Tayside Diabetes MCN Handbook
Management of Diabetes in the End Stages of Life

The purpose of this web page is to give all carers and health professionals information and points to consider that will enable the patient with diabetes to die with dignity and without suffering the more severe symptoms of uncontrolled diabetes.

Diabetes management during terminal illness may be complex from a physiological, clinical and ethical perspective. The management of diabetes during the last few weeks of life may pose some problems for patients and for those caring for them.

There is no agreed, evidence based guideline for end of life diabetes care. A number of physiological factors may influence glycaemic control during terminal illness. These include anorexia, cachexia, malabsorption, renal and hepatic failure. Drugs used in palliative care such as corticosteroid can have an impact of glycaemic control and monitoring will be required to assess their effects. 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

 

Aims of Management

Provide the appropriate level of support to patients and their carers to:

  • Avoid unpleasant osmotic symptoms of hyperglycaemia
  • Avoid treatment associated hypoglycaemia
  • Provision of quality care to manage and alleviate distressing symptoms

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 medications adjusted to reduce the risk of hypoglycaemia but avoid symptomatic hyperglycaemia.

Blood glucose monitoring

Blood glucose monitoring is a useful tool to assess the efficacy of treatment regimens. There are no agreed target blood glucose levels at the end of life a range of 4-15 mmol/L is acceptable; however other more individual targets can be agreed. The aim of monitoring is to determine if a patient is at risk of problems with hypoglycaemia or hyperglycaemia.

 

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. Stopping blood glucose monitoring should be carefully considered and agreed with the patient, carers and healthcare team.

 

Type 1 diabetes

Patients should be involved in decisions about their management where possible. Most patients with Type 1 diabetes self manage their diabetes and this should be continued so long as it is safe for the patient to do so. In the later stages of terminal illness a change to long acting insulin may be more appropriate at this time to give a background level of insulin. 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 care should be discussed with the GP or with the Diabetes Care Team. It is not appropriate to stop insulin in Type 1 diabetes.

Type 2 diabetes

 Patients with type 2 diabetes who are usually insulin-treated may no longer require this in the palliative care setting. There may be a variety of reasons for this including weight loss, reduced nutritional intake and more relaxed target glucose values. Oral hypoglycaemic drugs can be substituted if patients are still able to swallow but drug doses may require adjustment to take into account appetite, weight loss and/or steroid therapy. If the patient is on oral medication but has a poor appetite or is unable to eat, then consideration may be given to stopping this medication. Again a plan for care should be discussed with the patient and GP or Diabetes Care Team.

Pancreatic Carcinoma

Loss of endogenous insulin production means that continuation or introduction of insulin is often required in patients with pancreatic cancers. Consider using long acting insulin for example Insulatard or Humulin I to reduce the risks of hypoglycaemia as counter-regulatory responses may be impaired. Blood glucose monitoring will identify the efficacy of management.

Other Points to Consider

Diet - 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. Introduction of enteral feeding regimens and supplementary nutrition 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 or supplementary nutrition are reduced or stopped.

Steroids – corticosteroid therapy is used to alleviate the symptoms of pain, anorexia, raised intracranial pressure or nausea with advanced malignant disease. Steroid therapy can precipitate hyperglycaemia in those without a previous diagnosis of diabetes and cause deterioration in control in established patients. Blood glucose monitoring is essential to guide appropriate therapeutic interventions to control blood glucose. Remember doses of diabetes drugs and insulin may need to be reduced when reducing steroid doses. Candida infections can also occur and require prompt action with anti-fungal medication.

Weight loss - 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.

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

Altered Liver function – if liver failure is present patients may be at increased risk of hypoglycaemia. Therefore 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.

Resources

Diabetes UK summarises a consistant but high quality approach towards end of life care for people with diabetes by providing a sereis of clinical care recommendations.  The documents have been endorsed by leading diabetes organisations including: NHS Diabetes, ABCD, TREND-UK, IDOP, National Diabetes Nurse Consulatants, and the Diabetes Inpatient Nurses UK Group.

 

Diabetes UK End of Life Diabetes Care Second Edition October 2013: Clinical Care Recommendations: Key Principals of Care

  • Tailor glucose lowering therapy
  • Avoidance of metabolic decompensation and diabetes related emergencies DKA, HHS, hypoglycaemia
  • Avoidance of foot complications
  • Avoidance of symptomatic clinical dehydration
  • Appropriate intervention according to condition, respect for dignity
  • Supporting and maintaining individual patient empowerment

Key Action Points

  • Balance the benefits of diabetes interventions with prognosis/time of life left
  • Minimise interventions and monitoring as end of life approaches
  • Involve patients and family in decisions
  • Be aware and alter management according to steroid use, weight loss, liver disease

End of Life Diabetes Care: the Full Strategy Document 2nd edition October 2013

End of Life Diabetes Care: Clinical Care Recommendations 2nd edition October 2013

End of Life Diabetes Care: Supplementary Documents and Flow Charts

NHS Scotland palliative care guideline

 

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

Contact details

Diabetes Specialist Nurses

Patient contact telephone 01382 632293

Perth patient contact- 01738 473476

 

Dundee/Angus Healthcare Professional Line - 01382 496431 Bleep 3291

Perth Healthcare professional line- 01738 473476 Bleep 5288

 

Inpatient Diabetes Team contact details

Diabetes Specialist Nurse Ninewells 01382 660111 ext 36009 Bleep 4872

Diabetes Specialist Registrar bleep 5416

Diabetes and Endocrine referrals email Tay-UHB.diabendoreferrals@nhs.net

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 Handbook  

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