This guideline was adapted in collaboration with Dr Georgina Walker and the Palliative Care Team at Rowcroft Hospice. With thanks.

Transcription

1 Title: Directorate: Responsible for review: Ratified by: DIABETES, MANAGEMENT OF IN PALLIATIVE CARE PATIENTS General Medicine Diabetes Specialist Nurse Service Delivery Unit Clinical Director of Pharmacy Ref: 1641 Version 2 Classification: Guideline Due for Review: 02/03/20 Document Control Applicability: All patients as indicated This guideline was adapted in collaboration with Dr Georgina Walker and the Palliative Care Team at Rowcroft Hospice. With thanks. Background The aim of diabetes management in palliative care is to preserve quality of life; prevention of long term complications is usually unnecessary. Minimising adverse effects of diabetic treatment and avoiding metabolic decompensation, including symptomatic dehydration are key to ensuring good symptom control. Symptoms of hyperglycaemia may develop with glucose levels > 15mmol/l and of hypoglycaemia at < 4mmol/l. Glucose control targets No pre-meal glucose level < 8mmol/l No pre-meal glucose level > 15mmol/l. (Higher may be acceptable in the absence of symptoms. Discuss with senior decision maker within the team responsible for the patient). Tailoring medication at different stages of illness. These decisions to be made by senior decision maker from the team responsible for the patient and recorded in the patient s medical notes. Discussion with the patient also needs to be considered. In patients with several months expected prognosis, consider whether cardio-protective drugs, such as ACE inhibitors, angiotensin-receptor blockers, aspirin and statins could be stopped. In patients with 1-2 months estimated prognosis and on combinations of diabetic medications, consider converting to insulin alone, OD or BD regime. If the patient is already on BD insulin, consider changing to OD Isophane insulin at 75% of the total previous BD dose. In patients with an expected prognosis of weeks only, relax blood glucose control targets, but continue to assess for symptoms of hypo- and hyperglycaemia. If the prognosis is days, for Type 2 diabetic patients, stop all oral hypoglycaemic agents and consider whether insulin should be continued; for Type 1 diabetic patients, aim to continue long acting insulin. When continuing insulin, change to OD (morning) long-acting insulin, giving dose 25% less than previous total daily insulin dose. Check blood glucose at teatime, and if < 8 mmol/l, reduce insulin by 10-20%, but if >20mmol/l, increase insulin by 10-20% to reduce risk of ketosis. For both Type 1 and Type 2 diabetics, once a patient is unconscious (not induced by hyper or hypoglycaemia), and prognosis <48hrs, consider discontinuing insulin entirely. Page 1 of 4

2 Management of hypoglycaemia (Ref 0269 Hypoglycaemia in adults who have diabetes) The risk of hypoglycaemia is increased in patients with poor appetite, renal or liver impairment, and in patients on insulin and sulphonylureas. If the patient is awake and can swallow, give 150ml of Coke, 200ml of orange juice, 100ml of Lucozade or 60ml of glucojuice (in hypo box in drug cupboard), 3-5 glucotabs (4g glucose per tablet) or glucogel (25g). If after 10 minutes blood glucose is still < 4mmol/l, repeat above. Once blood glucose > 4mmol/l, give the patient a banana or glass of milk or 2 digestive biscuits or a slice of bread or something similar. If the patient is on PEG feeds, stop their feed and insert 60ml glucojuice into their PEG tube and repeat every 10 minutes until blood glucose > 4mmol/l. Once blood glucose above 4mmols, restart the feed. If the patient is unconscious due to hypoglycaemia, put them into the recovery position and administer 1mg glucagon IM or 40ml of 20% glucose IV over minutes. Once the patient is conscious, give drinks and snacks as above. Note that glucagon may be less effective in cachectic patients. General rules for oral diabetes medications Metformin is usually inappropriate in patients with an advanced malignancy due to its effect on appetite, weight and gastrointestinal side effects. It should be discontinued if creatinine is >150mmol/l or egfr <30. Sulphonylureas (e.g. gliclazide) should be reviewed in patients experiencing weight loss, anorexia or dysphagia due to the risk of hypoglycaemia. Guidelines state to review dose of sulphonylureas if renal function deteriorates but no cut-off level of function is described. Sulphonylureas can also cause hypoglycaemia in patients with reduced liver function. Pioglitazone is rarely appropriate in terminally ill patients and should not be used in patients with bladder tumours or heart failure. Gliptins, e.g. sitagliptin, should be reviewed in deteriorating renal function as doses may need to be reduced. The BNF states recommended dose reductions according to egfr. GLP-1 analogues, e.g. exenatide, are not recommended for patients with significant weight loss and should be withdrawn if the patient develops abdominal pain, pancreatitis or any other GI related symptoms. SGLT2 inhibitors- eg Dapagliflozin, Canagliflozin, Empagliflozin should be reviewed and will rarely be appropriate as they can be associated with weight loss and an increased risk of urinary tract symptoms or infections. They are contraindicated if GFR <60 Preventing acute metabolic complications in diabetic patients who are acutely unwell Offer the patient frequent sips of sugar-free fluids. If patients are suffering with vomiting or diarrhoea, metformin should be stopped. If the patient is a type 2 diabetic and is not eating and blood glucose is <15mmol/l, all diabetic Page 2 of 4

