What is the approach to managing diabetes and blood sugar in a patient who has transitioned to comfort care?

Diabetes Management in Comfort Care: A Symptom-Focused Approach

The conversation should center on shifting from glycemic control to preventing distressing symptoms—specifically hypoglycemia, severe hyperglycemia, and dehydration—while simplifying treatment to maximize comfort and dignity. 1

Core Message to Communicate

Your primary goal is no longer tight blood sugar control, but rather preventing symptoms that cause discomfort. 1, 2 This represents a fundamental shift in diabetes management philosophy. The American Diabetes Association explicitly states that end-of-life diabetes care should focus on "promoting comfort; controlling distressing symptoms (including pain, hypoglycemia, and hyperglycemia); avoiding dehydration; avoiding emergency room visits, hospital admissions, and institutionalization; and preserving dignity and quality of life." 1

Key Points to Discuss with Patient/Family

Simplifying Medications

Most diabetes medications can and should be reduced or stopped entirely to prevent hypoglycemia, which causes significant suffering. 1, 2

• For Type 2 diabetes: Consider stopping or significantly reducing insulin and oral medications, particularly sulfonylureas which carry high hypoglycemia risk 1, 2
• For Type 1 diabetes: Never completely stop insulin, but reduce doses appropriately to prevent dangerous hypoglycemia while avoiding severe hyperglycemia 2
• Preferred approach: Use oral agents with low hypoglycemia risk over complex insulin regimens when possible 1
• Respect autonomy: It is entirely appropriate for patients to refuse treatment and withdraw oral medications or stop insulin if desired during end-of-life care 1

Reducing Blood Sugar Monitoring

Frequent finger sticks are no longer necessary and add unnecessary burden. 1

• For Type 2 diabetes: Reduce monitoring from multiple daily checks to anywhere from twice daily to once every 3 days, depending on clinical stability 1
• For Type 1 diabetes: Some monitoring remains necessary, but frequency should be minimized 1
• Focus monitoring only on detecting dangerous extremes (severe hypoglycemia <70 mg/dL or severe hyperglycemia >300 mg/dL) rather than achieving target ranges 1, 2

What Symptoms We're Preventing

Help patients and families understand which symptoms we're actively managing:

• Hypoglycemia symptoms (confusion, shakiness, sweating, loss of consciousness) cause significant distress and must be treated immediately when blood glucose drops below 70 mg/dL 2
• Severe hyperglycemia symptoms (excessive thirst, frequent urination, dehydration) should be prevented by keeping glucose generally below 300 mg/dL 1
• Dehydration requires attention, especially when glucose levels are elevated 1

Critical Clarification About Hypoglycemia

Comfort care does NOT mean withholding treatment for hypoglycemia—this is a common and dangerous misconception. 2

• Hypoglycemia causes severe distress (confusion, agitation, sweating, tremors) that directly contradicts comfort-focused goals 2
• Always treat hypoglycemia immediately using standard protocols when blood glucose is <70 mg/dL 2
• The correct approach is preventing hypoglycemia through medication adjustment, not allowing it to occur and then deciding whether to treat 2
• Healthcare providers should not unilaterally withhold hypoglycemia treatment as this causes unnecessary suffering 2

Practical Treatment Adjustments

Offer specific, simplified regimens:

• Simple insulin approach: If insulin is needed, use scheduled basal insulin with minimal or no mealtime insulin, possibly with a very simple correction scale (e.g., "give 4 units if glucose >300 mg/dL") 1
• Hydration focus: Keep patients well-hydrated, especially when glucose levels exceed 300 mg/dL 1
• Meal flexibility: Allow patients to eat what they want, when they want, without dietary restrictions that diminish quality of life 1

What to Stop Doing

Be explicit about what burdens can be eliminated:

• Stop A1C testing and other diabetes-related laboratory monitoring 1
• Discontinue preventive measures like lipid management, blood pressure targets for diabetes complications, and foot care protocols focused on long-term prevention 1
• Eliminate complex insulin regimens with multiple daily injections 1
• Remove dietary restrictions that limit food enjoyment 1

Framing the Conversation

Present this as removing unnecessary burdens while maintaining comfort:

"Now that we're focusing on your comfort, we can simplify your diabetes care significantly. We'll reduce or stop most of your diabetes medications to prevent low blood sugars, which can be very uncomfortable. We'll check your blood sugar much less frequently—only enough to make sure you're not having symptoms. You can eat whatever appeals to you without worrying about carbohydrate counting or dietary restrictions. Our goal is simply to keep you comfortable by preventing the symptoms of very low or very high blood sugars." 1, 2

Common Pitfalls to Avoid

Do not continue aggressive glycemic control out of habit or fear of hyperglycemia. 1 The evidence shows that overly tight glycemic control in hospice patients causes unnecessary discomfort and does not improve quality of life 1. The shift to comfort care requires actively loosening glycemic targets, not maintaining previous standards.

Do not assume all monitoring and treatment should stop. 2 While simplification is appropriate, completely abandoning glucose monitoring and treatment can lead to preventable suffering from hypoglycemia or severe hyperglycemia with dehydration 2.