What considerations are taken when managing a patient with a severe stroke, type 2 diabetes (T2D), and midline shift, who is not adhering to their medication regimen, particularly at the end of life?

From the Guidelines

Managing a patient with severe stroke, type 2 diabetes, and midline shift who is non-adherent to medications at the end of life requires a palliative approach focused on comfort rather than strict disease control. The primary recommendation is to simplify the medication regimen by discontinuing preventative medications and focusing only on those that provide symptom relief. For stroke management, discontinue antiplatelet agents like aspirin or clopidogrel if they're not providing comfort. For diabetes, relax glycemic targets significantly (allowing blood glucose of 180-250 mg/dL or higher) and consider stopping insulin or oral hypoglycemics unless the patient experiences symptomatic hyperglycemia, as suggested by the most recent guidelines 1. Dexamethasone 4-8mg daily may help reduce cerebral edema causing the midline shift, providing symptom relief from headaches and neurological symptoms. Provide comfort medications as needed: morphine 2.5-5mg IV/SC every 4 hours for pain or dyspnea, lorazepam 0.5-1mg every 4-6 hours for anxiety or agitation, and haloperidol 0.5-1mg every 6 hours for delirium. This approach acknowledges that at end of life, the goals shift from disease management and longevity to maximizing comfort and quality of remaining life, which is supported by recent studies on palliative care in diabetes management 1. Regular assessment of symptoms and medication effectiveness is essential, with adjustments made based on the patient's response and changing needs.

Key considerations in managing this patient include:

• Simplifying the medication regimen to focus on symptom relief
• Relaxing glycemic targets for diabetes management
• Providing comfort medications as needed for pain, anxiety, agitation, and delirium
• Regular assessment and adjustment of the treatment plan based on the patient's response and changing needs
• Prioritizing the patient's comfort and quality of life over strict disease control, as emphasized in recent guidelines on palliative care for older adults with diabetes 1.

In terms of specific management strategies, the patient's care plan should be individualized to address their unique needs and preferences, taking into account their advanced disease state and limited life expectancy, as discussed in recent studies on diabetes management in older adults 1.

From the Research

Managing a Patient with Severe Stroke, Type 2 Diabetes, and Midline Shift

When managing a patient with a severe stroke, type 2 diabetes (T2D), and midline shift, who is not adhering to their medication regimen, particularly at the end of life, several considerations must be taken into account.

• Medical Risk Factors: The patient's medical history, including the presence of T2D, hypertension, and dyslipidemia, should be carefully evaluated 2, 3.
• Stroke Prevention and Management: Strategies for preventing further strokes, such as blood pressure control, antiplatelet therapy, and statin therapy, should be implemented 3, 4.
• Glycemic Control: Optimal management of hyperglycemia using insulin or oral hypoglycemic agents is crucial to reduce morbidity and mortality among diabetic inpatients 5.
• Palliative Care: Comprehensive palliative care, including psychosocial support, determination of patient-focused care objectives, and symptom management, is essential for patients with severe stroke and their families 6.

Modifiable Risk Factors

Modifiable risk factors, such as hypertension, dyslipidemia, and hyperglycemia, should be targeted to prevent further strokes and improve outcomes 2, 3, 4.

• Hypertension: Blood pressure should be controlled with a target of less than 130/80 mmHg, using medications such as ACE inhibitors 2, 3.
• Dyslipidemia: Lipids should be treated with a statin, regardless of the starting cholesterol level 2, 3.
• Hyperglycemia: Optimal management of hyperglycemia using insulin or oral hypoglycemic agents is crucial to reduce morbidity and mortality among diabetic inpatients 5.

Non-Modifiable Risk Factors

Non-modifiable risk factors, such as age and gender, should also be considered when managing a patient with severe stroke, T2D, and midline shift 6.

• Age: The patient's age should be taken into account, as older patients may have a higher risk of complications and poorer outcomes 6.
• Gender: The patient's gender should also be considered, as there may be gender-specific differences in stroke risk and outcomes 6.