Diabetes and end-of-life care

The general aims of end-of-life care in the months before progression to palliative care (terminal illnesses in the days or weeks before expected passing) for people with type 2 diabetes are to:¹ 

• consider ethical and legal aspects of care 
• improve and maintain dignity and quality of life 
• help the person achieve life goals 
• manage pain and distressing symptoms 
• talk honestly about prognosis and the person’s concerns, values and goals 
• achieve a dignified death in a place of the person’s choosing 
• advance care planning, will preparation, completion of enduring power of attorney, statements of choices and appropriate family meetings² 
• support family and carers. 

Clinically, this will usually involve modifying the person’s usual care so that an appropriate level of intervention is provided, according to terminal stage, prognosis, symptoms, personal values and dignity. This can be challenging, and requires general practitioners to manage:³ 

• changes to glycaemic targets 
• individual and carer expectation 
• risk of hyperglycaemia and hypoglycaemia 
• effects of other medications, such as corticosteroids 
• tailoring of glucose-lowering medications 
• de-intensification/deprescribing (eg aspirin, statins, blood pressure medications). 

Ideally, discuss dying with individuals and their families prior to the need for end-of-life care so that the important considerations can be addressed in advance care planning.¹ Liaison with a palliative care team and community diabetes team is recommended as part of a multidisciplinary approach to end-of-life diabetes care.⁴ 

Managing glycaemia 

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 people to optimise their wellbeing and cognitive function.^5,6 

Multiple factors can affect glycaemic management 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 the risk 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, falls risk and impaired cognitive function. 

Diabetes medications at end of life 

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:³ 

• insulin and long-acting sulfonylurea preparations (eg glibenclamide, glimepiride) if small meals are being taken due to risks of hypoglycaemia 
• sodium–glucose cotransporter 2 inhibitors (SGLT2i) 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-1RAs) if people 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.³ 

Consider referral to specialist care for assistance with complex treatment, such as managing frequent hypoglycaemia, the use of insulin or managing the effects of steroids on glycaemia. 

Voluntary assisted dying 

Voluntary assisted dying is an additional end-of-life choice that gives eligible people who are suffering and dying the option of asking for medical assistance to end their lives. There are strict eligibility criteria⁷ for accessing voluntary assisted dying. Please refer to state-based guidelines and criteria for more information. 

Refer also to ‘Type 2 diabetes management for older people and residential aged care facilities’. 

For health professionals 

• Deakin University has produced comprehensive information about end-of-life care for people with diabetes, including advance care planning, in the Guidelines for managing people with diabetes at the end of life care: Final report. 

• The Diabetes UK guideline End of life diabetes care: Clinical care recommendations provides recommendations for tailoring medication and an algorithm to manage diabetes at end of life. 

• The National framework for advance care planning documents supports advance care planning across all states and territories. 

For carers 

• Palliative Care Australia has produced information for family members and carers on diabetes and palliative care.