Management of Diabetes at the End of life: a case note audit 8th Annual Welsh Palliative Care Conference 2008 Management of Diabetes at the End of life: a case note audit Dr Siwan Davies Dr Simon Noble

Background Tight glycaemic control prevents long-term side effects of diabetes At the end of life, oral intake is reduced and diabetic patients are at an increased risk of hypoglycaemic episodes. It is appropriate to shift goal of therapy from tight control of blood sugar to maintaining comfort and enhancing quality of life.

Available Evidence Limited Mostly based on non-comparative studies and expert opinion (i.e. grade C and D evidence) However, published guidelines and recommendations are fairly consistent

Audit Standards Note: Guidelines were produced by the Diabetologists, before the appointment of a Consultant in Palliative Medicine at the Trust

Audit Standards Type 1 Diabetes: Insulin is life sustaining and should be continued unless patient requests withdrawal. Try to prescribe a once daily regime – reducing dose appropriately to changes in appetite. Blood glucose monitoring should be reduced to twice daily.

Audit Standards Type 2 Diabetes: Insulin and oral agents should be discontinued If symptomatic hyperglycaemia commence a once daily insulin Monitoring should be reduced to once daily

Method Retrospective case note audit All Medical In-Patients with Diabetes who died at the Royal Gwent Hospital between May 2007 and July 2007 Data analysed using SPSS 12.0

Results 37 case identified 0 Type 1 DM 30 Type 2 DM 1 secondary to steroids 6 case notes unavailable Treatment on admission Number (%) Diet 7 (23) Tablets 16 (51) Insulin 8 (25)

Results: cause of death Number Pneumonia Malignancy 7 6 Cerebral event IHD 5 4 Septicaemia 2 GI bleed Other

Results There was documentation of discussing the expected death with the patient or family in 94% of cases An NFR decision was documented in 97% of the case notes – by means of a ‘yellow’ DNAR order in 77% 29% were commenced on the ‘care pathway’ prior to death.

Results: oral intake Oral intake in the last 24 hours of life against treatment in the last 24 hours of life

Results: frequency of blood sugar monitoring in the last 48 hrs of life

Results: care pathway and end of life management of diabetes

Results: care pathway and end of life management of diabetes Diet Insulin Oral agents No Record Meds prescribed, not given Dextrose given All meds stopped

Summary of Results Discussion of expected deaths with families was well documented Care pathway commenced in less than 1/3 of expected deaths Oral hypoglycaemic agents and insulin were continued in the majority despite minimal or nil oral intake Frequent blood sugar monitoring continued despite reduced dietary intake

Recommendations Results presented at the trust directorate meeting and trust task and finish group on end of life care Increase awareness and use of the Care of the Dying Pathway to manage diabetes appropriately at the end of life Palliative Medicine contribution to the revised trust guidelines Consider incorporation of guidance into the All Wales Integrated Care Pathway Re-audit in 6 months (close loop)

Conclusions Local adherence to the guidelines is poor. Management of patients on the Care of the Dying Pathway at the end of life significantly increased compliance in terms of blood sugar monitoring and the discontinuation of hypoglycaemic agents and insulin.

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