palliative care intervention in the management of diabetes_dr steve jones

7/31/2019 Palliative Care Intervention in the Management of Diabetes_Dr Steve Jones

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Palliative care interventionin the management of

diabetesSteve Jones

Consultant EndocrinologistDean of Clinical Affairs for NUMed

Malaysia


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Contents

An introduction

An overview

What are the issues? The evidence

Management

Practical issues Psychological issues


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Newcastle University MedicineMalaysia


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Contents

An introduction

An overview


Management



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Diabetes and Cancer

346 million people have diabetes

3.4 million die as a result of high glucose

10 million people world wide arediagnosed with cancer each year.

Over 7 million people die of cancer eachyear

WHO 2011


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Diabetes and cancer

The incidence of diabetes in people with

cancer is six times that found in thegeneral population.

Quinn et al 2006

More than 50% of people with cancer in

Malaysia will have diabetes.


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Why is diabetes so common inpeople with cancer?

Shared risk factors

Age

Obesity

Cancer and its treatment raises glucose

Treatment with corticosteroids

Stress response


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Obesity and Cancer


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Central Adipose Tissues


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Contents

An introduction

An overview


Management



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Its tricky!

Factors that increaseglucose

Stress response to illness

Infection

Surgery

Steroids

Factors that decreaseglucose

Weight loss

Decreased appetite

Nausea and vomiting


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What are the issues?


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Concern about guidelines

Few establishedguidelines

No protocols

Trial and errorapproach with risk of

suboptimal care


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Stage of illness changes targets

Agreed

Less strict targets needed in last few weeksand days of life.

Concerns that

Symptoms that might be caused orexacerbated by high glucose

Breathlessness, dehydration, confusion,drowsiness


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The dilemma

There is that tension betweenuncomfortable intervention [finger pricking]but avoiding discomfort from somethingthat can be improved [diabetes control]


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Specific conditions

Different approaches needed for differenttypes of diabetes

Type 1

Type 2

Steroid induced

INSULIN TREATMENT!!


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Communication

Patients with long standing diabetes mayfind it hard to change eating and testingpatterns.

it is important that they dont see

cessation of insulin as kind of being anabandonment of all care


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Contents

An introduction

An overview


Management



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The evidence

0

2000040000

60000

80000

100000

120000

140000

160000

180000

Diabetes PC Both

23984

38

MEDLINE search May 2011

160461


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38 studies on Medline search

Irrelevant Diabetic neuropathy Diabetes management

22 11 3 literature reviews

2 original articles

Original articles

1. Audit of case notes2. Survey and focus groups of palliative care and endocrinology practitioners


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Contents

An introduction

An overview


Management



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Guidelines

Google searchdiabetes palliative

care guidelines 914 000 hits!

www.cancernorth.nhs.

uk
http://www.cancernorth.nhs.uk/http://www.cancernorth.nhs.uk/http://www.cancernorth.nhs.uk/http://www.cancernorth.nhs.uk/http://www.cancernorth.nhs.uk/http://www.cancernorth.nhs.uk/http://www.cancernorth.nhs.uk/http://www.cancernorth.nhs.uk/


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Principles 1: Communication

Discuss changing theapproach to diabetes

management withpatient and/or family.

If the patient remainson insulin agreemonitoring strategy.


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Principles 2: Testing

Keep invasive tests to a minimum. It is necessary to perform some tests to

ensure unpleasant symptoms do not occurdue to low or high blood sugars.

It is very difficult to identify symptoms dueto hypo or hyperglycaemia in a dyingpatient.

If observed symptoms could be due to bloodglucose levels a urine test should beperformed, followed by a blood glucose checkif necessary.


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Tips for patients on insulin

People with T2DM taking > 48 units perday are likely to develop osmoticsymptoms if insulin is stopped.

Choices for once daily insulin

Glargine

Humulin I

Insulatard

Reduce total daily dose by 25%


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Contents

An introduction

An overview of the problem

The evidence Management

Practical issues

Psychological issues


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Thank you for your attention

palliative care intervention in the management of diabetes_dr steve jones

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