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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
What are the issues? The evidence
Management
Practical issues Psychological issues
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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
What are the issues? The evidence
Management
Practical issues Psychological issues
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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
What are the issues? The evidence
Management
Practical issues Psychological issues
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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
What are the issues? The evidence
Management
Practical issues Psychological issues
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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/7/31/2019 Palliative Care Intervention in the Management of Diabetes_Dr Steve Jones
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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