General practice management of type 2 diabetes


Diabetes and end-of-life care
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Recommendations

Reference

Grade*

To minimise the risks of hypoglycaemia and metabolic compensation, a blood glucose range of 6–15 mmol/L is appropriate for most palliative care patients

265
Diabetes UK, 2013

None provided

Maintain at glycated haemoglobin (HbA1c) at no lower than 58 mmol/mol (7.5%) if on hypoglycaemic medication depending on the individual’s life expectancy, as HbA1c will be less relevant in patients with months or days left to live

265
Diabetes UK, 2013

None provided

*Refer to Summary, explanation and source of recommendations for an explanation of the level of evidence and grade of evidence

   


Clinical context


The aim of glycaemic control in patients at the end of life changes from preventing and managing long-term complications of diabetes to preserving quality of life.
Terminally ill patients often have multiple factors affecting their glycaemic control (refer to Box 11). Glucose-lowering therapy should be tailored to minimise the risks of hypoglycaemia and hyperglycaemic states and symptoms.

Box 11. Factors affecting glycaemic control in patients with type 2 diabetes at end of life

  • Stress response to severe or sustained illness
  • Organ failure
  • Malignancy
  • Chemotherapy
  • Use of steroids
  • Frequent infections
  • Poor appetite/smaller meals
  • Poor nutrition
  • Cachexia
  • Dehydration
  • Difficulty taking medications (eg difficulty swallowing, nausea, stress)
  • >Weight loss

 

Hyperglycaemia can worsen pain, confusion, thirst, cognition, confusion and incontinence. Blood glucose levels >15 mmol/L may cause polyuria and increase risks of infection.

Hypoglycaemia can also cause discomfort, confusion and impaired cognitive function. DKA can mimic terminal illness. If not recognised and treated, it can severely impair quality and even duration of life.
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.266,267
 

In practice


Aim to provide an appropriate level of intervention according to stage of illness, symptom profile and respect for dignity. In most cases, tight glycaemic control to meet general targets is no longer appropriate in patients nearing the end of life.

Ideally, discuss dying with patients and their families prior to the need for end-oflife care so that the important considerations can be addressed in advance care planning.268 Liaison with the palliative care team and community diabetes team is recommended as part of a multidisciplinary approach to end-of-life diabetes care.269

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.

Avoid long-acting sulphonylurea preparations (eg glibenclamide, glimepiride) if small meals are being taken.

Figure 7 shows an algorithm for an end-of-life diabetes care management strategy.265

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

Figure 7. Algorithm for an end-of-life diabetes care management strategy

Figure 7. Algorithm for an end-of-life diabetes care management strategy

*Byetta (Exenatide)/Victoza, (Liraglutide), Lyxumia (Lixisenatide)
†Humalog/Novorapid/Apidra
‡Humulin I/Insulatard/Insuman Basal
Reproduced with permission from Diabetes UK from End of life diabetes care: A strategy document. Clinical care recommendations. London: Diabetes UK, 2012. 


Diabetes Australian and RACGP logo's
 
  1. Diabetes UK. End of life diabetes care: Full strategy document. 2nd edn. London: Diabetes UK, 2013.
  2. Cox DJ, Kovatchev BP, Gonder-Frederick LA, et al. Relationships between hyperglycemia and cognitive performance among adults with type 1 and type 2 diabetes. Diabetes Care 2005;28(1):71–77.
  3. Sommerfield AJ, Deary IJ, Frier BM. Acute hyperglycemia alters mood state and impairs cognitive performance in people with type 2 diabetes. Diabetes Care 2004;27(10):2335–40.
  4. Dunning T, Martin P, Savage S, Duggan N. Guidelines for managing diabetes at the end of life. Geelong, Vic: Nurses Board of Victoria, 2010.
  5. Deakin University and Barwon Health, Diabetes Australia, Palliative Care Australia. Caring for people with diabetes at the end of life: A position statement. Geelong: Centre for Nursing and Allied Health Research, 2014.