PALLIATIVE

CARE IN
DIABETIC
Ns. Retno Setyawati, M.Kep., Sp.Kmb
 ANGIOPATHY
• Chronic complications of diabetes are primarily
those of end organ disease from damage to
blood vessels (angiopathy)  secondary to chronic
hyperglycemia
• Angiopathy is one of the leading causes of
diabetes-related deaths, with about 68% of
deaths caused by CVD and 16% caused by strokes
for  those ages 65 or older.
• Two categories: macrovascular complications
and microvascular complications.
Several theories exist as to how and
why chronic hyperglycemia
damages cells and tissues

Accumulation
Accumulation ofof damaging
damaging by-
by-
products
products of
of glucose
glucose metabolism
metabolism

Formation
Formation of
of abnormal
abnormal glucose
glucose
molecules
molecules in
in the
the basement
basement
membrane
membrane ofof small
small blood
blood vessels
vessels

Derangement
Derangement in in red
red blood
blood cell
cell
function
function that
that leads
leads to
to aa decrease
decrease inin
oxygenation
oxygenation toto the
the tissues.
tissues.
Macrovascular Complications

 Are diseases of the large and medium-

size blood vessels  include
cerebrovascular, cardiovascular, and
peripheral vascular disease.
 The macrocirculation (large blood
vessels) in people with DM undergoes
changes due to atherosclerosis;
abnormalities in platelets, red blood
cells and clotting factors; and changes in
arterial walls.
Coronary artery disease (CAD) is a type of
blood vessel disorder that is included in the
general category of atherosclerosis.

Fatty Streak

Developmental
Fibrous Plaque
Stages

Complicated
Lesion
Fatty Streak
■ Fatty streaks, the earliest lesions of
atherosclerosis, are characterized by lipid-filled
smooth muscle cells. As streaks of fat develop
within the smooth muscle cells, a yellow tinge
appears. Fatty streaks can be seen in the coronary
arteries by age 15 and involve an increasing
amount of surface area as one ages. Treatment
that lowers LDL cholesterol may reverse this
process.
Fibrous Plaque
■ The fibrous plaque stage is the beginning of progressive
changes in the endothelium of the arterial wall. These
changes can appear in the coronary arteries by age 30 and
increase with age.
■ Normally the endothelium repairs itself immediately.
This does not happen in the individual with CAD. LDLs
and growth factors from platelets stimulate smooth muscle
proliferation and thickening of the arterial wall. Collagen
covers the fatty streak and forms a fibrous plaque with a
grayish or whitish appearance.
 Complicated Lesion
■ The final stage in the development of the atherosclerotic lesion
is the most dangerous. As the fibrous plaque grows, continued
inflammation can result in plaque instability, ulceration, and
rupture.
■ Once the integrity of the  artery’s inner wall is compromised,
platelets accumulate in large numbers, leading to a thrombus.
further platelet aggregation and adhesion, further enlarging the
thrombus. At this stage the plaque is referred to as a
complicated lesion
 Microvascular Complications
• Microvascular complications result from thickening of the
vessel membranes in the capillaries and arterioles in
response to conditions of chronic hyperglycemia.
• Can be found throughout the body, the areas most noticeably
affected are the eyes (retinopathy), the kidneys
(nephropathy), and the skin (dermopathy). Microvascular
changes are present in some patients with type 2 diabetes at
the time of diagnosis.
• Microvessels play important roles in maintaining blood
pressure and proper nutrient delivery. The microcirculation
also has regulatory systems controlling vascular permeability
and myogenic responses that can adapt blood flow according
to local metabolic needs.
 Cont…
• Diabetes induces pathognomonic changes in the
microvasculature, affecting the capillary
basement membrane including arterioles in the
glomeruli, retina, myocardium, skin, and muscle,
by increasing their thickness, leading to the
development of diabetic microangiopathy.
• This thickening eventually leads to abnormality in
vessel function, inducing multiple clinical problems
such as hypertension, delayed wound healing, and
tissue hypoxia.
DIABETIC RETINOPATHY
■ Refers to the process of microvascular
damage to the retina as a result of
chronic hyperglycemia, nephropathy,
and hypertension in patients with
diabetes.
■ Diabetic retinopathy is estimated to be
the most common cause of new cases
of adult blindness.
Classification

