patient to have some nutrition in a form that is acceptable to them rather than keeping to a strict diet regimen. If there is marked weight loss NOT due to poorly controlled diabetes, it may be necessary to consider reducing doses of insulin, oral hypoglycaemics, statins and antihypertensives.

 

Introduction of enteral feeding regimens, parental nutrition and/or supplementary nutrition products can affect blood glucose levels but medications can be adjusted accordingly to reduce the risk of problematic hyperglycaemia. It is important to review treatment regimens if enteral feeding regimens, parenteral nutrition or supplementary nutrition are introduced, adjusted, reduced or stopped.

 

 

Cancer Treatments

Corticosteroid therapy is used to alleviate the symptoms of pain, anorexia, raised intracranial pressure and nausea with advanced malignant disease. Steroid therapy can precipitate hyperglycaemia in those with diabetes and sometimes those without a previous diagnosis of diabetes. Blood glucose monitoring is essential to guide appropriate therapeutic interventions to control blood glucose. It is essential to review doses of diabetes medication and/or insulin when the steroid dose is introduced, adjusted and/or stopped.

 

Chemotherapy and radiotherapy can have a variety of effects on activities of daily living which are inextricably linked to diabetes management.

 

The sedative effect of pain relief medication, for example opiates, can affect the patients ability to safely self manage their diabetes medications. Insulin omission can lead to diabetic ketoacidosis in people with Type 1 diabetes so adequate support should be available and offered if appropriate to support self management. Nurse or carers administration of insulin may be required.

 

Candida infections can result of a number of health issues including chemotherapy and uncontrolled glucose levels. Patients require prompt attention and treatment with anti-fungal medication.

 

Renal Function

If renal impairment or failure is present patients may require a reduced dose of insulin, oral hypoglycaemics and opioids.

Link to Diabetes and CKD

 

Altered Liver Function

If liver failure is present patients may be at increased risk of hypoglycaemia so medications likely to cause hypoglycaemia e.g. insulin or sulphonylureas should be reviewed. Thiazolidinediones are contra indicated in the presence of hepatic derangement due to the risk of acute hepatic failure.

 

Recommendations

Monitoring glucose and ketones

There is no published evidence to justify any particular glucose or HbA1c range to aim for in end of life diabetes care management. Blood glucose monitoring is a useful tool to assess the efficacy of treatment regimens. A range of 6-15 mmol/L is acceptable1; however individual targets can be agreed. The aim of monitoring is to determine if a patient is at risk of problems with hypoglycaemia or hyperglycaemia.

 

HbA1c target of 53-64 mmol/mol (7.0-8.0%) is appropriate but a HbA1c target up to 70 mmol/mol (8.5%) may be appropriate in those who are frail or demented. In those at end of life, the glycaemic target is predominantly to avoid symptomatic hyperglycaemia1.

 

For many patients blood glucose monitoring is part of their routine care and to stop monitoring may be distressing. When patients are in the end stages of life blood glucose monitoring should be more relaxed but negotiated and agreed with the patient and family. Many people with existing diabetes will be aware of previously set targets for glucose control and will need explanation and reassurance to agree relaxed targets levels. Risks and benefits of stopping glucose monitoring should be carefully considered and agreed with the patient, carers and healthcare team.

 

Type 1 diabetes 

Do not stop insulin in individuals with type 1 diabetes. People with type 1 diabetes have an absolute requirement for regular insulin treatment and should be involved in decisions about their management where possible. Most people with type 1 diabetes self manage their diabetes and this should be supported so long as it is safe for the patient to do so.

 

In the later stages of terminal illness insulin dosing can be reduced. A change to long acting insulin with or without mealtime bolus may be more appropriate at this time to give a background level of insulin and to offer flexibility around mealtimes if food intake is variable. This can help to reduce the risks of hypoglycaemia whilst keeping osmotic symptoms of thirst and polyuria under control.

 

If the patient has difficulty eating or is refusing to eat, an agreed plan for safe insulin management should be discussed with the GP or with the Diabetes specialist team. It is not appropriate to stop insulin in type 1 diabetes due to the risk of Diabetic Ketoacidosis.

