End of Life care in Diabetes
🕊️ End of life diabetes care focuses on comfort, symptom control, and avoiding harm rather than tight glycaemic targets. ⚠️ Hypoglycaemia is more distressing than mild hyperglycaemia → prioritise safety over control. 🎯 Aim: prevent symptomatic hypo/hyperglycaemia, not long-term complications. Work out what a reasonable solution is that is in the patient's interest and least onerous.
📖 Principles
- Shift from prevention → comfort-based care.
- Reduce treatment burden (fewer finger pricks, simpler regimens).
- Avoid hypoglycaemia (confusion, seizures, distress).
- Accept higher glucose targets.
- Individualise care (prognosis: months vs days).
🎯 Glycaemic Targets
- General target: 6–15 mmol/L
- Avoid <6 mmol/L (hypoglycaemia risk)
- Avoid >20 mmol/L (risk of dehydration, DKA, HHS)
💊 Type 2 Diabetes Management
- ❌ Stop non-essential drugs: metformin, SGLT2 inhibitors, GLP-1 analogues (↓ benefit, ↑ risk)
- ⚠️ Sulfonylureas → high hypo risk → usually stop
- ✔️ Consider low-dose insulin if symptomatic hyperglycaemia
- ✔️ If eating poorly → often stop all oral agents
💉 Type 1 Diabetes Management
- 🚨 NEVER stop insulin completely (risk of DKA)
- Simplify regimen:
- Switch to once-daily long-acting insulin
- Stop rapid-acting if not eating
- Reduce dose (often 25–50%) depending on intake
🍽️ Nutrition & Fluids
- Encourage eating for comfort, not control
- No need for strict diabetic diet
- Reduced intake → ↓ insulin requirements
- Avoid burdensome interventions (e.g. IV fluids unless symptomatic)
🧪 Monitoring
- Reduce frequency (e.g. once daily or symptom-triggered)
- Stop HbA1c monitoring ❌
- Avoid excessive finger pricks
⚠️ Recognising Problems
- Hypoglycaemia: sweating, confusion, drowsiness → treat promptly (oral glucose if able)
- Hyperglycaemia: thirst, polyuria, drowsiness
- DKA risk (Type 1): nausea, abdominal pain, Kussmaul breathing
- HHS risk (Type 2): dehydration, confusion
💡 Last Days of Life (Actively Dying Phase)
- Stop most diabetes medications
- ✔️ Continue low-dose basal insulin (especially Type 1)
- Minimal monitoring (only if symptomatic)
- Focus entirely on comfort
🧠 Clinical Pearls (Exam + Real Life)
- Hypoglycaemia causes more immediate harm than hyperglycaemia
- DKA can still occur late in life → never omit insulin in Type 1
- SGLT2 inhibitors ↑ risk of euglycaemic DKA → stop early
- Sliding scale insulin is usually NOT appropriate in palliative care
- Think: “safe sugars, minimal burden”
