Dr. Anuja Damani is an Associate Professor at the Department of Palliative Medicine and Supportive Care at Kasturba Medical College, Manipal, India.
Dr. Arun Ghoshal is a Clinical Fellow in Palliative Care at the University Health Network in Toronto, Canada.
Diabetes is one of the commonest non communicable diseases in India. According to a global survey published in 2019, India ranks 2nd among the countries with highest number of diabetic adults. 77 million people were living with diabetes in India in 2019, which is estimated to increase to 101 million by 2030 and 134.2 million by 2045. Diabetes contributes to 1 in 9 deaths in adults aged 20-79 years globally. According to World Health Organization data, around 70% of global deaths were associated with complications of diabetes and more than 60% of these deaths were in persons over 60 years of age. People with diabetes may have other coexisting chronic illnesses like cardiovascular, renal, neurologic and metabolic problems, which may result as complications due to long standing diabetes or may occur concomitantly. These contribute to compromised functioning and increased morbidity and mortality.
Although longstanding diabetes is associated with microvascular complications and end organ damage, normalising blood glucose, lipids and blood pressure, reduces the risk of such complications and may increase life expectancy. Palliative care team works towards addressing suffering, prognostication, excellent communication, care coordination and symptom management. Palliative care teams can facilitate in formulating goals of care and documenting patient preferences, keeping in mind the patient’s values from early in the course of illness. This would especially help older patients, who are at increased risk of complications, to make informed choices and decisions.
Some of the indicators for involving palliative care teams in the care of diabetic patients are deteriorating health and functioning of patient, recurrent unplanned hospitalizations, uncontrolled and difficult to manage symptoms, reduced response to treatment, patient preference for no active treatment, sudden significant and progressive weight loss, hypoalbuminemia, decreased muscle mass, long standing diabetics with increased risk of falls, micro- or macro- vascular complications, poorly controlled neuropathic pain, sudden fluctuations in blood sugar levels, multiple comorbidities or cancer diagnosis, severe hypoglycaemic episodes, diabetic foot ulcers, polypharmacy, associated depression, suicidal risk and psychosocial issues. These indicators suggests the need for beginning discussions around advanced care planning to formulate a holistic, individualized and evidenced based treatment plan for each patient. It is also important to acknowledge the uncertainty of course of illness and support the patient and their caregivers. Patients should get an opportunity to choose comfort and quality of life over longer duration of life if they wish to do so, and healthcare professionals should be able to recognize and establish futility of care escalation.
Some of the features of diabetes palliative care during the early controlled diabetes are supporting the patient, anticipating and preventing complications and managing symptoms. During the beginning of functional decline, a detailed assessment of complications and their reversibility, addressing symptoms and nutritional needs of patients, discussing patients’ preferences, values and goals, and formulating care plan accordingly is done. When there is a significant and an irreversible functional decline, it is important to review patient preferences and their goals and care plan, address polypharmacy, change oral hypoglycaemics to insulin if needed, manage symptoms and optimize their quality of life. During the terminal stage of illness, the palliative care teams ensure the shared care planning by involving all the treating medical professionals, while being mindful of the patient’s values and preferences to provide comfort care and a dignified quality of life and death while also supporting family and caregivers.
Thus, proactive diabetes palliative care is important. It complements the usual diabetes care during the long illness trajectory and enhances the quality of healthcare provision, leading to better patient and family satisfaction. It is therefore an important responsibility of the healthcare professional to prognosticate, initiate timely discussions, plan for appropriate and shared care, document and communicate patient’s wishes, prevent unnecessary admissions and recognize and prevent futile invasive interventions at end of life. Integration of palliative care in diabetes management would ensure a holistic approach towards patient care.
Acknowledgement: Image courtesy: https://www.cardiosmart.org/assets/infographic/diabetes