|Year : 2016 | Volume
| Issue : 2 | Page : 116-121
Diabetes management patterns in a palliative care unit in Saudi Arabia
Sami Ayed Alshammary1, Balaji Duraisamy2, Abdullah Alsuhail2, Mohammad Mhafzah2, Lobna M. A. Saleem2, Nadir Mohamed2, Savithiri Ratnapalan3
1 Comprehensive Cancer Center, Palliative Care Unit, King Fahad Medical City; Centre for Postgraduate Studies in Family Medicine, Ministry of Health, Riyadh, Saudi Arabia
2 Comprehensive Cancer Center, Palliative Care Unit, King Fahad Medical City, Riyadh, Saudi Arabia
3 Department of Paediatrics, Dalla Lana School of Public Health, Toronto, Ontario, Canada
|Date of Web Publication||7-Apr-2016|
Sami Ayed Alshammary
Comprehensive Cancer Center, Palliative Care Unit, King Fahad Medical City, Riyadh
Background: The terminally ill diabetic inpatients who had blood glucose monitoring continued until the day of death ranged from 32% to 76% according to previous studies. Researches regarding the management of diabetes in palliative care services in Saudi Arabia are insufficient, although it is of high prevalence. Balancing the goals of avoiding symptoms of hyperglycaemia and hypoglycaemia as well as minimising the burden of blood glucose monitoring and treatment have become a struggle to palliative care physicians due to limited evidence-based resources. This intensifies the complexity of managing diabetes during a terminal illness.
Objective: The purpose of this study was to describe the management of diabetes among patients who were admitted to hospital-based palliative care unit (PCU) at King Fahad Medical City, Riyadh, Saudi Arabia.
Methods: A retrospective chart review, cohort study for all PCU inpatients was done. The study was conducted on the charts of 12 months from January to December 2013. Measures included diabetes prevalence, monitoring of blood glucose by laboratory and/or bedside testing and diabetes treatment with the use of oral hypoglycaemic agents and insulin. Prevalence of diabetes associated comorbidities, hypertension and dyslipedemia were also measured along with their treatment. A descriptive analysis of collected data was carried out.
Results: Eighteen adult diabetic patients (15.25%) out of the whole 118 patients admitted to PCU over the 12 months' study period were reported. Ten (55.6%) were males, and 8 (44.4%) were females, with a mean age of 59.26 years. Blood glucose monitoring in the diabetic patients was done for ten patients; bedside glucometer utilized for 9 patients (50%), glucometer + serum glucose measurement done in one patient (5.6%), and no glucose monitoring was done in eight patients (44.4%). The majority of the patients 11/18 (61%) stayed at the hospital until death while 7/18 (39%) did well and were discharged. The monitoring of blood sugar was continued for six patients until the last week of life. Blood glucose management dropped to 33% at the end of life. Initially, half of the patients (50%) had their blood glucose managed with hypoglycaemic medications with or without insulin. This dropped during the last week of life to 33%. In the comorbidity group, 72% were using antihypertensive or lipid lowering agents, as a result of which it dropped to 50% during the last week of life.
Conclusion: Diabetes management varied among PCU patients. There is a real need for evidence-based guidelines for diabetes management among patients at the end of life. These guidelines should be tailored to patients' individual preferences in goals of care. Advance care planning should include discussion about patient preferences for management of diabetes at the end of life.
Keywords: Comorbidity, diabetes, end of life, guidelines, management of diabetes, palliative care
|How to cite this article:|
Alshammary SA, Duraisamy B, Alsuhail A, Mhafzah M, Saleem LM, Mohamed N, Ratnapalan S. Diabetes management patterns in a palliative care unit in Saudi Arabia. J Health Spec 2016;4:116-21
|How to cite this URL:|
Alshammary SA, Duraisamy B, Alsuhail A, Mhafzah M, Saleem LM, Mohamed N, Ratnapalan S. Diabetes management patterns in a palliative care unit in Saudi Arabia. J Health Spec [serial online] 2016 [cited 2019 Oct 19];4:116-21. Available from: http://www.thejhs.org/text.asp?2016/4/2/116/179819
| Introduction|| |
Diabetes is found to be 6 times more prevalent in cancer patients than in the general population. In Saudi Arabia, the rate of diabetes is around 23.7% compared to 6.4% rate worldwide. Despite this overwhelming rate, research about diabetes management is still scarce.
Guidelines for the management of type II diabetes have been standardised after the publication of UK Prospective Diabetes Study in 1998. However, these international standards are scientifically impractical if applied to the society in general and possibly contrary to the quality-of-life goals that the palliative care promotes.
