Management of diabetes may be challenging as patients approach death.
Treatment goals for patients near the end of life are to avoid symptomatic hypo and hyperglycemia and minimize the burdens of diabetes treatment, but not to prevent long-term complications. Tight glycemic control is not a coherent goal in palliative care.
Both diabetic treatments and uncontrolled diabetes can be burdensome and symptomatic.
- Hypoglycemia from insulin or oral hypoglycemics can cause diaphoresis, anxiety/panic, tremors, weakness, palpitations, seizure, and coma.
- Hyperglycemia, sustained for several days, can cause an osmotic diuresis leading to dehydration, thirst, and polyuria. Sustained, severe hyperglycemia (often >800 mg/dL) causes a hyperosmolar hyperglycemic state (HHS) that can cause thirst, dry mouth, lethargy, and coma.
- Diabetic ketoacidosis (DKA) from lack of insulin can develop rapidly (less than a day), and can cause hyperventilation, nausea, vomiting, abdominal pain, and coma.
- Treatment burdens include painful fingersticks and gastrointestinal side effects of oral hypoglycemics.
For patients with anticipated survival of a few months
Counsel them about reducing tight glycemic control and the increased risk of hypoglycemia as oral intake becomes erratic. Stop glycohemoglobin tests. The goal is to keep blood glucose levels low enough to prevent osmotic symptoms while minimizing the risk of hypoglycemia.
- Type 1 diabetics should continue insulin to prevent DKA.
- Type 2 diabetics on insulin as well as oral medications solely for optimal glycemic control (and not to prevent dehydration or HHS), should stop insulin use.
For patients with anticipated survival of weeks
- Type 1 diabetics or type 2 diabetics prone to dehydration should continue insulin therapy to prevent DKA, assuming that is compatible with their care goals.
- Most type 2 diabetics can stop hypoglycemic agents entirely in the final weeks of life, unless they are prone to dehydration; blood sugars can be checked and hyperglycemia treated if symptoms such as thirst or polyuria develop.
For patients in the final days of life
Most patients have decreasing levels and periods of consciousness, and minimal oral intake. All insulin, hypoglycemics, and monitoring can be stopped in type 2 diabetics.
See reference for more information.
Adapted from Jeffreys E, Rosielle DA. Diabetes management at the end-of-life. Palliative Care Network of Wisconsin. Fast facts and concepts #258. Internet. Accessed on May 6, 2018.