From the Guidelines
For patients who are actively dying and receiving comfort care, continuing insulin and glucose control is generally not recommended unless the patient is experiencing symptoms related to hyperglycemia. The primary goal in this scenario is to prioritize the patient's comfort and quality of life, rather than strict glycemic control 1.
Key Considerations
- The focus should be on avoiding hypoglycemia and symptomatic hyperglycemia while reducing the burdens of glycemic management 1.
- For a dying person, most agents for type 2 diabetes may be removed, but there is no consensus for the management of type 1 diabetes in this scenario 1.
- If the patient shows signs of discomfort from very high blood glucose levels, then minimal insulin therapy may be appropriate, using a simplified regimen such as once-daily long-acting insulin or small doses of regular insulin for glucose levels above 300-350 mg/dL 1.
- Frequent fingerstick glucose monitoring should be discontinued as it causes unnecessary discomfort, and the goal shifts from tight glycemic control to preventing symptomatic hyperglycemia only 1.
Management Approach
- Respect the patient's right to refuse treatment and withdraw oral hypoglycemic agents and/or stop insulin if desired during end-of-life care 1.
- Consider decreasing the complexity of treatment and having a higher threshold for additional diagnostic testing, including capillary monitoring of glucose 1.
- Focus on promoting comfort, controlling distressing symptoms, avoiding dehydration, and preserving dignity and quality of life 1.
Conclusion is not allowed, so the response ends here.
From the Research
Glycemic Control in Critically Ill Patients
- The optimal glycemic target for critically ill patients is still unclear, but most medical societies recommend a target range of 140-180 mg/dL 2, 3, 4, 5, 6.
- Hyperglycemia is associated with increased morbidity and mortality in critically ill patients, and insulin therapy is the most appropriate method for controlling glycemia in hospital 3, 4.
- However, intensive insulin therapy targeting blood glucose levels of 80 to 110 mg/dL has been found to have no benefits and even increased harm in some trials 6.
- Emerging literature has evaluated other glycemic indices, including time-in-target blood glucose range, glycemic variability, and stress hyperglycemia ratio, which may be important in determining the optimal glycemic target for individual patients 2, 6.
Insulin Therapy in Hospitalized Patients
- Insulin therapy is associated with an increased risk of hypoglycemia, which is a barrier to achieving glycemic goals 4.
- Continuous intravenous insulin infusion is the best method for achieving glycemic targets in critically ill patients, while a basal-bolus insulin strategy may be more appropriate for non-critically ill patients 4.
- The ideal glucose goals for non-critically ill patients remain undefined and must be individualized according to the characteristics of the patients 4.
Glycemic Control for Comfort Care
- There is no direct evidence to suggest that continuing insulin/glucose control is necessary for comfort care in patients who are actively dying.
- However, maintaining a target glucose range of 140-180 mg/dL may be appropriate for most critically ill patients, including those receiving comfort care 4, 5, 6.