Do I need to treat hypoglycemia (low blood sugar) in a patient receiving comfort care (palliative care)?

Treatment of Hypoglycemia in Comfort Care Patients

Yes, you should treat hypoglycemia in comfort care patients, as preventing hypoglycemia is explicitly identified as a primary goal of palliative diabetes management alongside preventing distressing symptoms and preserving quality of life. 1

Core Principle

The American Diabetes Association clearly states that palliative medicine promotes "comfort, symptom management and prevention (pain, hypoglycemia, hyperglycemia, and dehydration)" in patients with limited life expectancy. 1 Hypoglycemia causes distressing symptoms (confusion, sweating, tremor, altered consciousness) that directly contradict comfort-focused goals. 1

Treatment Approach

Immediate Management

• Treat hypoglycemia immediately when blood glucose is <70 mg/dL (<3.9 mmol/L) - treatment should not be delayed even while notifying the healthcare provider. 1
• Use standard hypoglycemia protocols (15-15 rule with fast-acting carbohydrates for conscious patients, glucagon or D50 for severe cases). 1

Prevention Strategy

The goal is to prevent hypoglycemia from occurring rather than simply treating it reactively. 1 This requires:

• Simplify medication regimens - reduce or eliminate agents that cause hypoglycemia (insulin, sulfonylureas). 1
• Relax glycemic targets - aim to prevent both hypoglycemia AND severe hyperglycemia (>250-300 mg/dL), not tight control. 1
• Reduce monitoring frequency - decrease capillary glucose checks to what's necessary to detect problematic hypo- or hyperglycemia, not for tight management. 1

Medication Adjustments in Comfort Care

For Type 2 Diabetes:

• Prefer oral agents over insulin when possible, choosing those with low hypoglycemia risk. 1
• If insulin is needed, use simplified basal-only regimens without rapid-acting insulin. 1
• Discontinue or reduce sulfonylureas - these carry high hypoglycemia risk. 1
• Avoid agents causing GI distress (nausea, weight loss) as these worsen comfort. 1

For Type 1 Diabetes:

• Never completely stop insulin even as oral intake decreases, but reduce doses appropriately. 1
• Preventing hypoglycemia becomes the paramount concern. 1

Monitoring Considerations

• Reduce but don't eliminate glucose monitoring - check only as frequently as needed to detect dangerous hypo- or hyperglycemia. 1
• Monitor oral intake carefully - variable food consumption increases hypoglycemia risk. 1
• Consider giving insulin after meals rather than before to match actual carbohydrate intake. 1

Critical Distinction

Comfort care does NOT mean withholding treatment for distressing symptoms. 1 The patient has the right to refuse testing and treatment, but healthcare professionals should not unilaterally withhold hypoglycemia treatment, as this causes significant discomfort and suffering. 1

The appropriate approach is to prevent hypoglycemia through medication adjustment rather than allowing it to occur and then deciding whether to treat. 1

Common Pitfall

Do not confuse "relaxing glycemic control" with "ignoring hypoglycemia." 1 Relaxing control means accepting higher glucose levels (avoiding A1C targets, allowing glucose 150-250 mg/dL) while still preventing the distressing extremes of severe hypoglycemia and symptomatic hyperglycemia. 1