Diabetes Care. End of Life. Michelle Clancy. Palliative Care Clinical Nurse Consultant Sue Conway Diabetes Clinical Nurse consultant
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1 Michelle Clancy Diabetes Care at End of Life Palliative Care Clinical Nurse Consultant Sue Conway Diabetes Clinical Nurse consultant
2 Session Objectives Discuss the relevant literature available regarding End of Life Diabetes Care Provide information regarding a clinical audit within RDNS & Peninsula Home Hospice (PHH) Explain the clinical guide/flowchart developed for managing these clients Discuss staff competencies in end of life care
3 Palliative care is defined as: An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (World Health Organisation, 2009) The goal of palliative care is to achieve the best quality of life for patients and their families. Most people gradually deteriorate towards the active dying phase after a period of illness: less than 10% die suddenly or unexpectedly (Emanuel et al. 2008).
4 Diabetes & Palliative care Advanced Care Planning Care Plan Management
5 Literature Reviews Guidelines for Managing Diabetes At End of Life Trisha Dunning, Peter Martin, Sally Savage, Nicole Duggan End of Life Diabetes Care Clinical Recommendations. Commissioned by Diabetes UK
6 Audit Assess the number of palliative clients diagnosed with Diabetes Assess what medications/treatments clients where taking for Type 1/Type 2 diabetes Record the number palliative clients taking Steroid medication Review how many clients had a Diabetes Assessment or involvement of a Diabetes CNC Determine if Diabetes advanced care planning had been initiated or considered.
7 Audit - Palliative Care Clients Date Prednisalone Dexamethasone Oral Hyperglycaemic Insulin Clients with Diagno sis Total clients October Doses ranged from 5-25mgs Average dose was 5mgs Doses ranged from 2-16mgs. Average dose was 4mgs daily Diabex Diaformin Metformin Diamicron Gibmepiride Glucovance Novomix Lantus Novorapid Levemir Humalog Dex + Oral Hyperglycaemic Prednisalone + Oral Hyperglycaemic Dex + Insulin 4 1 3
8 Management of Diabetes in End of Life care Diabetes Diagnosis Type 1- Insulin dependent Type 2- with or without oral hypoglycaemics - with or without insulin Diabetes presents as an existing diagnosis or develops during the period of palliative care Palliative Care Nurse, CNC Palliative Care RN1, EEN, Admission Nurse Potential Diabetes Diagnosis -Taking high dose corticosteroids (Medicine induced) -Palliative diagnosis involving Kidney, Liver, Pancrease Palliative and Diabetes Assessment Refer to: Guidelines for Managing Diabetes at the end of Life Trisha Dunning Peter Martin Palliative Assessment and Diabetes Screening -identify risk factors and BGL Refer to CNC Diabetes or diabetes resource nurse if available Care considerations: 1. Consider palliative phase (PCOC) see guideline and follow management principles for phase. 2. Educate client/carers regarding changes to usual Diabetes regime and focus on symptom management and comfort 3. Monitor medication affects i.e. corticosteroids, OHA s, Insulin and effect on BGL s and seek to adjust as required 4. Refer to endocrinologist or endo registrar at treating hospital for complex regimes or unstable BGL s or involve CNC Diabetes if available Corticosteroid implications - mask signs & symptoms of infection -predispose to fractures & pain - long term predispose to falls and muscle weakness/ atrophy - suppress insulin production and increase cortisol production leading to Hyperglycaemia -Increase fragility of skin and suppress immune function Care considerations: 1. Consider palliative phase (PCOC) see guideline and follow management guidelines for diabetes status unknown 2 Educate carers regarding treatments that may lead to hyperglycaemia and actions required to manage symptoms 3. Monitor BGL and set appropriate targets 4. Monitor BGL and antidiabetic agents as steroid doses reduced, educate on hypo management 5. Refer to Palliative Care specialist or CNC Diabetes if available
9 Staff Competencies in End- Of-Life Diabetes Care Develop competencies for palliative care staff to: Initiate and develop personalised care plans incorporating advanced care planning (Experienced staff) Plan, implement and deliver education programs around Diabetes and palliative care(senior expert staff) Identify the need for change, generating practice innovations and policy review/development
10 Recommendations Review current Diabetes Policy according to guidelines Review current Diabetes Nursing care plans to consider end of life advanced care planning Develop a multi-choice questionnaire as part of the RDNS/PHH palliative care learning contract program Incorporate Diabetes End of Life Care in Palliative care education
Guidelines for managing people with diabetes at the end of life
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