Diabetes management patterns in a palliative care unit in Saudi Arabia

Abstract

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.

Full text

116 © 2016 Journal of Health Specialties | Published by Wolters Kluwer - Medknow
Diabetes management patterns in a palliative
care unit in Saudi Arabia
Sami Ayed Alshammary1,2, Balaji Duraisamy1, Abdullah Alsuhail1, Mohammad Mhafzah1,
Lobna M. A. Saleem1, Nadir Mohamed1, Savithiri Ratnapalan3
1Comprehensive Cancer Center, Palliative Care Unit, King Fahad Medical City, 2Centre for Postgraduate Studies in Family Medicine,
Ministry of Health, Riyadh, Saudi Arabia, 3Department of Paediatrics, Dalla Lana School of Public Health, Toronto, Ontario, Canada
Original Article
ABSTRACT
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insufcient,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intensies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
Access this article online
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DOI:
10.4103/1658-600X.179819
How to cite this article: Alshammary SA, Duraisamy B, Alsuhail A, Mhafzah M,
Saleem LM, Mohamed N, et al. Diabetes management patterns in a palliative
care unit in Saudi Arabia. J Health Spec 2016;4:116-21.
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as
the author is credited and the new creations are licensed under the identical
terms.
For reprints contact: reprints@medknow.com
Address for correspondence:
Dr. Sami Ayed Alshammary, Comprehensive Cancer Center, Palliative
Care Unit, King Fahad Medical City, Riyadh, Saudi Arabia.
E‑mail: drsamiayed@gmail.com
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Alshammary, et al.: Patterns of management of diabetes in a palliative care unit in Saudi Arabia
INTRODUCTION
Diabetes is found to be 6 times more prevalent in cancer
patients than in the general population.[1] In Saudi
Arabia, the rate of diabetes is around 23.7% compared
to 6.4% rate worldwide.[2] 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.[3] 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.[4] 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.[5] 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.[6] 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.[6] 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.[1]
Automatic neuropathy can cause type I diabetes patients
to experience hypoglycaemia unawareness.[7] 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.[8]
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.[9]
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.[10]
Potentially, hypoglycaemia and hyperglycaemia may
cause life‑threatening complications. This concerns
many diabetic patients and their families.[11] 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
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118 Journal of Health Specialties / April 2016 / Vol 4 | Issue 2
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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.).[1]
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.[1]
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.[10]
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.[12,13]
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.[10]
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.[9]
Quinn et al.[1] developed focus groups and performed
a survey to address questions regarding diabetes
management in palliative care patients. More recently,
Angelo et al.[14] 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[15] 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.[16] 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.[16]
Objectives
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
Study design
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].
Table 1: Monitoring of diabetes in palliative care unit
Monitoring tools Number of patients Percentage
Monitoring with glucometer (sliding scale) 9/18 50
Monitoring with both glucometer and
plasma glucose
1/18 5.6
No monitoring 8/18 44.4
Table 2: Management of diabetes in palliative care unit
Management Number of patients Percentage
Diabetes management 9/18 50.00
Oral hypoglycaemic agents 2/18 11.10
Insulin 4/18 22.20
Insulin and OHA 3/18 16.70
OHA: Oral hypoglycaemic agents
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The majority of diabetic patients 11/18 (61%) stayed
in the hospital until death while only 7/18 (39%) were
well and discharged.
Monitoring
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 Tables 3 and 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 [Tables 3 and 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 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%.[2] 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
Table 3: Glucose monitoring in the last week of life
Monitoring tools Number of patients Percentage
Glucometer monitoring 6 33.30
No monitoring 5 27.70
Table 4: Management of diabetes in the last week of life
Management Number of patients Percentage
Insulin 6 33.3
No management 5 27.7
Table 5: Prevalence of co‑morbidities in diabetics in palliative care
unit
Co‑morbidities Number of patients Percentage
No co-morbidities 5 27.70
Lipid lowering agents 2 11.20
Anti HTN 10 55.60
Anti HTN and lipid lowering 1 5.50
HTN: Hypertension
Table 6: Co‑morbidities management in the last week of life
Co‑morbidities Number of patients Percentage
Lipid lowering agents 1 5.5
Anti HTN 7 39
Anti HTN and lipid lowering 1 5.5
HTN: Hypertension
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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.[11] 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.[17,18]
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[19,20] and at the end of life when oral intake
is negligible.
Limitations
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.
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Journal of Health Specialties / April 2016 / Vol 4 | Issue 2 121
Alshammary, et al.: Patterns of management of diabetes in a palliative care unit in Saudi Arabia
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.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
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