3 medications should be stopped, but if blood glucose continually >15mmol, consider increasing diabetic medications or administering PRN short-acting insulin. In type 1 diabetics do not stop insulin even if not eating, maintain hydration and monitor blood sugars closely. Contact the Diabetes Team and consider whether admission to the acute sector may be required. Examples of insulin that could be used: Actrapid Short-acting. Quick onset of action within minutes, peak action between 2-4 hours, duration of action up to 8 hours Novorapid Rapid-acting. Rapid onset of action within 15 minutes, peaks at 2 hours, duration of action 3-4 hours Humulin I Intermediate acting. Isophane insulin Of particular value for initiation of BD acting regimes. Onset of action 1-2 hours, peak action 6 hrs, duration of action up to 18 hrs Insulatard Intermediate acting. As Humulin I Levemir Long-acting in that it is given once or twice daily. Onset of action of 1-2 hours, maximum effect at 4-12 hours, duration of action hours Page 3 of 4

4 End of Life Management for use in Last Days of Life These Decisions must be made by a Senior Decision Maker responsible for the patient and recorded in the patients medical notes Principles Keep tests to a minimum. It may be necessary to perform tests to ensure unpleasant symptoms do not occur due to low or high blood glucose. It is difficult to identify symptoms due to hypo or hyperglycaemia in a dying patient. If symptoms are observed it could be due to abnormal blood glucose levels. Test urine or blood for glucose if the patient is symptomatic Observe for symptoms in previously insulin treated patient where insulin has been discontinued Once the patient is unconscious (not induced by hyper or hypoglycaemia or other reversible cause) and prognosis <48 hours, consider discontinuing insulin entirely. Flowchart Discuss changing the approach to diabetes management with patient and/or family if not already explored. Call Diabetic Specialist Nurse for advice if needed, especially if remains on insulin. Type 2 diabetes Diet controlled or Metformin treated Type 2 diabetes on other tablets and / or insulin / or GLP1 Agonist Type 1 diabetes always on insulin Stop Metformin Stop monitoring blood sugars Stop tablets and GLP1 injections Consider stopping insulin depending on dose Continue once daily morning dose of isophane insulin with reduction in dose. If insulin stopped consider: Urinalysis for glucose daily if over 2+ check capillary blood glucose. If blood glucose over 20 mmols/l and symptomatic, give 6 units rapid acting insulin and recheck capillary blood glucose after 2 hours. If patient requires rapid acting insulin more than twice consider daily isophane insulin If insulin to continue: Prescribe once daily morning dose of isophane insulin based on 25% less than total previous daily insulin dose. Check blood glucose once a day at teatime: If below 8 mmols/l reduce insulin by 10-20% If above 20 mmols/l increase insulin by 10-20% to reduce risk of symptoms or ketosis Contact the Diabetes Specialist Nurses if advice required Page 4 of 4

