How to manage fluctuating blood sugar levels in terminal patients?

Managing Fluctuating Blood Sugar Levels in Terminal Patients

In terminal patients, prioritize comfort over tight glycemic control by simplifying treatment regimens, reducing glucose monitoring frequency, and accepting higher glucose targets (allowing values up to 250 mg/dL or even higher in dying patients) to prevent hypoglycemia and distressing symptoms. 1

Primary Goals of Care at End of Life

The fundamental shift in diabetes management at end of life focuses on 1:

• Promoting comfort and controlling distressing symptoms (including pain, hypoglycemia, and hyperglycemia)
• Avoiding dehydration, emergency room visits, and hospitalizations
• Preserving dignity and quality of life
• Preventing hypoglycemia as the priority over preventing hyperglycemia 1

Patient-Specific Management Strategy

The American Diabetes Association categorizes terminal patients into three groups with distinct management approaches 1:

Stable Terminal Patient

• Continue previous diabetes regimen with modifications 1
• Focus primarily on preventing hypoglycemia rather than achieving tight control 1
• Keep glucose levels below renal threshold (approximately 180-250 mg/dL) to avoid glucosuria and dehydration 1
• Discontinue A1C monitoring as it provides no benefit in this population 1

Patient with Organ Failure

• Preventing hypoglycemia becomes paramount 1
• For Type 1 diabetes: Reduce but do not stop insulin as oral intake decreases 1
• For Type 2 diabetes: Reduce or discontinue agents that cause hypoglycemia (sulfonylureas, meglitinides, insulin) 1
• Allow glucose values in the upper level of desired range (200-250 mg/dL acceptable) 1
• Aggressively prevent and treat dehydration 1

Actively Dying Patient

• For Type 2 diabetes: Discontinuation of all diabetes medications is reasonable given minimal to no oral intake 1
• For Type 1 diabetes: Continue small amounts of basal insulin only to prevent diabetic ketoacidosis 1
• Accept glucose levels >250 mg/dL to minimize intervention burden 1

Glucose Monitoring Modifications

Dramatically reduce monitoring frequency based on patient status 1:

• For Type 2 diabetes in terminal care: Reduce from multiple daily checks to twice daily or even once every 3 days depending on stability 1
• For Type 1 diabetes: Monitoring frequency may need to remain higher due to ketoacidosis risk 1
• Consider continuous glucose monitoring (CGM) when frequent finger sticks are burdensome but some monitoring remains necessary 1

Alert Thresholds for Terminal Patients

Implement a simplified notification system 1:

Immediate notification required:

• Glucose <70 mg/dL (3.9 mmol/L) - treat hypoglycemia immediately without delay 1

Notify as soon as possible when:

• Glucose 70-100 mg/dL (3.9-5.6 mmol/L) on multiple occasions - regimen needs adjustment 1
• Two or more values >250 mg/dL (13.9 mmol/L) within 24 hours with clinical status change 1
• Consistently >300 mg/dL (16.7 mmol/L) over 2 consecutive days 1
• Patient symptomatic with hyperglycemia, vomiting, or poor oral intake 1

Treatment Simplification Strategies

Simplify medication regimens to reduce treatment burden and hypoglycemia risk 1:

• Prefer oral glucose-lowering agents over complex insulin regimens when appropriate 1
• Use simplified insulin regimens with low hypoglycemia risk (avoid sliding scale, prefer basal-only or basal-bolus with conservative dosing) 1
• Discontinue medications that increase hypoglycemia risk (sulfonylureas, meglitinides) 1
• Consider post-meal insulin dosing to match actual carbohydrate intake in patients with unpredictable eating 1
• Respect patient's right to refuse treatment and withdraw medications if desired 1

Critical Pitfalls to Avoid

Common errors in terminal diabetes care 1:

• Overly tight glycemic control driven by quality metrics - Healthcare Effectiveness Data and Information Set (HEDIS) measures do not apply to terminal patients 1
• Discomfort with reducing or stopping chronic medications - providers must overcome reluctance to de-escalate therapy 1
• Restrictive "diabetic diets" - these worsen nutritional status and should be replaced with preferred foods 1, 2
• Continuing aggressive monitoring and treatment in actively dying patients - this increases suffering without benefit 1

Nutritional Considerations

Liberalize diet restrictions to maintain comfort and nutrition 1, 2:

• Eliminate "no concentrated sweets" or "no sugar" diet orders 2
• Offer regular diet with preferred food items 1, 2
• Avoid therapeutic diets that decrease food intake and cause unintentional weight loss 1, 2
• Accept irregular and unpredictable meal consumption as normal in this population 1

Communication and Shared Decision-Making

Initiate early conversations about goals of care 1:

• Discuss the changing balance of benefits and harms of glucose control as death approaches 3, 4
• Address the emotional impact of changing diabetes routines that patients may have followed for years 3, 4
• Involve patients, families, and care partners in decisions about monitoring and treatment intensity 1, 2
• Document patient preferences regarding treatment withdrawal 1

Management of Comorbidities

Coordinate diabetes management with other end-of-life symptoms 1:

• Manage pain from diabetic neuropathy, falls, and other complications 1
• Address depression and behavioral problems with non-pharmacological approaches when possible 1
• Consider withdrawing lipid-lowering therapy to improve quality of life 1, 2
• Relax blood pressure management targets 1