End-of-life is defined in many perspectives. However, in palliative care, it is identified as the moment when the person is faced with a declining health condition. Improving the outlook toward life of patients and their families facing life-threatening illness through prevention and relief of suffering defines palliative care. Its approach involves early identification, flawless assessment, pain management and other aspects such as physical, psychosocial and spiritual care. Disease management has always been top priority, maximising what the medical advancements have to offer to lengthen the life of people who are suffering with multiple comorbidities.
Since the palliative care unit (PCU) in King Fahad Medical City (KFMC) was established in March 2010, it has received from referral systems numerous patients with advanced cancer and diabetes. Assessment of the prevalence of diabetes mellitus among its patients and patterns of management are the main aims of this study.
Coordination among physicians and other multidisciplinary teams is of importance. Lack of coordination leads to complexities in the management of diabetes during terminal illness. Balancing the goals of avoiding symptoms of hyperglycaemia and hypoglycaemia versus minimising the burden of blood the glucose monitoring and diabetes management during the last weeks of life becomes an endemic burden to palliative care clinicians due to limited orientation and background. Maintaining tight glycaemic control for years prevents patients from long-term complications such as diabetic retinopathy and nephropathy. Treatment goals are set not to prevent patients from long-term complications but to prevent them from symptomatic hypo - or hyperglycaemia as well as minimise the burden of diabetes treatment. Rationally, tight glycaemic control can be too risky to nearly end-of-life patients. This may intensify the burden as it requires frequent blood investigations and increases number of medication with no guarantee for a positive outcome.
Increased incidence of diabetes, advanced disease in older people, diabetogenic medicines such as corticosteroids, obesity and metabolic changes due to cancer are the multifactorial causes of diabetes in patients with advanced disease. Due to lack of insulin, these patients are unable to utilise their glucose. Furthermore, their body's stored fats and protein which supply energy are not mobilised if insulin which enhances and replaces blood glucose is not given. Reduced appetite and fatigue are common manifestations of patients with advanced cancer. These hinder them to have optimal energy requirements and glycaemic control, which are very important for diabetic patients.
A person with diabetes recognises hypoglycaemia and hyperglycaemia in association with body cues. These may intensify over time with increasing duration of diabetes or when triggered by other diseases or medicines. Some medicines given to patients with advanced cancer such as corticosteroids and diuretics trigger hyperglycaemia. Nausea and lethargy are some symptoms that occur as a consequence. At this stage, health professionals find it difficult to determine the underlying causes of the symptoms.
Automatic neuropathy can cause type I diabetes patients to experience hypoglycaemia unawareness. Frequent desensitisation decreases the patients' ability to recognise hypoglycaemia symptoms. A person detects hypoglycaemic symptoms through the glycaemic threshold. It lowers down once the brain no longer signals for adrenaline release and up-regulation of brain glucose transporters.
Furthermore, if the underlying cause of the hyperglycaemia is not clearly identified, it may cause unpleasant symptoms such as lethargy, low mood, nausea and vomiting; and exacerbates pain that may not be adequately relieved.
It is best recommended that if a person experiences hypoglycaemic unawareness or an inability to respond or indicate that they are hypoglycaemic, blood glucose should constantly be monitored.
Potentially, hypoglycaemia and hyperglycaemia may cause life-threatening complications. This concerns many diabetic patients and their families. In line with this, results from the former related research show that numerous such patients prefer active management to continue at their end of life. There has even been a recommendation from some health professionals that finger pricking in the peak days of life be done to de-stress the patient (Quinn et al.).
Glycaemic control is very essential for diabetic patients. This can successfully be achieved by glucose-lowering medicines and careful monitoring of blood glucose levels, and proper diet.
The literature review shows the fact that glycaemic management for patients with advanced cancer may vary and lack enough evidence to prove its suitability.
Managing diabetes at the end of life has been a struggle for palliative care healthcare professionals because it is not addressed in the available major palliative care and diabetes management guidelines.
It has been found in the previous studies that among the terminally ill inpatients in diabetic hospitals, 32 - 76% received continual blood glucose monitoring until the day of death.,
Majority of the diabetic patients are still unaware of the advanced care plans available in managing diabetes. However, some of them are still firm in their views that they want to undergo the diabetes management only when they are very ill. They also set expectations from the people around them to respect their preference.
Clinicians always face challenges in managing diabetes mellitus in a hospice patient. There are only few related and applicable resources available to serve as their references.
