1. 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

2. 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.

3. 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

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

5. 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.

6. 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

7. 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

8. 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)

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

10. 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.

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

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

13. Results: care pathway and end of life management of diabetes

14. 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

15. 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

16. 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)

17. 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.

18. Diolch yn Fawr