Diabetes introduction

A Guideline for the Management of Diabetes in Palliative Care

Dr Maddy Turley

Key Points

  1. Provision of support to allow people to die with dignity, keeping them as comfortable as possible until the end, and assisting families to manage this often distressing experience
  2. Highlight the awareness, identify training and educational needs for high quality end of life diabetes care
  3. To foster partnerships in end of life diabetes care with established palliative care plans

Introduction

There is very little gold standard evidence for managing diabetes in the palliative care population, mainly due to the vulnerability of this group and difficult recruitment. The following guidelines are, therefore, based on review of available literature and clinical experience shared by the diabetes and palliative care teams.

Purpose of the document

The aim of these guidelines for management of diabetes in end of life care is to:

  • Avoid hypoglycaemia
  • Limit symptomatic hyperglycaemia
  • Avoid unnecessary blood glucose checks and complex insulin regimes
  • Prompt checking of CBG if symptoms of hypo or hyper glycaemia are present, or if a diabetic patient’s condition changes.
  • Consider treatment of diabetic emergencies
  • Ensure the patient is on the lowest effective dose of steroid

Management will be different for each patient and will need to be reviewed as their condition changes – for example, as their oral intake and weight changes.

Scope

This is a regional guideline for all adults with palliative care needs, regardless of their care setting. It can be used in hospital, hospice and community. There will be specific situations which will demand slight alterations in the way the guidance is used, and this will be highlighted throughout the document.

Definitions

QDS – four times a day
TDS – three times a day
BD – twice daily
OD – once daily
ACEi – ACE inhibitor
ARB – Angiotensin receptor blocker
GP1 analogue – Glucagon like peptide

Normoglycaemia – normal blood glucose
CBG – capillary blood glucose
DSN – diabetes specialist nurse
DKA – diabetic ketoacidosis
HHS – Hyperglycaemic, hyperosmolar state
LA – long acting (insulin)
HPA-axis – Hypothalamic-pituitary-adrenal axis

Hypoglycaemia

  • Defined as CBG below 4.0 mmol/L
  • Symptoms include
    • pallor, sweating, tremor, tachycardia, loss of concentration,
    • aggression/confusion, fits, transient neurological deficit, reduced conscious level
  • Causes in palliative care population include
    • Weight loss
    • Anorexia
    • Renal failure (drugs not metabolised)
    • Liver failure (decreased glycogen and gluconeogenesis)
  • Treatment should be instigated when identified, if appropriate to do so. (See Management: Hypoglycaemia)

Hyperglycaemia

  • Defined as CBG above 15.0 for the purpose of this guidance (See references 1,3)
  • Symptoms include
    • Thirst, dry mouth, confusion, drowsiness, polyuria and lethargy
  • Causes in palliative care population include
    • Steroid use
    • Stress response to illness
    • Co-existent infection
    • Pre-existing diabetes
    • Pancreatic cancer
  • Treatment should be instigated if there are symptoms, which generally occur when the CBG is >15 (See reference 4). Which treatment depends on the individual case.

Disclaimer (SPAGG - Rewrite)

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.