Ideally, discuss dying with patients and their families prior to the need for end-of-life care so that the important considerations can be addressed in advance care planning.2 Liaison with a palliative care team and community diabetes team is recommended as part of a multidisciplinary approach to end-of-life diabetes care.3
Although there is little evidence about optimal blood glucose range, it is generally agreed that a range of 6–15 mmol/L is appropriate for most palliative care patients to optimise patient wellbeing and cognitive function.4,5
Multiple factors can affect glycaemic control in terminally ill people (Box 1). Glucose-lowering therapy should be tailored to minimise the risks of hypoglycaemia and hyperglycaemic states and symptoms.
Hyperglycaemia can worsen pain, confusion, thirst, cognition, confusion and incontinence. Blood glucose levels >15 mmol/L may cause polyuria and increase risks of infection. Diabetic ketoacidosis can mimic terminal illness. If not recognised and treated, it can severely impair quality and even duration of life.
Hypoglycaemia can also cause discomfort, confusion and impaired cognitive function.
Box 1. Factors affecting glycaemic control in people with type 2 diabetes at end of life
- Stress response to severe or sustained illness
- Poor appetite/smaller meals
- Poor nutrition
- Organ failure
- Difficulty taking medications (eg use of steroids, difficulty swallowing, nausea, stress)
- Frequent infections
- Weight loss
Diabetes medications at end of life
Insulin alone is a simpler option for patients and their carers than combinations of tablets and insulin. Consider switching patients from combinations to insulin alone, once or twice daily. Patients on insulin with poor intake will need lower doses.
The key considerations for decision making regarding glucose-lowering medication are risk minimisation and quality of life. The following classes of medications should be avoided in certain cases:1
- long-acting sulfonylurea preparations (eg glibenclamide, glimepiride), if small meals are being taken
- sodium glucose co-transporter 2 (SGLT2) inhibitors, if dietary intake is reduced; reduced intake can increase ketone production and may increase the risk of ketoacidosis, which can be euglycaemic
- glucagon-like peptide-1 receptor agonists (GLP-1 RAs), if patients have reduced or poor appetites.
Renal function may also decline, and several non-insulin glucose-lowering medications should be discontinued in response to this.
The Diabetes UK guideline End of life diabetes care: Clinical care recommendations provides recommendations for tailoring medication at different stages of end-of-life care. An algorithm for managing diabetes in the last days of life is also provided.
Consider referral to specialist care for assistance with complex treatment such as managing frequent hypoglycaemia, use of insulin or managing the effects of steroids on glycaemia.