**1. Introduction**

Diabetes is the most common chronic disease. People are at risk of diabetes due to genetic inheritance, epigenetic factors, age and lifestyle-related factors. The International Diabetes Federation (IDF) [1] estimated 123 million people aged 65–99 had diagnosed diabetes and predicted the number would increase to 438 million by 2045. Most older people have type 2 diabetes (T2DM), but people with type 1 diabetes (T1D) survive to older age. These data do not take account of the people with prediabetes who may already have one or more life-limiting diabetes complications at diagnosis.

An estimated ~ 20 million people globally need palliative care the year before they die; a further 20 million need end-of-life care per year [2]. The World Health Organization (WHO) estimated that 71% of deaths in 2016 were associated

with diabetes complications. Most (~67%) occur in people aged 60 and older [3]. Therefore, older people with diabetes may have more than one life-limiting condition.

Aging is associated with reduced insulin production and insulin sensitivity that lead to insulin resistance, which increases by 1–2% per year [4]. Older age is generally defined as older than age 65 [5]. However, chronological age is not a good guide to disease, functional status, care needs or life expectancy. Biological age is a more accurate indicator of the rate at which body cells deteriorate but is more difficult to measure. Significantly, the individual's chronological and biological age may be different [5].

Many older people have several coexisting comorbidities/geriatric syndromes, including cardiovascular disease, renal disease, sensory impairments, lower limb pathology, cognitive changes/dementia, some forms of cancer and frailty that individually and collectively affect life expectancy [6–9]. Frailty predicts admission to a care home and mortality and increases the risk of death [10, 11]. Frailty is assessed in various ways, including phenotype and accumulation of deficits. The latter may be more useful to prognostication.

Many older people with diabetes have at least three coexisting comorbidities, but these are often managed as single entities that may not address the many diffuse symptoms [12–14] or the need to change the focus of care from achieving normoglycaemia to prevent complications to focus on comfort by managing existing complications and preventing hypoglycaemia and hyperglycaemia.

People with diabetes who can maintain near-normal glycaemia (~7%) and normal lipids and blood pressure are less likely to develop complications and may not have significantly reduced life expectancy. However, these parameters are often abnormal some 10–15 years before type 2 diabetes (T2DM) is diagnosed, and complications can be present and affect life expectancy from diagnosis [7, 12]. In addition, older people are less likely to benefit and more likely to be harmed by 'tight blood glucose control'. Therefore, blood glucose and HbA1c target ranges need to be individualized to minimize risk, especially hypoglycaemia risk and other risk factors being managed [15, 16].

Diabetes and the associated comorbidities affect the quality of life, compromise function and self-care and increase the need for hospital admissions and readmissions and eventually lead to death [11, 13, 17]. Over 50% of people aged 65–80 experience moderate to severe disability and increased dependency. On average, they need care 24 hours/day between 1.3 and 6.9 years [18].

Significantly, older people with diabetes and concomitant heart failure who have several recent hospital admissions and consult multiple prescribers are at risk of readmission within 30 days [19]. Hospital admissions near the end of life often result in burdensome and futile treatment that causes significant suffering and stress for the individual and their family [19, 20]. Likewise, people with cognitive impairment face many challenges, including decisions about their care.

Thus, starting conversations about the likely prognosis early in the disease trajectory can enhance people's capacity to make meaningful decisions and enable them to document their values and care preferences [21, 22]. In turn, clearly documented values and care preferences enhance family and health professionals' capacity to make care decisions consistent with the person's values and reduce decisional uncertainty.

