Management of diabetes can create challenges during palliative care. Although clinical decisions must be individualized, the following are useful recommendations about diabetes care in palliative care patients.

Main reflections
- Tight glycemic control only benefits patients (e.g., prevents diabetic retinopathy and nephropathy) with prognoses of years. Treatment goals for patients near the end-of-life are to avoid symptomatic hypo- and hyperglycemia and minimize the burdens of diabetes treatment.
- Both diabetic treatments and uncontrolled diabetes can be burdensome and symptomatic.
- Hypoglycemia from insulin or oral hypoglycemics causes diaphoresis, anxiety/panic, tremors, weakness, palpitations, seizure, coma. Anticipated caloric intake helps prevent hypoglycemia.
- Hyperglycemia, sustained for several days, can cause an osmotic diuresis leading to dehydration, thirst, and polyuria. Sustained, severe hyperglycemia is associated with thirst, dry mouth, lethargy, and coma.
- Diabetic ketoacidosis (DKA) from lack of insulin can develop rapidly (less than a day), and causes hyperventilation, nausea, vomiting, abdominal pain and coma.
- Treatment burdens include painful fingersticks and gastrointestinal side effects of oral hypoglycemics.

Patients with an estimated survival of a few months.
• Advice about reducing tight glycemic control and the increased risk of hypoglycemia when oral intake is irregular. There is no clear consensus about blood sugar targets; expert recommendations have suggested targeting fasting glucose up to 180 mg/dL; but some raise the target to ≤270 and even ≤360.
• Type 1 diabetics should continue insulin to prevent DKA, as should type 2 diabetics prone to symptomatic hyperglycemia without insulin.
• Type 2 diabetics on insulin in addition to oral medications solely for optimal glycemic control should stop insulin use.

Patients with estimated survival of weeks.
- Type 1 diabetics or type 2 diabetics predispose to hyperosmolar nonketotic hyperglycemia (HHS) should continue insulin therapy to prevent DKA, assuming that is compatible with their care goals. Insulin doses should be personalized to keep fasting blood sugars >180 mg/dL to minimize the risk of hypoglycemia. Some amount of basal/long-acting insulin is needed, and for patients with irregular oral intake, short-acting insulin should only be used when eating.
- Most type 2 diabetics can stop hypoglycemic agents entirely in the final weeks of life, unless they are prone to HHS; blood sugars can be checked and hyperglycemia treated if symptoms such as thirst, polyuria develop.

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. DKA can still develop rapidly (<1 day) for type 1 diabetics, and it can be reasonable to continue insulin therapy with tolerant (e.g. <360mg/dL) blood sugar targets.

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, 2019.