8.0.0.0 END-‍OF-‍LIFE CARE

Rec­om­men­da­tions

12.16 When pal­lia­tive care is need­ed in older adults with di­a­betes, strict blood pres­sure con­trol may not be nec­es­sary, and with­draw­al of ther­a­py may be ap­pro­pri­ate. Sim­i­lar­ly, the in­ten­si­ty of lipid man­age­ment can be re­laxed, and with­draw­al of lipid-‍low­er­ing ther­a­py may be ap­pro­pri­ate. E

12.17 Over­all com­fort, pre­vention of dis­tressing symp­toms, and preser­va­tion of qual­i­ty of life and dig­ni­ty are pri­ma­ry goals for di­a­betes man­age­ment at the end of life. E

The man­age­ment of the older adult at the end of life re­ceiv­ing pal­lia­tive medicine or hos­pice care is a unique sit­u­a­tion. Over­all, pal­lia­tive medicine pro­motes com­fort, symp­tom con­trol and pre­vention (pain, hy­po­glycemia, hy­per­glycemia, and de­hy­dra­tion), and preser­va­tion of dig­ni­ty and qual­i­ty of life in pa­tients with lim­it­ed life ex­pectan­cy (47,51). A pa­tient has the right to refuse test­ing and treat­ment, where­as pro­viders may con­sid­er with­draw­ing treat­ment and lim­it­ing di­ag­nos­tic test­ing, in­clud­ing a re­duc­tion in the fre­quen­cy of finger­stick test­ing (52). Glu­cose tar­gets should aim to pre­vent hy­po­glycemia and hy­per­glycemia. Treat­ment in­ter­ven­tions need to be mind­ful of qual­i­ty of life. Care­ful mon­i­tor­ing of oral in­take is war­rant­ed. The de­ci­sion pro­cess may need to in­volve the pa­tient, fam­i­ly, and care­givers, lead­ing to a care plan that is both con­ve­nient and ef­fec­tive for the goals of care (53). The phar­ma­co­log­ic ther­a­py may in­clude oral agents as first line, fol­lowed by a sim­plified in­sulin reg­i­men. If need­ed, basal in­sulin can be im­ple­ment­ed, ac­com­pa­nied by oral agents and with­out rapid-‍act­ing in­sulin. Agents that can cause gastroin­testi­nal symp­toms such as nau­sea or ex­cess weight loss may not be good choic­es in this set­ting. As symp­toms progress, some agents may be slow­ly ta­pered and dis­con­tin­ued.

Dif­fer­ent pa­tient cat­e­gories have been pro­posed for di­a­betes man­age­ment in those with ad­vanced dis­ease (28).

  1. A sta­ble pa­tient: con­tin­ue with the pa­tient’s pre­vi­ous reg­i­men, with a focus on the pre­vention of hy­po­glycemia and the man­age­ment of hy­per­glycemia using blood glu­cose test­ing, keep­ing lev­els below the renal thresh­old of glu­cose. There is very lit­tle role for A1C mon­i­tor­ing and low­er­ing.

  2. A pa­tient with organ fail­ure: pre­vent­ing hy­po­glycemia is of greater significance. Dehy­dra­tion must be pre­vented and treat­ed. In peo­ple with type 1 di­a­betes, in­sulin ad­min­is­tra­tion may be re­duced as the oral in­take of food de­creases but should not be stopped. For those with type 2 di­a­betes, agents that may cause hy­po­glycemia should be down­ti­trat­ed. The main goal is to avoid hy­po­glycemia, al­low­ing for glu­cose val­ues in the upper level of the de­sired tar­get range.

  3. A dying pa­tient: for pa­tients with type 2 di­a­betes, the dis­con­tin­u­a­tion of all med­i­ca­tions may be a rea­son­able ap­proach, as pa­tients are un­like­ly to have any oral in­take. In pa­tients with type 1 di­a­betes, there is no con­sen­sus, but a small amount of basal in­sulin may main­tain glu­cose lev­els and pre­vent acute hy­per­glycemic com­pli­ca­tions.