Management of Diabetes Mellitus in Adults at the End of Life: A Review of Recent Literature and Guidelines

Abstract

Background: The prevalence of diabetes mellitus (DM) is rising with an increased risk of developing it as a person ages. Therefore, more persons will have comorbid DM throughout their health journey and are potentially prone to unpleasant symptoms associated with poor glycemic control at the end of life (EOL). We performed an in-depth literature review to examine evidence-based recommendations on DM management at the EOL. Design: A librarian-assisted systematic and gray literature search was performed in electronic clinical databases and Google™ for diabetes management articles (DMAs). National and international diabetes, palliative care, and general guideline websites were searched for clinical practice guidelines (CPGs). Inclusion criteria: adults ≥18 years with terminal illnesses, articles published between 2007 and 2017 with blood sugar target, monitoring frequency, and management recommendations for type 1 and type 2 DM. Exclusion criteria: conference poster abstracts and CPGs without published year or references. Two independent appraisers evaluated the CPGs using the "Rigour of Development" domain of the Appraisal of Guideline Research and Evaluation II (AGREE II) instrument. Results: Nine full-text DMAs were included for review from 2476 screened articles. Twenty-one CPG websites were searched. For the six included CPGs, the AGREE II "Rigour of Development" domain scores ranged from 6% to 34%. We found no high-quality evidence for DM management at the EOL. Treatment recommendations were based primarily on expert opinion (level IV evidence). Conclusions: Higher quality studies are required to inform a standardized approach to the management of DM at the EOL.

Keywords: clinical practice guidelines; diabetes mellitus type 1; diabetes mellitus type 2; end-of-life care; palliative care.