diabetes at the end of life - adea

Caringaboutdiabetesatthe

endoflife

Dr.JessicaBorbasi

PalliativeMedicineAdvancedTrainee

• Whatispalliativecare?

• Palliativecareanddiabetes

• Principlesofdiabetesmanagementattheendoflife

• Casestudies

• Management

• Conclusionandquestions

Myths

PalliativeCareAnapproachthatimprovesthequalityoflifeofpatientsandtheirfamilieslivingwith

lifethreateningillness.

Buss,M.,Rock,L.,McCarthy,E.(2017).UnderstandingPalliativeCareandHospice:AReviewforPrimaryCareProviders.MayoClini proc92(2):280-286

PalliativeCareanddiabetes

UniversityofSydney.BEACH.(2015).CareofOlderPeopleinAustralianGeneralPractice

Whybother?

• Hyperglycemia• Thirst,urinaryfrequency,lethargy• Increasedbypain• Contributestodelirium,confusion• Reducedmood• Affectsqualityoflife

• Hypoglycemia• Affectsmemory• CantriggerMI• Sweating,faint,unwell• Death

• Pharmacologyofdiabetesmedicationschange

• Thegoalsofcarechange

• Changingexpectations

Mrs.FS- 89yearoldwomanathomewithherhusband

T2DM,CKD,HTN,COPD,IHD,CCF

Medications

Humalograpid26unitsmane,22unitsmidday,8unitsnocte

Lantus13unitsdaily

Candesartan8mgmane

Ranitidine150mgBD

Bumetadine 1mgmane

Nicorandil 20mg

Nebivolol 10mg

Aspirin100mg

Magmin x3daily

MegaB x1daily

Hair/skinnailsmultivitamindaily

Atorvastatin40mgnocte

Lorazepam1mgnocte

Mirtazepine 15mgnocte

CephalexindailyforUTIprevention

*allnameshavebeenchanged

Mrs.FS

2nd Nov11.8prebreakfast,7.9prelunch,10.6predinner5th Nov3.7prelunch6th Nov3.6prelunch7th Nov3.8prelunch,6.2predinner8th Nov5.3prelunch

4Questionstoconsider

Doesthispersonwarrantthinkingabouttheirdiabetesdifferently?• Prognosticationtools

Whatstagearetheyin?• Stable,unstable,deteriorating,terminal

Whatarethegoalsofcare?

Howdoweneedtochangetheirdiabeticmanagementaccordingly?• Theprinciplesofendoflifediabetescare

Doesthispersonwarrantthinkingabouttheirdiabetesdifferently?

https://www.spict.org.uk/

Doesthispersonwarrantthinkingabouttheirdiabetesdifferently?

Whatstagearetheyin?

https://ahsri.uow.edu.au/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow222232.pdf

Whatarethegoalsofcare?

Qualityoverquantityoflife

Avoidhospitalization

Symptommanagementwithafocusoncomfortnotlifeprolongation

Todieathomepeacefully

Howdoweneedtochangetheirdiabeticmanagementaccordingly?

Theprimefocusisonsafety,comfortandqualityofliferatherthanachieving’tight’glycemiccontrol

Endoflifediabetescare,DiabetesUK

Glycemictargets

Reducingtheriskofhyposandhyperglycemia

Managingothermedications

Personalizedapproach

Managingexpectations

Mrs.FSHumalograpid26unitsmane,22unitsmidday,8unitsnocteLantus13unitsdaily

Endoflifediabetescare,DiabetesUK

Endoflifediabetescare,DiabetesUK

Mrs.FS

RelaxedglycemictargetsNoglucoselevellessthan6,noglucoselevelhigherthan15

AdjustmedicationsAimreducedregularrapidacting

Discussgoalsofcareandexpectations

https://www.news.com.au/lifestyle/health/health-problems/vanessa-juresics-final-heartbreaking-words-to-her-

grieving-family-and-friends/news-story/fc61484315b33bb02286947bcee5ba1c

Mr.DJ

35yearoldlandscaperwithT1DM

Marriedwitha4yearoldson

Glioblastomamultiforme

MEDICATIONS

Dexamethasone2mgdailySertraline100mgLamotrigine200mgBDOxycontin 10mgBDKeppra 500mgBDLacosamide 100mgBDLorazepam2mgnocte

Insulinpumpmedtronic withnovorapid

Hba1C9%

4Questionstoconsider

Doesthispersonwarrantthinkingabouttheirdiabetesdifferently?• Prognosticationtools

Whatstagearetheyin?• Stable,unstable,deteriorating,terminal

Whatarethegoalsofcare?

Howdoweneedtochangetheirdiabeticmanagementaccordingly?• Theprinciplesofendoflifediabetescare

Steroidsattheendof

life

https://www.nwcscnsenate.nhs.uk/files/2814/3394/6186/Corticosterioids.pdf

Endoflifediabetescare,DiabetesUK

Guidelinesformanagingdiabetesattheendoflife

Commonpitfalls

• Abandonment

• Stabilityandfamiliarity

• Lowpriorityforpallcarenurses

Endoflifediabetescare,DiabetesUK

Inconclusion

• Youmaybethefirstpersontorecognizeapatientisapproachingendoflife• Principlesofdiabetesmanagementattheendoflife• Ensuresymptomscontrol- minimizediabetesrelatedeffects• Shiftfocusfromlongtermpreventiontonewgoalsofcare• Individualizedapproach- tailortherapies• Ensureplentyofpatientinvolvementandeducation

• Diabetesdoesmatterattheendoflife

References• Clinicalcarerecommendations(2018).Endoflifediabetescare.3rd edition.DiabetesUK.• Dunning,T.,Martin,P.,Savage,S.&Duggan,N.(2010).Guidelinesformanagingdiabetesattheendoflife.• Dunning,T.,Savage,S.,Duggan,N&Martin,P.(2014).Palliativeandendoflifecareforpeoplewithdiabetes:atopicalissue.DiabetesManagement,4(5).,pp.449-460.• Buss,M.,Rock,L.,McCarthy,E.(2017).UnderstandingPalliativeCareandHospice:AReviewforPrimaryCareProviders.MayoClini proc92(2):280-286• UniversityofSydney.BEACH.(2015).CareofOlderPeopleinAustralianGeneralPractice• https://www.spict.org.uk/