#### **2. Diabetes care**

Quality diabetes care is described in many clinical guidelines such as the IDF [7], American Association of Diabetes/European Association for the Study of

**111**

*Diabetes and Palliative Care: A Framework to Help Clinicians Proactively Plan...*

Diabetes [23], Australian Diabetes Society [24] and Diabetes UK [25]. Many recommend 'relaxing' glycaemic targets in older people to reduce the risk of hypoglycaemia and its consequences: they usually do not include *comprehensive* guidance about other key aspects of palliative and end-of-life care. Exceptions are the IDF Global Guideline for Managing Older People with T2DM [7] and Guidelines for Managing Diabetes at the End of Life (currently under review) [8]

Quality diabetes care encompasses achieving normoglycaemia (HbA1c <6.5 7%), controlling blood lipids and blood pressure using diet and exercise and commencing glucose-lowering (GLM), lipid-lowering and antihypertensive agents and other medicines when indicated, providing diabetes self-care education and undertaking regular health assessments. Self-care and adherence to recommendations are important to maintain health and meet metabolic

Assessments could also encompass determining when the individual could benefit from palliative care and when to document an end-of-life care plan and an advance care directive (ACD). However, many clinicians find it difficult to discuss death and dying (giving bad news). Consequently, they miss opportunities to initiate conversations about these issues, and beneficial palliative care can be delayed [20, 21, 27]. Death cannot be cured: people's end-of-life can be made comfortable, dignified and consistent with their values and care preferences when these are

Many clinicians regard death and dying as treatment failure [28]. The terms 'failure' and 'bad news' are inherently negative. People often know they are not going to recover and want affirmation from their health professionals [28]. Some people express the wish to die while their identity and personhood can be maintained and not when they are terminally ill and incapable of making rational thoughts and informed decisions [29]. When such discussion does occur, health professionals often present the options as a choice between continuing and withdrawing

Palliative care originated in the 1960s and largely focused on end-of-life care at that time. More recently, there is increasing recognition that people with chronic disease could benefit from palliative care; thus the term broadened in meaning and scope to include non-communicable chronic diseases [30]. Most adults with chronic disease need palliative care as a result of cardiovascular disease [9, 11]. Diabetes is the leading cause of cardiovascular disease, and, in turn, cardiovascular disease is the leading underlying cause of diabetes-related deaths [3, 6, 31]. All health professionals who care for people with diabetes have a role in timely implementation of palliative care. Therefore, health services need to integrate such care into the

The patterns of dying are changing as more people follow the chronic disease trajectory, which is characterized by periods of deterioration followed by recovery until physiological reserves are depleted and the person reaches the terminal and end-of-life stages [32–34]. Many experts recommend palliative care should be implemented early in the disease trajectory, sometimes from diagnosis, for greatest benefit [30, 32]. In fact, Murray et al. recommend '[clinicians] should routinely and systematically consider whether our patients might benefit from early palliative care' [34]. **Table 1** explains the terms palliative care, life-limiting illness, end-of-life

*DOI: http://dx.doi.org/10.5772/intechopen.83534*

known, clearly documented and communicated.

and Diabetes UK [26].

targets.

treatment.

**3. Palliative care**

services they offer and policies [32].

care and advance care planning.

*Diabetes and Palliative Care: A Framework to Help Clinicians Proactively Plan... DOI: http://dx.doi.org/10.5772/intechopen.83534*

Diabetes [23], Australian Diabetes Society [24] and Diabetes UK [25]. Many recommend 'relaxing' glycaemic targets in older people to reduce the risk of hypoglycaemia and its consequences: they usually do not include *comprehensive* guidance about other key aspects of palliative and end-of-life care. Exceptions are the IDF Global Guideline for Managing Older People with T2DM [7] and Guidelines for Managing Diabetes at the End of Life (currently under review) [8] and Diabetes UK [26].

Quality diabetes care encompasses achieving normoglycaemia (HbA1c <6.5 7%), controlling blood lipids and blood pressure using diet and exercise and commencing glucose-lowering (GLM), lipid-lowering and antihypertensive agents and other medicines when indicated, providing diabetes self-care education and undertaking regular health assessments. Self-care and adherence to recommendations are important to maintain health and meet metabolic targets.

