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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: • • • • • • • • 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 • • • • 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 • • • • 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)