5 Protocols & Guidelines Document Control This is a controlled document. It should not be altered in any way without the express permission of the author or their representative. On receipt of a new version, please destroy all previous versions. Ref: 1641 Title: Date of Issue: 2 March 2017 Next Review Date: 2 March 2020 Version: 2 Author: Diabetic Specialist Nurse Index: General Medicine Classification: Guideline Applicability: All patients The guidance contained in this document is intended to be inclusive for Equality Impact: all patients within the clinical group specified, regardless of age, disability, gender, gender identity, sexual orientation, race and ethnicity & religion or belief. Evidence based: Information not supplied References: Produced following audit: No Audited: No Approval Route: See ratification Date Approved: 17 January 2017 Approved By: Service Delivery Unit Clinical Director of Pharmacy Links or overlaps with other policies: 0269 Hypoglycaemia in adults who have diabetes All TSDFT Trust strategies, policies and procedure documents. PUBLICATION HISTORY: Issue Date Status Authorised 1 1 August 2014 New Consultant In Diabetes and Endocrinology Consultant in Palliative Care Clinical Director of Pharmacy 2 2 March 2017 Revised Service Delivery Unit Clinical Director of Pharmacy 2 20 February 2018 Review Date Extended 2 Years to 3 Years Document Control Information Page 1 of 1

6 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. The Mental Capacity Act 2005 Page 1 of 1

7 Quality Impact Assessment (QIA) Please select Who may be affected by this document? Patient / Service Users Visitors / Relatives General Public Voluntary / Community Groups Trade Unions GPs NHS Organisations Police Councils Carers Staff Other Statutory Agencies Others (please state): Does this document require a service redesign, or substantial amendments to an existing process? NO If you answer yes to this question, please complete a full Quality Impact Assessment. Are there concerns that the document could adversely impact on people and aspects of the Trust under one of the nine strands of diversity? Age Disability Gender re-assignment Pregnancy and maternity Marriage and Civil Partnership Race, including nationality and ethnicity Religion or Belief Sex Sexual orientation If you answer yes to any of these strands, please complete a full Quality Impact Assessment. If applicable, what action The guidance contained in this document is intended to be inclusive has been taken to mitigate for all patients within the clinical group specified, regardless of age, any concerns? disability, gender, gender identity, sexual orientation, race and ethnicity & religion or belief. Who have you consulted with in the creation of this document? Note - It may not be sufficient to just speak to other health & social care professionals. Patients / Service Users Visitors / Relatives General Public Voluntary / Community Groups Trade Unions GPs NHS Organisations Police Councils Carers Staff Details (please state): Other Statutory Agencies Discussed as a group with Dr Kate Lissett, Consultant In Diabetes and Endocrinology Dr Jo Sykes, Consultant in Palliative Care Paul Foster, Clinical Director of Pharmacy and Alison Henderson, DSN - Quality Impact Assessment Page 1 of 1

8 Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Policy Author Version and Date An (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users Staff Other, please state Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Age Yes No Gender Reassignment Yes No Sexual Orientation Yes No Race Yes No Disability Yes No Religion/Belief (non) Yes No Gender Yes No Pregnancy/Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy could affect particular Inclusion Health groups less favorably than Yes No the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Yes No NA Are the services outlined in the policy fully accessible 6? Yes No NA Does the policy encourage individualised and person-centered care? Yes No NA Could there be an adverse impact on an individual s independence or autonomy 7? Yes No NA EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Who was consulted when drafting this policy? Patients/ Service Users Trade Unions Protected Groups (including Trust Equality Groups) Staff General Public Other, please state What were the recommendations/suggestions? Does this document require a service redesign or substantial amendments to an existing Yes No process? PLEASE NOTE: Yes may trigger a full EIA, please refer to the equality leads below ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Signature Validated by (line manager) Signature Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call or marisa.cockfield@nhs.net For Torbay and South Devon NHS Trusts, please call or pfd.sdhct@nhs.net This form should be published with the policy and a signed copy sent to your relevant organisation. Rapid Equality Impact Assessment Page 1 of 1