Can labs be drawn and insulin and intravenous (IV) fluids be administered as part of comfort care?

Insulin and IV Fluids in Comfort Care

In comfort care settings, labs can be drawn and insulin and IV fluids can be administered if they contribute to patient comfort, but should be discontinued if they cause discomfort or do not align with the goals of care.

Understanding Comfort Care and Medical Interventions

Comfort care (also called palliative care) focuses on providing relief from symptoms and improving quality of life rather than pursuing curative treatments. When considering interventions like lab draws, insulin administration, and IV fluids, the primary consideration should be whether these interventions:

1. Relieve distressing symptoms
2. Improve quality of life
3. Do not cause additional suffering

Guidelines for Specific Interventions in Comfort Care

Laboratory Tests

• Draw labs only if results will directly impact comfort measures
• Avoid routine or frequent lab draws that cause pain or distress
• Consider discontinuing labs that don't affect symptom management

Insulin Administration

• Continue insulin if hyperglycemia causes uncomfortable symptoms (excessive thirst, frequent urination, etc.)
• Simplify insulin regimens when possible
• For patients who can take oral intake:
  • Consider transitioning from IV to subcutaneous insulin
  • Use simplified dosing schedules (1-2 times daily)
  • Target higher glucose ranges (180-250 mg/dL) to avoid hypoglycemia 1

IV Fluids

• May be appropriate if dehydration causes distressing symptoms (dry mouth, thirst)
• Consider oral hydration when possible as an alternative
• IV fluids can be equivalent to oral fluids in lowering blood glucose in stable patients 2
• Discontinue if they cause edema or other discomfort

Decision-Making Algorithm for Interventions in Comfort Care

1. Assess if the intervention addresses a symptom causing discomfort

   • Is the patient experiencing symptoms from hyperglycemia?
   • Is the patient showing signs of dehydration causing distress?

2. Evaluate if the intervention aligns with goals of care

   • Has the patient or surrogate expressed preferences about these interventions?
   • Will the intervention improve quality of life?

3. Consider the burden vs. benefit

   • Does the discomfort of the intervention outweigh symptom relief?
   • Can the intervention be modified to be less burdensome?

4. Regularly reassess necessity

   • As condition changes, interventions that were once helpful may become burdensome

Special Considerations

For Insulin Management

• If continuing insulin, consider using subcutaneous insulin rather than IV insulin when possible 1
• For patients with diabetes who can eat, maintain basal insulin to prevent ketosis which can cause discomfort
• Consider higher glucose targets (150-200 mg/dL) to avoid hypoglycemia risk 1

For IV Fluid Management

• Consider intermittent rather than continuous administration
• Lower volumes may provide comfort without fluid overload
• Monitor for signs of edema or respiratory distress which would indicate need to reduce or stop fluids

Common Pitfalls to Avoid

1. Continuing interventions by default - Each intervention should have a specific comfort-related goal
2. Rigid glucose targets - Strict glycemic control is not appropriate in comfort care
3. Failing to reassess - Patient needs and goals may change rapidly
4. Causing iatrogenic discomfort - Multiple needle sticks for labs or insulin can cause suffering without benefit

Remember that comfort care requires individualized assessment of what provides comfort for each specific patient. Regular communication with the patient (when possible) and family about goals of care is essential to guide these decisions.