Download Diabetes and Advanced Illness

DIABETES AND
ADVANCED ILLNESS
WESTERN AREA GUIDANCE
AIMS
• To optimise benefits and minimise burden of
diabetes related care during the terminal phase of
life.
• To adapt treatment continually to reflect
physiological changes and increasing frailty.
• To stress the core importance of individualised
person centred approach
• To involve the patient and/or carers (often experts
in their own diabetes) in clinical decision making
where possible.
• Guidance adapted from Diabetes UK by:
• Dr Neil Black, Consultant Endocrinologist and
Clinical Lead Diabetes, WHSCT
• Sr Lisa King, Diabetes Specialist Nurse Lead, AAH
• Western Trust Primary Palliative Care Team
• Foyle Hospice Medical Team
LOCAL ADVICE
• Northern Sector
• Hospital Diabetes Team:
• Name
Phone
• Email
• Community Diabetes Team
• Name
Phone
• Email
LOCAL ADVICE
• Southern Sector
• Hospital Diabetes Team:
• Name
Phone
• Email
• Community Diabetes Team
• Name
Phone
• Email
ISSUES OF IMPORTANCE: 1.
Illness related symptoms are increasingly prevalent during
the last year of life:
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Changes in appetite/food intake
Cachexia/ weight loss
Nausea/ Vomiting
Diarrhoea
Dehydration
Electrolyte imbalances
Frequent infections
Effect of pain on glycaemic levels
• Implications for diabetic control; Consider need to
monitor carefully and adjust treatment.
ISSUES OF IMPORTANCE : 2
Iatrogenic Problems also prevalent:
• Drug induced hyperglycaemia (e.g. steroids)
• Drug related hypoglycaemia (e.g. some
chemotherapies)
• Other drug related side effects ( e.g. GI Upset:
Nausea, diarrhoea:- metformin)
• Implications for control and treatment: need to
monitor, adjust treatment
GLUCOSE TARGETS IN END OF LIFE
CARE (DIABETES UK)
• No pre meal glucose lower than 6mmol/l.
• No pre meal glucose higher than 15mmol/l .
• Main issue is quality of life; comfort.
• Note: less than 6mmol/l increases risk of
hypoglycaemia
• Greater than 15mmol/l can lead to symptomatic
hyperglycaemia.
• Individual assessment of stability and risk of DKA/
hyperosmolar hyperglycaemia.
GLUCOSE TARGETS IN END OF LIFE
CARE
• Consider need to monitor and frequency of
monitoring on an Individual Basis.
• Hypoglycaemia generally a more significant risk
than hyperglycaemia (appetite loss etc.) so target
pre-meal levels need to be higher.
• Adjust targets further upwards if:
• patient having hypoglycaemia before meals
despite snacks
• Long gaps between meals due to anorexia.
REVIEW OF MEDICATIONS: STAGE 1
(PROGNOSIS OF ?A YEAR OR MORE)
• Review need for and dose of:
• ACE Inhibitor/ ARB (dose reductions commonly
needed)
• Aspirin (Increased risk GI effects; risk may outweigh
benefit)
• Statins (benefit questionable; side effects increase if
liver or renal function affected)
• Watch for weight loss and review blood glucose
targets and treatment.
REVIEW OF MEDICATIONS; STAGE 2
(PROGNOSIS OF ?2-3 MONTHS)
• Above stage plus:
• Simplify all treatment (Insulin alone simpler than
insulin and tablets)
• Flexibility needed if physical changes progressing.
• Once daily insulin simpler than BD (75% of total
previous dose), especially where weight or appetite
reducing.
• Side effects of oral medications heightened.
• ? Monitor renal function if on OHAs (esp metformin).
REVIEW OF MEDICATIONS; STAGE 3
(PROGNOSIS OF 2-3 WEEKS)
• Above stages plus:
• Review and consider relaxation of glucose targets .
• May need to intensify frequency of monitoring for
insulin users/ relax frequency for stable type 2.
• Well being, appetite, intake can vary from day to
day.
STAGE 4; LAST DAYS OF LIFE
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Diabetes UK End of life care guidance.
Individual.
Withdraw or simplify treatment where possible.
Minimise monitoring as much as possible.
DIABETES UK: DEFINING PRINCIPLES OF
END OF LIFE CARE IN DIABETES.
• Avoidance of foot complications in frail, bed-bound
patients with diabetes
• Avoidance of symptomatic clinical dehydration
• Provision of an appropriate level of intervention
according to stage of
illness, symptom profile, and respect for dignity
• Supporting and maintaining the empowerment of
the individual patient(in their diabetes selfmanagement) and carers to the last possible stage
GENERAL PRINCIPLES: ORAL
HYPOGLYCAEMIC AGENTS
• Role of dietitian very important: may need to rely on
sugary or high calorie foods.
• Avoid long acting SUs (risk hypoglycaemia)Gliclazide MR, glibenclamide, Glimepiride
Consider change from OHAs to low dose insulin to
allow flexibility and minimise OHA related side effects
• Review Metformin ( large tablets, hard to swallow,
cause GI upset++, renal function monitoring.)
• Review GLP-1 receptor agonist (nausea, risk
hypoglycaemia, risk pancreatitis.)
• Treat pain effectively.
PARTICULAR RISK FACTORS
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Poor/erratic appetite
Deteriorating renal function
Liver disease/carcinoma
Weight loss.
ROLE OF DIABETES SPECIALIST TEAM;
REFER WHEN:
1. Failure to control distressing symptoms of
hyperglycaemia
2. Where further management requires complex
treatment decision-making, e.g. commencing steroids,
changing an insulin regime
3. In the presence of marked dehydration or infection
failing to respond to treatment when diabetes-related
emergencies supervene such as hyperosmolar
hyperglycaemia state
4. When withdrawal of glucose-lowering therapies
including insulin are being considered.
5. In the face of marked patient or carer anxiety
WITHDRAWAL OF TREATMENT IN
DIABETES: CONSIDER WHEN:
• When the patient with diabetes is entering the
terminal phase of life
• Where frequent treatment-related hypoglycaemia
is causing distress and significant management
difficulties
• Where continued treatment with insulin poses an
unacceptable risk of hypoglycaemia or where the
benefits of stricter glucose control cannot be justified
• Where continued use of blood pressure or lipid
lowering therapy cannot be justified on health benefit
considerations
• Where continued food or fluids is not the choice of
the patient
SUMMARY; GUIDING PRINCIPLES
• Simplify treatment as far as possible
• Minimise side effects of treatment.
• Assess individual risk of instability (appetite, weight
loss, renal/liver function, polypharmacy); consider
replacing OHAs with low dose insulin if risks high.
• Steroids. Individual management plan during days
of treatment.
• Role of patients and carers remains central. Assess
wishes; shared/planned decision making.
USEFUL RESOURCES
Presentation based on Diabetes UK End of Life Care Strategy July 2012.
http://www.diabetes.org.uk/upload/Position%20statements/End%20of%
20Life%20Diabetes%20Care%20Stategy.pdf
See also:
www.book.pallcare.info
(Palliative Care Adult Network Guidelines)