Quinn et al. developed focus groups and performed a survey to address questions regarding diabetes management in palliative care patients. More recently, Angelo et al. published an approach to guide clinicians in diabetes care for a palliative care patient by delineating three patient categories (active disease but relatively stable, impending death or organ or system failure and actively dying) with accompanying suggestions for a palliative plan of care. Tice  likewise suggested management approach of diabetes at end of life. Of central concern, though, is the need to be proactive in developing an appropriate and continually evolving plan of care that focuses on quality of care and patient-identified goals of care. Nutritional and physiological changes as the end of life approaches mandate a need to be vigilant in recognising signs and symptoms of hypoglycaemia, as well as in making medication adjustments in anticipation of need.
This study had two primary outcomes. First, to describe the management of diabetes and related condition among patients admitted to hospital-based PCU at KFMC, Riyadh. Second, to determine the prevalence of diabetes mellitus among palliative care patients.
Secondary outcomes are, to find out the comorbidity such as hypertension (HTN), dyslipidaemia associated with diabetes and the patterns of their management.
| Methods|| |
A retrospective chart review, cohort study for all PCU inpatients was done. The study was conducted on the charts of a 12-month period from January to December 2013. Measures included diabetes prevalence, monitoring of blood glucose by laboratory and/or bedside testing and diabetes treatment with the use of oral hypoglycaemic agents and insulin. Prevalence of diabetes associated comorbidities, HTN and dyslipidaemia were also measured along with their treatment. Descriptive analysis of collected data was done.
| Results|| |
Overall, 18 patients out of 118 patients (15.25%) in the PCU had diabetes at the time of admission to the PCU. The diagnosis of diabetes was done by history and a review of blood glucose levels. Of these, ten patients had blood glucose monitoring by some means while eight patients were not monitored [Table 1].
On the management of blood glucose, 9 out of the 18 patients (50%) received either oral hypoglycaemic agents or insulin or both [Table 2].
The majority of diabetic patients 11/18 (61%) stayed in the hospital until death while only 7/18 (39%) were well and discharged.
The monitoring of blood sugar was only observed in 10 out of 18 diabetic patients. The glucometer was used as a tool to monitor the blood sugar for all those ten patients while one of those 10 used both glucometer and plasma glucose. However, the monitoring continued for only six patients until the last week of life (27.7%). Bedsides glucometer monitoring every 6 h, regular insulin according to sliding scale was used to manage blood glucose levels.
As shown in [Table 3] and [Table 4], blood glucose monitoring decreased to 33.3% in the last week of life and its management dropped to 33% as well. Six patients received insulin to manage diabetes even in their last week of life [Table 3] and [Table 4].
There were seven patients who were discharged home and did not enter the last week of life in the PCU.
[Table 5] shows 72% of patients who had diabetes also suffered from other comorbidities such as HTN and dyslipidaemia.
|Table 5: Prevalence of co-morbidities in diabetics in palliative care unit|
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[Table 6] shows that 50% of PCU patients (or 9 patients) had continued management for comorbidities even in their last week of life [Table 6].
| Discussion|| |
Obesity, sedentary lifestyle and lack of exercise are some of the risk factors for cancer patients to acquire diabetes. Blood sugar levels of these patients are very hard to control and manage because they are commonly exposed to toxic chemotherapy and steroids as part of cancer therapy. A review of the prevalence of diabetes in cancer patients might reveal a higher if not the same percentage compared to that in the general population. Our study has a further highly selected subpopulation of palliative care patients with active symptoms or near end of life, admitted to the inpatient PCU in a tertiary cancer centre in Riyadh. Our prevalence of 15% diabetics in this population is conceivable. There is a very high prevalence of diabetes mellitus in Saudi Arabia, 23%. Our selected study population is different from the general population.
Achieving quality of life for patients who have a shorter survival period versus prevention of long-term complications by tight glycaemic control in those who can live for years or without life-threatening disease is the primary goal of palliative care. It is more concerned regarding the welfare and comfort of the patients and their families, especially during the end-of-life stage. In Internal Medicine or Family Medicine inpatients, nearly 100% of diabetics are monitored for blood glucose level compared to only 55% in the palliative care inpatient diabetic population. This reflects the difference in the goals of care between palliative care and other specialties.
Saudi Arabia has a high rate of diabetes mellitus cases. Due to this, we have high apprehensions that we would encounter quite a number of diabetic patients with terminal diseases. The reviewed literatures unanimously showed that there are no clear guidelines available for managing diabetes, especially at the end-of-life stage. Doctors instead use approaches based on their experience as a medical practitioner. The essence of care through blood glucose monitoring would not be achieved if the tests and the results are not documented at all.
