Palliative and End-of-Life Care Settings and Issues to Be Considered in Each

Home• Clear policies and protocols to support clinical and other care for people with type 1 or type 2 diabetes should be in place. These protocols should outline clear, bidirectional processes and documentation for care transitions such as to and from a hospital.
• The complexity of home care can be similar to that provided in a hospital. Thus, the family must be able to cope with complex care regimens. Caregiving is hard work, particularly managing medications when people are dying. Therefore, caregivers’ health and well-being should be assessed when relevant.
• Many people with diabetes are accustomed to managing their diabetes and should be encouraged to continue to do so for as long as possible. Families require support, education, and resources when they undertake diabetes self-care and other care for their relative with diabetes. They need access to advice when needed, including access to the primary care provider and diabetes and palliative care experts. They also need a plan for when to call the doctor or an ambulance or to take their relative to the hospital. This information can be included in sick day and hypoglycemia management plans. Caregivers must be able to recognize and manage atypical presentations of hypoglycemia, hyperglycemia, and cardiac events.
• Most people prefer to stay at home for as long as possible, and many want to die at home, but that is not always possible. The individual’s ACP should be respected and used to guide care. Conflict can arise in some situations such as when an individual becomes ill and refuses to go to the hospital when the family thinks such a transfer is needed.
• Family members may have concerns about caring for their relative when they die at home. They worry about watching their relative die in pain and suffering or over-medicating them.
• The social aspects of care need to be considered and addressed (e.g., when a patient should stop driving). All written information should be in plain language considering the health literacy of the patient and family.
Hospice• Hospices specialize in caring for people who are dying and provide various supportive treatment options not usually available in hospitals (e.g., music therapy, aromatherapy, massage, or pet therapy).
• Hospices should have clear policies and protocols, resources, and access to diabetes clinicians for advice, if needed, to support the care of patients with diabetes. Staff must have the skills and knowledge to care for older people with diabetes when they are dying and must know when to stop glucose-lowering medications and blood glucose monitoring. If patients elect to continue their diabetes self-care, they should be supported in doing so.
• The individual’s ACP should be respected and used to guide care.
Hospital• Hypoglycemia, hyperglycemia, illness, cardiovascular events, foot infections, falls, and acopia are some common reasons older people present to the hospital.
• Patients’ ACP should accompany them during care transitions and be respected and used to guide care.
• Patients can spend considerable time waiting for services, and an ED is not a nice place to die. Patients may present to an ED and then be transferred to various other places such as a geriatric evaluation unit, a medical ward, or an intensive care unit.
• Diabetes can be diagnosed in an ED. For those with existing diabetes, the medical record should clearly state whether the patient has type 1 or type 2 diabetes.
• Up-to-date policies and protocols to support the care for people with diabetes should be in place.
• Bidirectional processes for managing care transitions must be in place and include clear communication among the various wards within the hospital, as well as communication from the hospital to the primary care provider and diabetes and palliative care experts, as relevant, at discharge or other transitions. Information such as the results of investigations and adjustments to the medication regimen should be communicated.
• Discharge education is important and should include patients’ family, when relevant. Allow time, and use teach-back techniques rather than didactic teaching styles to enhance understanding and recall. Written information should be provided in plain language considering the health literacy of the patient and family.
• Integrated care pathways are used in some places for end-of-life care transitions.
Aged Care Homes and LTC Facilities• Older people can be admitted to an aged care home or LTC facility for respite care, rehabilitation, and palliative care or to live permanently. The reason for and duration of the admission influences their care. The care plan must state whether the person has type 1 or type 2 diabetes.
• Monitor patients for depression and loneliness. Permanent admission often triggers grief and loss of dignity, independence, and beloved pets; thus, patients need to be supported and given time to adapt to their new situation.
• Ideally, people with diabetes have an ACP before they are admitted to an aged care home or LTC permanently. If they do not have such a plan, one should be drawn up as soon as possible.
• Up-to-date clear policies, protocols, and guidelines must be in place and used to support diabetes care and palliative and end-of-life care, as well as care of the body after death, which should be consistent with religious and cultural customs.
• Staff must have the skills and knowledge to care for older people with diabetes. Many facilities are understaffed or employ non–health professional staff who do not have the education and training to care for people with complex care needs.
• Relevant equipment should be available (e.g., supplies to treat hypoglycemia, glucagon, and ketone strips to test for ketoacidosis).
• All people taking glucose-lowering medicines should have a hypoglycemia risk assessment and an individualized hypoglycemia care plan based on their risk. This plan should include when to call the doctor and the information to provide to the doctor to facilitate care decisions.
• Every person with diabetes should have a personalized sick day care plan that includes a plan for blood glucose monitoring and ketone testing, especially for older people.
• Food plans need to be flexible and consider the individual’s medication regimen, food intake, and activity levels. Many older people eat erratically, which means they are at risk for hypoglycemia.
• Sliding-scale insulin should not be used. Basal insulin with a small dose of rapid-acting insulin when the individual eats is safer but more labor-intensive (5,13).
• Some people will be on enteral feeding. Products with less impact on blood glucose, such as Glucerna, are preferred.
• LTC facility staff need support when a resident dies. They often suffer unresolved grief or stress at such times.
  • ACP, advance care plan; LTC, long-term care.