21st May 2025

Diabetes in Palliative care

Caring for people with diabetes as they approach EOL care can often be complex due to the variety of insulin and non-insulin therapies available. Mortality data shows that over 20% of patients each year have a form of diabetes. The management of diabetes in EOL care can be broadly split into three categories: 

• The last months of life 
• The final weeks of life
• The last days of life. 

These are discussed in more detail below.

Overview of the Medical Management

Patients with lifelong diabetes have often had to stick to stringent clinical targets to mitigate the risks of long-term micro and macrovascular complications. Understandably, if it becomes evident that a patient is approaching EOL, regular monitoring of blood glucose levels can be relaxed. This shift in treatment approach can often cause concern and distress. Therefore, engaging individuals and their families about how they want their care to transition as they approach EOL is essential. This process should be conducted with utmost sensitivity, emphasising that the primary goal of care should transition towards enhancing their quality of life. It necessitates comprehensive discussions on the adjustments required in their medical management. The sections below provide an overview of Non-Insulin Therapies, Insulin Therapies, and Continuous Subcutaneous Insulin Infusion (Insulin Pump Treatment).

Non – Insulin Therapies

During their lifetime, individuals with type 2 diabetes usually transition from diet control to requiring pharmacological treatment. Traditionally, first-line pharmacological management involves metformin; however, this may progress to utilising multiple agents in combination. The patient’s HbA1c levels guide the intensification of therapy. 

When a diagnosis indicates that an individual is reaching the end of their life, it becomes essential to re-evaluate their medication regimen. At this stage, the fundamental principles of drug management remain the same. Particular emphasis should be on optimising medication choices to minimise the side effects and improve quality of life. This includes balancing the risk of both symptomatic hyper- and hypoglycaemia. Additionally, it is crucial to consider factors such as the evolving burden of the disease, the individual’s diminished appetite, and the deterioration of renal and hepatic function.

Table 2: Common medication and risk of hypoglycaemia

Insulin therapies (Type 1 and Type 2 Diabetes)

Individuals diagnosed with type 1 diabetes have an absolute dependence on insulin therapy and should continue to have insulin despite being EOL due to their risk of developing diabetic ketoacidosis.

Conversely, most individuals with type 2 diabetes still maintain some level of endogenous insulin production, protecting them against ketoacidosis. However, they are at risk of developing hyperosmolar hyperglycaemic states, particularly if given corticosteroids.

As an individual’s health deteriorates and they approach EOL, a review of their insulin dosage becomes necessary, often resulting in a reduction. The occurrence of reduced appetite and declining body weight often prompts this adjustment. As food intake diminishes, fast-acting insulin can likely be discontinued, and basal insulin will suffice, even for people with type 1 diabetes.

It is recommended to initiate a conversation about target glucose levels and treatment objectives early to ensure that individuals and their families understand the likelihood of dose reductions.

Continuous subcutaneous insulin infusion (Insulin Pump Treatment)

Insulin pumps have become increasingly common amongst patients with type 1 diabetes because they provide better flexibility. However, as they rely on frequent capillary blood glucose testing and adjusting bolus doses according to the carbohydrate content of their food, they need monitoring and adjustment towards the EOL. Therefore, early involvement of the Diabetes Specialist Pump Team is required.

Managing diabetes in the last year to months of life

Recognising people in their last year of life is essential and allows meaningful conversations about what matters most to the individual. It means individuals can express their views and priorities about future care. During this time, stringent blood glucose targets should be relaxed. Although there is no published evidence for target glucose or HbA1c levels, Diabetes UK suggests;

• Aim 1 – no glucose level less than 6 mmol/l 
• Aim 2 – no glucose level higher than 15 mmol/l

It is essential to recognise that the optimal range will vary according to the stage of illness, the individual’s ability to eat and drink normally, the presence of hypoglycaemia, the nutritional status, and the treatments given. 

As an individual approaches their last year to months of life, complex regimens should be reviewed and rationalised. It is much easier for the patient to be on insulin alone rather than multiple combinations of oral hypoglycaemic agents alongside insulin. Insulin regimens should be simplified, e.g. changing from twice to once daily (long-acting) insulin, even in patients with type 1 diabetes.

Managing diabetes in the last weeks of life

During the last weeks of life, patients approaching EOL should have been identified. In keeping with the advice above, the patient’s medications should be rationalised and adjusted; however, there may be little time to get used to a new insulin regimen. Support should be sought from the diabetic team as help is often needed for dose adjustments, as well-being, activity and appetite can change daily. 

Also, choosing relaxing targets for control may seem like “giving up” for some patients and their families, whilst others may view managing diabetes in addition to their terminal illness as “futile”. The development of hypoglycaemia in people not previously prone to this is a poor prognostic sign.

The main aim of treatment here is to:

• Keep invasive tests to a minimum – look at the method and frequency of checking blood glucose levels. It is advisable to perform a single capillary blood test each day just before administering insulin to confirm that blood glucose levels fall within the desired range and to pre-empt the occurrence of hypoglycaemia.
• Be alert to hypo or hyperglycaemia symptoms and have appropriate medication/interventions available to address these if they develop. 
• Aim for a target blood glucose reading of 6-15mmol/L. 
• Rationalise the amount of medication needed to control their diabetes.

Managing diabetes in the last days of life

Ideally, by this point, diabetes treatment has been minimised so that few changes are required. Diabetes at end-of-life encompasses changes to: 

• Tailoring of diabetes medications

Table 3: Diabetes medications

• Glycaemic targets 

Table 4: Glycaemic targets

• Individual and carer expectations
• Reducing the risk of hyperglycaemia and hypoglycaemia 
• Managing the effects of other EOL medications, e.g. glucocorticosteroids