Retinopathy

Non
Proliferative
proliferative
Nonproliferative retinopathy

■ Partial occlusion of the small blood vessels

in the retina causes microaneurysms to
develop in the capillary walls.
■ The walls of these microaneurysms are so
weak that capillary fluid leaks out, causing
retinal edema and eventually hard
exudates or intraretinal hemorrhages.
■ Vision may be affected if the macula is
involved.
 Proliferative retinopathy
■ The most severe form, involves the retina and the vitreous.
■ When retinal capillaries become occluded, the body
compensates by forming new blood vessels to supply the
retina with blood, a pathologic process known as
neovascularization.
■ New vessels are extremely fragile and hemorrhage
easily, producing vitreous contraction.
■ If these new blood vessels pull the retina while the
vitreous contracts, causing a tear, partial or complete
retinal detachment will occur.
■ If the macula is involved, vision is lost.
 NEPHROPATHY
■ Diabetic nephropathy is a microvascular
complication associated with damage to the
small blood vessels that supply the glomeruli
of the kidney.
■ Hypertension significantly accelerates the
progression of nephropathy.
■ Therefore aggressive Blood Pressure (BP)
management is indicated for all patients with
diabetes.
■ Tight blood glucose control is also critical in the
prevention and delay of diabetic nephropathy.
Diabetic neuropathy is nerve damage that occurs
because of the metabolic derangements associated
with diabetes mellitus.

■ This can lead to the loss of protective

sensation in the lower extremities, and coupled
with other factors, significantly increases the
risk for complications that result in a lower limb
amputation.
■ Screening for neuropathy should begin at the
time of diagnosis in patients with type 2
diabetes and 5 years after diagnosis in
patients with type 1 diabetes.
■ The pathophysiologic processes of diabetic
neuropathy are not well understood. Several
theories exist, including metabolic, vascular, and
autoimmune factors.
■ The prevailing theory is that persistent
hyperglycemia leads to an accumulation of
sorbitol and fructose in the nerves that causes
damage by an unknown mechanism. The
mechanisms of hyperglycemia-induced polyol
pathway, injury from AGEs (Advanced glycation
end products), and enhanced oxidative stress
have been implicated in its pathogenesis.
■ The result is reduced nerve conduction and
demyelinization. Ischemic damage by chronic
hyperglycemia in blood vessels that supply the
peripheral nerves is also implicated in the
development of diabetic neuropathy.
■ The damage to peripheral nerves may be mediated
by effects on nerve tissue or by endothelial injury or
vascular dysfunction. Peripheral neuropathy in
diabetes appears in several forms depending on the
site, manifesting as sensory, focal/multifocal, and
autonomic neuropathies.
 Classification
 The two major categories of diabetic neuropathy are
sensory neuropathy,  which affects the peripheral
nervous system, and autonomic neuropathy.
 Sensory Neuropathy. The most common form of
sensory neuropathy is distal symmetric
polyneuropathy, which affects the hands and/or feet
bilaterally.
 Characteristics of distal symmetric
polyneuropathy include loss of sensation,
abnormal sensations, pain, and paresthesias.
 Cont…
 Autonomic Neuropathy. Autonomic
neuropathy can affect nearly all body systems
and lead to hypoglycemic unawareness, bowel
incontinence and diarrhea, and urinary
retention.
 Gastroparesis (delayed gastric emptying) is a
complication of autonomic neuropathy that
can produce anorexia, nausea, vomiting,
gastroesophageal reflux, and persistent
feelings of fullness. Gastroparesis can trigger
hypoglycemia by delaying food absorption.
 COMPLICATIONS OF FEET AND
LOWER EXTREMITIES
■ People with diabetes are at high risk for foot ulcerations
and lower extremity amputations.  The development of
diabetic foot complications can be the result of a
combination of microvascular and macrovascular diseases
that place the patient at risk for injury and serious infection
■ Sensory neuropathy and peripheral artery disease (PAD) are
risk factors for foot complications. In addition, clotting
abnormalities, impaired immune function, and autonomic
neuropathy also have a role.
■ Sensory neuropathy is a major risk factor for lower
extremity amputation in the person with diabetes.  Loss of
protective sensation (LOPS) often prevents the patient from
being aware that a foot injury has occurred.
 Decision cycle for patient-centered glycemic management in type 2 diabetes.