 

Continuous Subcutaneous Insulin Infusion (CSII) Pump therapy

The use of insulin pumps by people with type 1 diabetes is becoming increasingly common. The majority of users are competent in managing their diabetes and adjusting bolus doses according to the carbohydrate content of their food and maintaining basal insulin delivery rates by programming their pumps.

 

Technologies such as flash glucose monitoring or continuous glucose monitoring systems are used by many people with type 1 diabetes as an essential aid to balancing food, activity and insulin dosing.

 

These technologies offer flexibility to respond to the changing insulin requirements at the end of life, providing the individual (or their partners/carers) have the skills and support to use it.

 

All people using CSII should have insulin and devices for subcutaneous insulin injections in the event of pump failure. It may be necessary to change to subcutaneous insulin by injection if the person is too unwell to self manage the pump.

 

Type 2 diabetes

Many people with type 2 diabetes who are prescribed insulin continue to produce some endogenous insulin that protects them from diabetic ketoacidosis if it is stopped. However, caution should be considered in people with longstanding type 2 diabetes who may be insulin deficient and therefore at risk of DKA.

 

With the risk of long term complications of diabetes no longer a major concern, people with type 2 diabetes can relax their management but require to be safeguarded from the unpleasant and potentially problematic symptoms of hyper and hypoglycaemia.

 

Treatment regimens can be reviewed and altered according to the person’s condition as there may be weight loss, reduced nutritional intake and with more relaxed target glucose values the need for treatment can reduce.

 

Medications in type 2 diabetes

Review the prescribed medicines aiming to minimise the risk of side effects, while keeping the individual free of symptomatic hyperglycaemia. People on no pharmacological therapy or Metformin alone should not be at risk of hypoglycaemia. Drug doses may require adjustment to take into account appetite, weight loss and/or corticosteroid therapy.

 

People with type 2 diabetes who are insulin-treated sometimes no longer require this in the palliative care setting. In some people oral hypoglycaemic drugs can be substituted instead of insulin but it is important to note that oral medication dosing is less flexible than insulin. Additionally, oral medications may previously been stopped due to renal or hepatic impairment. In some cases treatment with insulin rather than oral medication is preferable and more flexible for dose adjustment.

 

As appetite reduces and weight drops, agents such as GLP 1-RA that promote satiety and weight reduction may no longer be required.

 

SGLT21 (‘gliflozins’) may be inappropriate if maintaining hydration is a problem due to their diuretic effect.

 

If the person has a poor appetite or is unable to eat, then consideration may be given to stopping medication.

 

A plan for care should be discussed with the patient and GP or Diabetes Specialist Team.

 

 

Pancreatic Carcinoma

 

Loss of endogenous insulin production means that continuation or introduction of insulin is often required in patients with pancreatic cancer. Consider using long acting insulin for example Insulatard or Humulin I can be used twice daily to allow dose adjustment. It is important to reduce the risk of hypoglycaemia as counter-regulatory responses may be impaired. Blood glucose monitoring will identify the efficacy of management. A plan for care can be discussed with Diabetes Specialist Team.

 

Resources

Comprehensive information available in Diabetes UK End of Life Diabetes Care

 

NHS Scotland palliative care guideline

 

Diabetes and Cancer Patient booklet

 

During weekday working hours 9-5 the Diabetes team is available for consultation and advice.

 

Contact details for Diabetes Specialist Nurses

Dundee patient contact telephone 01382 632293

Perth patient contact- 01738 473476

 

Dundee/Angus Healthcare Professional Line - 01382 496431

Perth healthcare professional line- 01738 473976 Bleep 5288

 

Inpatient Diabetes Team contact details

Diabetes Specialist Inpatient Nurse Ninewells 01382 660111 ext 36009 Bleep 4872

Diabetes Specialist Registrar bleep 5416

Diabetes and Endocrine referrals email Tay.diabendoreferrals@nhs.scot

Perth Royal Infirmary tel 01738 473476 Bleep 5288

 

Out of office hours help and advice can be given by GP and District Nurse.

For general information on diabetes patient management see the Tayside Diabetes Hanbook

 

Reference

  1. Diabetes UK END OF LIFE DIABETES CARE Clinical Care Recommendations 3rd Edition March 2018 (last accessed February 2021)

 

 

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