Diabetes Mellitus: Recognizing When Palliative or Hospice Care May Be Appropriate

Diabetes mellitus is one of the most common chronic diseases, affecting 12% of people in the U.S. and nearly 29% of those aged 65 years or older. As progressive diseases, both Type 1 and Type 2 diabetes can lead to challenging symptoms and complications, especially in older age.

Patients in the later stages of diabetes may benefit from specialized support in the form of palliative or hospice care. Clinicians can help their diabetic patients enjoy greater comfort and control at every stage by proactively referring them to palliative or hospice care when it becomes beneficial.

The Benefits of Palliative Care for Diabetes Patients

Palliative care is often misunderstood and underutilized. According to the World Health Organization, diabetes is one of the most common chronic diseases that can call for palliative care. This specialized form of support can work alongside conventional medical treatment to help diabetic patients feel more fully supported — physically, mentally, emotionally, and spiritually.

Palliative care teams are interdisciplinary and can support patients by:

• Managing symptoms: Perhaps the best-known aspect of palliative care for diabetes patients is its focus on helping them achieve greater comfort. Clinicians on the palliative care team can help manage physical symptoms to enhance patients’ quality of life, and counselors, social workers, and chaplains can help patients gain mental, emotional, and spiritual comfort.
• Caring for the whole person: Another emphasis of palliative care is supporting the whole person — not just providing for physical needs. Counseling, for example, can help patients process the mental weight of their health challenges. Palliative care teams also connect patients to relevant resources, such as support groups.
• Coordinating care: When a patient’s health is declining, they may see various specialists to address their health challenges. Scheduling appointments, communicating with the appropriate providers, and coordinating medications can be cumbersome for patients or their family caregivers. Palliative care teams can help ensure seamless synchronization across providers and prescriptions.
• Developing an advance care plan (ACP): If diabetic ketoacidosis, a stroke, or another complication leaves the patient incapacitated, their preferences should be clearly outlined for caregivers and loved ones, including their desire to continue or discontinue insulin therapy. Palliative care team members can assist patients with documenting their wishes and designating a health care proxy.
• Empowering family caregivers: Family caregivers often play an important role for patients with chronic conditions, including diabetes. Palliative care teams work with family caregivers to help them understand their loved one’s condition(s), how they can help provide care, and when to reach out for help.

The Benefits of Hospice Care for Diabetes Patients at the End of Life

Hospice largely offers the same benefits as palliative care for diabetes patients. In fact, patients who start in palliative care can experience a relatively seamless transition to hospice care at the appropriate time and continue to experience the same holistic support.

The key distinction between palliative and hospice care is that hospice is designed specifically for patients with a prognosis of six months or less who are no longer undergoing curative medical care. Because of the stage of illness for these patients, hospice care includes a subtle shift in focus to end-of-life care, offering:

• An emphasis on comfort: Hospice emphasizes comfort rather than balancing it with other priorities. For diabetic patients, this involves a shift away from strict glucose control. Hospice care teams may counsel a patient to discontinue some medications or otherwise alter their diabetes mellitus treatment plan to prioritize their comfort and quality of life over long-term outcomes.
• End-of-life planning: ACP is even more critical at this stage, and hospice professionals can initiate this conversation and walk patients and families through the process. They can also walk patients and their families through medical decision-making and funeral planning.
• Emotional and spiritual counseling: Life-limiting illness can impact the patient’s mental and emotional health just as severely as their physical health. Counselors, social workers, and chaplains can offer patients support through this difficult experience.
• Bereavement support: Hospice care can continue to support families during bereavement. Connections to support groups and special ways of honoring their loved one’s memory can bring comfort as they grieve.

The Role of Clinicians in Referring Diabetic Patients to Palliative and Hospice Care

Determining when to refer a patient to palliative or hospice care usually isn't marked by a single lab value, but by a shift in the patient's overall trajectory and the complexity of their care.

It may be the right time to consider a referral if you notice:

• Functional decline and frailty: The patient is experiencing progressive loss of independence, such as a decreased ability to perform activities of daily living (ADLs).
• Treatment fatigue: The patient or their caregivers are overwhelmed by managing various providers, treatments, and tests.
• Recurrent acute events: The patient has experienced frequent emergency department visits or hospitalizations for severe hypoglycemia, hyperglycemic hyperosmolar state (HHS), infections, or other health events.
• Advanced comorbidities: Diabetes may not be the primary driver of morbidity, but it is complicating the management of a late-stage condition, such as heart failure or chronic kidney disease.
• Progressive cognitive impairment: Dementia is making strict glycemic control dangerous due to the patient’s inability to communicate symptoms of hypoglycemia or follow dietary requirements.

If a patient meets some of these criteria and has a life expectancy of six months or less, hospice may be a better fit than palliative care. Physicians can discuss options and ensure patients understand the distinctions between these forms of care.

Health care providers can play a key role in helping patients understand and access palliative and hospice care. One study found that patients with diabetes were reluctant to discuss end-of-life care in their last months of life, although they wished to discuss this topic with their clinicians. By initiating the conversation, health care providers can empower their patients and families with the information they need to make an informed decision.

These conversations shouldn’t wait until a patient’s health is declining dramatically. Early referral can help patients experience less physical pain and emotional distress and feel more fully supported as they navigate the challenges of diabetes and other chronic health conditions.

Choosing a Partner in Care: The WesleyLife Difference

The transition from strictly clinical management to palliative or hospice care is not a sign of "giving up." Rather, it is a pivot that honors the patient’s current reality. Ultimately, the goal of diabetes care in the later stages of life should be to minimize the burden of the disease and maximize the joy in each day.

WesleyLife is here to partner with you in providing the highest standard of care. Our team provides both in-home palliative and hospice care to support patients with diabetes and many other conditions. Our team is available 24/7 and will work hard to begin caring for your patient as soon as possible, many times on the same day as referral. Learn more or refer a patient.