Management of diabetes and other related HTN and dyslipidaemia in inpatients with terminal cancer including both, the method of blood glucose monitoring and the type of drug given is what this study most aims at. Baseline blood glucose monitoring or liver function, as well as the antidiabetic or antihypertensive pharmacological groups, are excluded in the scope of this study.
Of 118 patients admitted to the PCU during the period of the study, 18 patients were diabetic (15.25%). Nine patients were monitored by glucometer only while one patient was monitored by both glucometer and serum glucose monitoring. Among the 18 diabetic patients, nine patients (50%) were not on insulin or oral hypoglycaemic agents, two patients (11.1%) were on an oral hypoglycaemic agent, and four patients (22.2%) were on insulin. The rest received both insulin and oral hypoglycaemic agents. Ten patients (55.6%) were using antihypertensive agents, two patients (11.1%) using lipid lowering agents and five patients (27.8%) were not using either; one patient received both.
Lesser number of patients received treatment for diabetes in their last week of life. Five patients (27%) were not receiving any treatment. Blood glucose monitoring and insulin was used in 6 patients (33%) while 5 patients (27%) had no blood glucose monitoring or insulin in their last week of life. Overall, there was a decrease in intensity of diabetes management in the final week of life. Three patterns of diabetes management were observed:
- Never treated
- Initially treated, but discontinued prior to the last week of life
- Treatment continued until the end of life.
The previous studies suggest that there are a lot of patients who prefer management until the end of their lives. This study does not include the assessment of the varied reasons of the health practitioners in applying diabetes management to patients.
Due to the scarcity of resources available regarding the proper management of diabetes towards the end-of-life, exploring more studies on this aspect is indeed a necessity. In palliative care setting, randomised control trial is so difficult to be done for ethical reasons. However, a lot of studies done in geriatric population clearly show that tight control for frail patients who have a poor prognosis of <5 years will lead to increased mortality. The geriatric guidelines could be of great value to us if applied in palliative care patients because both have several similarities, which are as follows:
- Poor prognosis: Both populations have very poor prognosis ranging from months to years. So the chance of long-term hyperglycaemia complication such as neuropathy, nephropathy and retinopathy are less likely, especially if HbA1c is <9 or average random blood sugar <15 mmol/L
- Poor appetite: Reducing weight and poor oral intake is very common in both populations. So the chances of hypoglycaemic complications are more likely. The hypoglycaemic complications are more dangerous than a hyperglycaemic complication in that population. The study in geriatric population showed clearly that the mortality with tight control group was more than the less tight control group in frail geriatric population. That way, they recommended being more liberal with these population in terms of blood sugar control.
From these similarities, there is a greater chance that if these guidelines could be a great tool to explore in palliative care until having the best results.,
Palliative care literature suggests that monitoring and treatment of diabetic patients in palliative care setting depend on the following:
- Cancer prognosis
- Hyperglycaemia symptoms such as thirst, polyuria and lethargy which affects quality of life
- Level of blood sugar. Recommended to keep blood sugar between 10 and 20 mmol/L
- Use of agents that raise blood sugar such as dexamethasone.
For inpatients in PCU, the recommendations are:
- Stop oral hypoglycaemic agents at the end of life
- Use sliding scale to monitor and treat symptomatic hyperglycaemia
- Keep target blood sugar between 10 and 20 mmol/L
- Stop monitoring if blood sugar never reaches 20 mmol/L , and at the end of life when oral intake is negligible.
This study has encountered several factors that hinder its full maximisation.
- Study being done in only one centre
- Sample size being small
- Homogenous patients (all terminal cancer patients)
- Management of diabetes report.
(Either HbA1c and blood sugar levels or specific pharmacological agents).
There is need to conduct a wider-scoped study on this subject to identify the underlying reasons for poorly controlled diabetes and its impact in palliative care patients. This could also be a means for us to develop evidence-based guidelines applicable to terminally ill patients with diabetes.
| Conclusion|| |
After several processes upon completion of this study being conducted, it has been found that there is necessity for evidence-based guidelines in the management of diabetes applicable to the patients receiving palliative care at the end of life. These guidelines should be tailored according to patients' preferences and differences in goals of care. The fact that there is a variation in the management of diabetes among patients in the PCU is a great opportunity for researchers to focus for their future research and studies.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]