Assessments could also encompass determining when the individual could benefit from palliative care and when to document an end-of-life care plan and an advance care directive (ACD). However, many clinicians find it difficult to discuss death and dying (giving bad news). Consequently, they miss opportunities to initiate conversations about these issues, and beneficial palliative care can be delayed [20, 21, 27]. Death cannot be cured: people's end-of-life can be made comfortable, dignified and consistent with their values and care preferences when these are known, clearly documented and communicated.

Many clinicians regard death and dying as treatment failure [28]. The terms 'failure' and 'bad news' are inherently negative. People often know they are not going to recover and want affirmation from their health professionals [28]. Some people express the wish to die while their identity and personhood can be maintained and not when they are terminally ill and incapable of making rational thoughts and informed decisions [29]. When such discussion does occur, health professionals often present the options as a choice between continuing and withdrawing treatment.

#### **3. Palliative care**

*Palliative Care*

condition.

be more useful to prognostication.

factors being managed [15, 16].

decisional uncertainty.

**2. Diabetes care**

with diabetes complications. Most (~67%) occur in people aged 60 and older [3]. Therefore, older people with diabetes may have more than one life-limiting

Aging is associated with reduced insulin production and insulin sensitivity that lead to insulin resistance, which increases by 1–2% per year [4]. Older age is generally defined as older than age 65 [5]. However, chronological age is not a good guide to disease, functional status, care needs or life expectancy. Biological age is a more accurate indicator of the rate at which body cells deteriorate but is more difficult to measure. Significantly, the individual's chronological and biological age may be different [5]. Many older people have several coexisting comorbidities/geriatric syndromes, including cardiovascular disease, renal disease, sensory impairments, lower limb pathology, cognitive changes/dementia, some forms of cancer and frailty that individually and collectively affect life expectancy [6–9]. Frailty predicts admission to a care home and mortality and increases the risk of death [10, 11]. Frailty is assessed in various ways, including phenotype and accumulation of deficits. The latter may

Many older people with diabetes have at least three coexisting comorbidities, but these are often managed as single entities that may not address the many diffuse symptoms [12–14] or the need to change the focus of care from achieving normoglycaemia to prevent complications to focus on comfort by managing existing

People with diabetes who can maintain near-normal glycaemia (~7%) and normal lipids and blood pressure are less likely to develop complications and may not have significantly reduced life expectancy. However, these parameters are often abnormal some 10–15 years before type 2 diabetes (T2DM) is diagnosed, and complications can be present and affect life expectancy from diagnosis [7, 12]. In addition, older people are less likely to benefit and more likely to be harmed by 'tight blood glucose control'. Therefore, blood glucose and HbA1c target ranges need to be individualized to minimize risk, especially hypoglycaemia risk and other risk

Diabetes and the associated comorbidities affect the quality of life, compromise function and self-care and increase the need for hospital admissions and readmissions and eventually lead to death [11, 13, 17]. Over 50% of people aged 65–80 experience moderate to severe disability and increased dependency. On average,

Significantly, older people with diabetes and concomitant heart failure who have several recent hospital admissions and consult multiple prescribers are at risk of readmission within 30 days [19]. Hospital admissions near the end of life often result in burdensome and futile treatment that causes significant suffering and stress for the individual and their family [19, 20]. Likewise, people with cognitive

Thus, starting conversations about the likely prognosis early in the disease trajectory can enhance people's capacity to make meaningful decisions and enable them to document their values and care preferences [21, 22]. In turn, clearly documented values and care preferences enhance family and health professionals' capacity to make care decisions consistent with the person's values and reduce

Quality diabetes care is described in many clinical guidelines such as the IDF [7], American Association of Diabetes/European Association for the Study of

impairment face many challenges, including decisions about their care.

complications and preventing hypoglycaemia and hyperglycaemia.

they need care 24 hours/day between 1.3 and 6.9 years [18].

