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 Even though diabetes care guidelines recommend a less aggressive
approach to controlling blood sugar when individuals have a limited
life expectancy, many hospice patients continue their blood sugar
testing and diabetes medications.
"The usual process of dying involves eating less, so most patients
with diabetes will need less and less medicine as their disease
advances," said lead author Dr. Sei J. Lee, an associate professor
of geriatrics at the University of California San Francisco.
Patients who continue to monitor their blood sugar with painful
fingerprick tests, and keep up their blood sugar-lowering
medications, are needlessly at risk of low blood sugar –
hypoglycemia - when the main reasons for controlling high blood
sugar no longer apply, the study team writes in the American Journal
of Hospice and Palliative Medicine.
Lee and his coauthors examined the reasons that patients continue to
receive diabetes treatment in hospice.
"Patients and families fear abandonment from their providers, and
unless carefully explained, recommending less medicine may feel like
they are receiving less care and attention," Lee told Reuters
Health.
In addition, doctors have often counseled these patients for many
years about the need to control their blood sugar more tightly.
"Doing an ‘about-face’ and recommending controlling blood sugars
less tightly may be uncomfortable to doctors," he said.
While aggressive treatment may be appropriate for young, healthy
patients, it is almost never appropriate for hospice patients, the
authors emphasize.
The main benefit of keeping blood sugar tightly controlled is to
stave off damage to small blood vessels and the resulting
complications, such as damage to the eyes and kidneys.
But the benefits of keeping a tight control on blood sugar are only
seen after many years, Lee and his colleagues point out.
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Many doctors and patients are also concerned that letting blood
sugar get too high - hyperglycemia - may make the patient feel tired
and sick. The authors point out, however, that little is really
known about the level of hyperglycemia that can cause noticeable
symptoms.
Lee and his colleagues call for more research on appropriate blood
sugar levels for individuals with a limited life expectancy, but in
the meantime they recommend more leeway for patients in hospice.
The overall position of this paper is consistent with that of the
American Diabetes Association (ADA), said Dr. Samuel Dagogo-Jack,
the ADA president for medicine and science.
"But just like this paper is unable to present very specific
evidence, we also cannot give very rigid guidelines," he told
Reuters Health. "The studies are just not there."
Dagogo-Jack noted that physicians who take care of patients in
different settings need to individualize care. “For example, we
can’t check blood sugar noninvasively,” he said.
“We have to stick the patient’s finger or draw blood from a vein. So
when in hospice, we relax the goals of treatment and we also make
the decision of what is rational as far as the frequency in testing
blood sugar levels. We have to practice the principle of doing no
harm and maximizing the comfort of the patient,” Dagogo-Jack said.
Lee and his coauthors recommend that doctors speak with patients
enrolling in hospice and explain that as their illness progresses,
their appetite will wane, and when that happens, using less (or no)
diabetes medicines can prevent unwanted additional symptoms and keep
patients most comfortable.
SOURCE: http://bit.ly/1Ai1GF0 American Journal of Hospice and
Palliative Medicine, online April 7, 2015.
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