Melanie J. Davies et al. Dia Care 2018;41:2669-2701

©2018 by American Diabetes Association

Management Strategies of Diabetes
■ Managing diabetes is challenging, especially in
palliative and end-of-life situations.
■ The prime focus is usually on safety, comfort and
quality of life rather than on achieving ‘tight’
blood glucose control. Preventing hypo- and hyper-
glycemia is an important aspect of comfort and
quality of life.
■ The care plan and blood glucose targets need to be
personalized to suit the individual’s health and
functional status, medicine regimen, risk profile and
life expectancy, and, importantly, developed with the
individual and sometimes their family carers.
 GENERALPRINCIPLES
■ Diabetes occurs more frequently in palliative care patients
than the general population.
■ Patients with pancreatic cancer are more susceptible to
developing diabetes.
■ Management of diabetes in palliative care patients should be
adjusted according to individual requirements and may alter
depending on the stage of the disease. Complications may
usually be managed in a palliative care setting but if severe,
admission to an acute unit may be required e.g. for
hyperglycaemia associated with ketoacidosis.
■ Good diabetic control will help to avoid symptoms of
hyperglycaemia or hypoglycaemia and so maintain quality
of life. However, strict diabetic control may be less important
in palliative care because of a reduced emphasis on avoiding
late diabetic complications.
 Table 1. explains the terms palliative care, life-limiting
illness, end-of-life care and advance care planning
Terms Explanation Consideration
Life-limiting The term life-limiting illness Diabetes experts
illness (LLI) describes people at high risk recommend normalizing
of dying in the subsequent 12 blood glucose, lipids and
months. Many people admitted to blood pressure to reduce
hospitals and ICUs have a life- the risk of complications
limiting illness. The Gold that can reduce life
Standards Framework (GSF) expectancy
Proactive Indicator. Diabetes is Palliative care experts and
not specifically mentioned in the many geriatricians
GSF. recommend people to
Diabetes is the main underlying document their values and
cause of renal disease, end-of-life preferences
cardiovascular disease and some while they are able to
forms of cancer, frailty and make informed,
dementia. autonomous decisions
Terms Explanation
Palliative The aim of palliative care is to
care improve the quality of life, relieve
suffering and manage distressing
symptoms
Palliative care involves symptom
management, prognostication,
advance care planning and
transition to the dying/terminal
stage
Palliative care can be used at any
time and can complement usual
diabetes care. Palliative care
should be commenced early for
maximum benefit to archive these
aims
Consideration
Many older people with
diabetes could benefit from
combining palliative care
into their usual diabetes care
as function changes and the
burden of medicines and
complications increaseThey
also benefit from the support
to document advance care
directives much earlier than
it currently occurs
Terms Explanation
End-of- The last 12 months of life
life care and includes imminent death
in a few hours or days.
Four phases are described:
stable, unstable,
deteriorating, terminal
Consideration
Many people want to
die at home, but most
older people with
multiple comorbidities
die in hospital
Recognize/diagnose
dying Identify whether
unstable disease is
likely to be remediable
or likely to continue to
deteriorate and progress
to the terminal
stageTreat or implement
end-of-life care
Terms Explanation
Advance Advance care planning
care (ACP) is the process used to
directive develop and ACD
(ACD) ACD is a document that
clearly describes an
individual’s values and the
type of treatment they
want if they are not capable
of deciding for themselves
and guides their medical
treatment decision-maker
and clinicians to make
decision on their behalf that
accord with their values and
care preference
Consideration
Important information
for older people with
diabetes to document in
their ACD are the things
they value and give
meaning and purpose to
their life (values
directive), the care they
want to receive and the
care they do not want to
receive
Some strategies to enhance such conversations are shown in
Table
• Use a value-based approach rather than focusing on medical
decisions
• Conversations can be planned or opportunistic
• If planned ask the individual who they would like to be
present during the conversation and have all relevant
information and documents ready
• Ensure the environment is confidential and welcoming
• 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 similar conditions
• Recognize and respond to verbal, non-verbal and emotional
cues appropriately
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 do I need to know about you to help me give you the best
possible care and advice?
• What things make your life worth living or matter to you?
Rather than asking about the quality of life.
• What does suffering mean to you?
• What does a good death mean to you?
Not interrupting the individual is a key skill
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 might not be
identified
Understand and accept that not everybody is capable of making informed
decisions during a crisis and some people prefer certainty, i.e. to be ‘told what
to do’