**110**

Palliative care originated in the 1960s and largely focused on end-of-life care at that time. More recently, there is increasing recognition that people with chronic disease could benefit from palliative care; thus the term broadened in meaning and scope to include non-communicable chronic diseases [30]. Most adults with chronic disease need palliative care as a result of cardiovascular disease [9, 11]. Diabetes is the leading cause of cardiovascular disease, and, in turn, cardiovascular disease is the leading underlying cause of diabetes-related deaths [3, 6, 31]. All health professionals who care for people with diabetes have a role in timely implementation of palliative care. Therefore, health services need to integrate such care into the services they offer and policies [32].

The patterns of dying are changing as more people follow the chronic disease trajectory, which is characterized by periods of deterioration followed by recovery until physiological reserves are depleted and the person reaches the terminal and end-of-life stages [32–34]. Many experts recommend palliative care should be implemented early in the disease trajectory, sometimes from diagnosis, for greatest benefit [30, 32]. In fact, Murray et al. recommend '[clinicians] should routinely and systematically consider whether our patients might benefit from early palliative care' [34]. **Table 1** explains the terms palliative care, life-limiting illness, end-of-life care and advance care planning.


**Table 1.**

*Explanation of the terms life-limiting illness, palliative care, end-of-life care and advance care directives.*

**113**

**Table 2.**

*Diabetes and Palliative Care: A Framework to Help Clinicians Proactively Plan...*

**4. Diagnostic uncertainty and prognostic challenges: Challenges to** 

It is certain that everybody will die eventually. The uncertainty lies in when and how an individual will die. The trajectory to death for people with diabetes can be a long and healthy one but is often a long process of physical and social decline followed by recovery until the final stages of life: the so-called chronic disease trajectory [2, 43, 44]. People can die, seemingly suddenly, during a disease exacerbation. However, most of these people have one or more indicators of limited life expectancy. Thus, their death was *possibly* predictable: the time of death might not have been. Episodes of deterioration become increasingly frequent over time and reduce the remaining physiological reserve and the person's ability to recover from

The chronic disease trajectory to end of life is unpredictable and includes many periods of deterioration and recovery before death occurs [38, 43, 44], which creates a degree of diagnostic uncertainty for many health professionals, people with diabetes and families. The uncertainty is compounded by challenges associated with prognostication and, sometimes, from misinterpreting individual's questions such as 'how long have I got Doc?' Mostly the individual wants an idea about how long they have left 'to put their house in order' and 'say my goodbyes'. Such questions could be a cue to health professionals to begin advance care planning to document the individual's values and care goals and preferences. Some strategies to enhance

Diagnostic uncertainty encompasses cognitive, emotional and ethical reactions, which are affected by the need to discuss care options with the individual

• If planned ask the individual who they would like to be present during the conversation and have all

• Ensure the person brings any communication aids they need with them, e.g. spectacles and hearing aids • Present the information in easy-to-understand words and formats, and assess their understanding • Frame the conversation as part of the individual's life story. Use own knowledge of life expectancy in

Some useful questions include the following: these questions should *not be used as a* '*tick box*' *list*. They must be personalized to the individual and the situation. The questions need not be asked in any particular order

• What things make your life worth living or matter to you? Rather than asking about the quality of life.

Older people need time to process the question in order to respond—a complex cognitive process, especially when the topic is emotive. Interrupting can cause confusion and change the discussion, and important issues

Understand and accept that not everybody is capable of making informed decisions during a crisis and some

*Strategies to enhance conversations about palliative and end-of-life care among older people with diabetes,* 

*DOI: http://dx.doi.org/10.5772/intechopen.83534*

subsequent exacerbations.

such conversations are shown in **Table 2**.

• Conversations can be planned or opportunistic

relevant information and documents ready

similar conditions

might not be identified

*families and clinicians [40, 49, 64, 65].*

• What does suffering mean to you? • What does a good death mean to you? Not interrupting the individual is a key skill

people prefer certainty, i.e. to be 'told what to do'

• Ensure the environment is confidential and welcoming

• Use a value-based approach rather than focusing on medical decisions

• Recognize and respond to verbal, non-verbal and emotional cues appropriately

• What do I need to know about you to help me give you the best possible care and advice?

**discussing palliative and end-of-life care**
