Managing Fluctuating Blood Sugar Levels in Terminal Patients

Primary Goals of Care at End of Life

The American Diabetes Association recommends promoting comfort and controlling distressing symptoms, including pain, hypoglycemia, and hyperglycemia, in terminal patients 1
The primary goal is to avoid dehydration, emergency room visits, and hospitalizations, while preserving dignity and quality of life 1
Preventing hypoglycemia is the priority over preventing hyperglycemia in terminal patients, according to the American Diabetes Association 2

For stable terminal patients, the American Diabetes Association suggests continuing previous diabetes regimen with modifications, focusing primarily on preventing hypoglycemia, and keeping glucose levels below renal threshold (approximately 180-250 mg/dL) 2
For patients with organ failure, preventing hypoglycemia becomes paramount, and reducing or discontinuing agents that cause hypoglycemia is recommended 2
For actively dying patients, discontinuation of all diabetes medications is reasonable, and accepting glucose levels >250 mg/dL to minimize intervention burden is acceptable 6

The American Diabetes Association recommends dramatically reducing monitoring frequency based on patient status, with reduced monitoring for Type 2 diabetes in terminal care (twice daily or every 3 days) 1
For Type 1 diabetes, monitoring frequency may need to remain higher due to ketoacidosis risk 1

The American Diabetes Association suggests simplifying medication regimens to reduce treatment burden and hypoglycemia risk, preferring oral glucose-lowering agents over complex insulin regimens 1
Using simplified insulin regimens with low hypoglycemia risk and discontinuing medications that increase hypoglycemia risk is recommended 2

Overly tight glycemic control driven by quality metrics is a common error in terminal diabetes care, and healthcare providers should avoid this approach 4
Discomfort with reducing or stopping chronic medications is another pitfall, and providers must overcome reluctance to de-escalate therapy 4

Liberalizing diet restrictions to maintain comfort and nutrition is recommended, with elimination of "no concentrated sweets" or "no sugar" diet orders 5
Offering regular diet with preferred food items and avoiding therapeutic diets that decrease food intake and cause unintentional weight loss is suggested 5

Coordinating diabetes management with other end-of-life symptoms, such as managing pain from diabetic neuropathy and addressing depression and behavioral problems, is essential 1
Withdrawing lipid-lowering therapy to improve quality of life and relaxing blood pressure management targets may be considered 2