diabetes at the end of life - adea
TRANSCRIPT
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/