From the Guidelines
Palliative care plays a crucial role in managing Diabetes Mellitus (DM) by prioritizing comfort, preventing distressing symptoms, and preserving quality of life and dignity, particularly in older adults and those at the end of life.
Key Aspects of Palliative Care in DM Management
- Goals of care: The primary goals are to promote comfort, control distressing symptoms (such as pain, hypoglycemia, and hyperglycemia), and preserve dignity and quality of life 1.
- Simplification of treatment: Simplifying medication plans, relaxing the intensity of lipid management, and considering the withdrawal of lipid-lowering therapy may be appropriate 1.
- Glucose management: Avoiding hypoglycemia and symptomatic hyperglycemia is crucial, with a focus on preventing dehydration and emergency room visits 1.
- Patient-centered approach: Respecting a patient's right to refuse treatment, withdraw oral hypoglycemic agents, and/or stop insulin if desired during end-of-life care is essential 1.
- Individualized care: Treatment plans should be tailored to the individual's needs, taking into account their overall health, oral intake, and goals of care 1.
Specific Considerations
- Type 1 vs. Type 2 diabetes: The management approach may differ between type 1 and type 2 diabetes, particularly at the end of life, with a lack of consensus on the management of type 1 diabetes in this scenario 1.
- Deintensification of treatment: As organ failure develops, deintensification of treatment and discontinuation of one or more agents may be necessary to reduce the burdens of glycemic management 1.
From the Research
Role of Palliative Care in Managing Diabetes Mellitus (DM)
The role of palliative care in managing Diabetes Mellitus (DM) is multifaceted and essential for improving the quality of life of patients with DM. Some key aspects of palliative care in DM management include:
- Early initiation of palliative care to improve symptom management, comfort, and quality of life 2
- Proactive planning for end-of-life care to reduce disease burden and unnecessary treatment 2
- Identification of patients with DM who could benefit from a palliative approach to care, using criteria such as those proposed by Rosenwax et al. 3
- Relaxation of glycaemic control in dying patients with type 2 diabetes mellitus to avoid symptomatic hypoglycaemia 4
- Continued insulin therapy and regular blood glucose measurements for terminal but conscious type 1 diabetes mellitus patients 4
Challenges and Strategies
Challenges in providing palliative care for patients with DM include:
- Limited guidance on managing diabetes-related complications in end-of-life patients 5
- Difficulty in prognosticating life expectancy in patients with DM 2
- Need for skilled conversations and evidence-based frameworks to discuss complex issues and make advance care plans 2, 6 Strategies to address these challenges include:
- Development of guidelines and frameworks for managing diabetes-related complications in end-of-life patients 5
- Use of tools such as the Gold Standard Framework and diabetes-related indicators of reduced life expectancy to identify patients at high risk of mortality 2
- Education and training for diabetes clinicians on how to discuss end-of-life care and initiate conversations about palliative care 6
- Collaboration among chronic disease programs, palliative care, and primary care to identify patients at end of life who have diabetes and develop care guidelines for this population 3
Communication and Language
Effective communication and language are crucial in discussing palliative and end-of-life care with patients with DM. Key findings include:
- People with diabetes prefer clear language when discussing death and dying, while diabetes clinicians often use euphemisms 6
- Diabetes clinicians may benefit from education and strategies to help them initiate conversations about end-of-life diabetes care 6
- Co-designing information with patients, families, and clinicians can improve the relevance and effectiveness of communication about palliative and end-of-life care 6