As an experienced hospice nurse, I understand that managing diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) at end of life can be challenging, especially when patients choose to stop taking their diabetic medications or when those medications are no longer an option. In this article, I will provide information on recognizing the signs and symptoms of hyperglycemic crises and outline comfort-based treatment options that align with hospice goals of care.
Signs and Symptoms of Hyperglycemic Crises
A hyperglycemic crisis is when the blood sugar level is too high and causes damage to the body. There are two main types of hyperglycemic crises: diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). They have different causes, but they both need urgent medical attention.
Some of the signs and symptoms that may indicate a hyperglycemic crisis are:
High blood sugar levels: The patient may need to pee a lot (polyuria) or drink a lot of water (polydipsia) because their kidneys are not working well.
Altered mental status: The patient may feel confused, disoriented, or very sleepy. They may have trouble speaking or answering questions.
Rapid breathing: The patient may breathe fast and deep (Kussmaul respirations) because their lungs are trying to get rid of the extra acids in their blood.
Fruity breath odor: The patient may smell like fruits or acetone because their body is breaking down fat for energy (ketones).
Dry mouth and skin: The patient may be dehydrated because they lose water through urine and sweat.
Weakness and fatigue: The patient may feel weak and very tired because their body is using up its energy.
Abdominal pain: Some patients may feel pain or discomfort in their belly.
If you notice any of these signs or symptoms in someone who has diabetes, you should call for help right away. The healthcare team, including hospice professionals, can help you give the patient fluids, insulin, electrolytes, and other treatments to lower their blood sugar level and make them feel better. They can also help you find out what caused the crisis and how to prevent it from happening again.
Comfort-Based Treatment Options
When managing DKA or HHS at the end of life, the main goal is to make the patient feel comfortable and less distressed. The focus changes from trying to fix the blood sugar problem to a gentler approach. Some of the ways to help the patient feel better are:
Fluid and Electrolyte Management: Give fluids to the patient to help them stay hydrated and balanced. This can help with symptoms like dry mouth and skin, which can make the patient feel uncomfortable.
Symptom Control: Give medicines to the patient to help with symptoms like nausea, vomiting, belly pain, and trouble breathing. These symptoms can make the patient feel extremely sick and unhappy.
Pain Management: Give painkillers to the patient if they have pain. Pain can make the patient feel unbelievably bad and stressed. Painkillers can help them feel calmer and more relaxed.
Mouth Care: Keep the patient’s mouth clean and moist. This can help with dry mouth, which can make it hard to talk or swallow. You can use a soft toothbrush, mouthwash, or lip balm to help the patient’s mouth feel better.
Psychosocial and Emotional Support: Listen to the patient and their loved ones with kindness and care. Give them emotional support and comfort. Let them talk about their feelings and worries. You can also offer them resources for spiritual or emotional guidance if they want.
Family Education: Teach the patient’s family and caregivers about the signs and symptoms of hyperglycemic crises, as well as the gentle treatments you are giving. This can help them feel more confident and prepared to help the patient. It can also help them know when to call for medical help.
It’s crucial to remember that managing hyperglycemic crises at the end of life is about maintaining comfort and dignity rather than aggressive medical interventions. The hospice team will work closely with the patient, family, and caregivers to ensure the best possible quality of life during this challenging time.
Conclusion
Managing diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) at the end of life requires a shift in focus from aggressive medical interventions to a comfort-based approach. Recognizing the signs and symptoms of hyperglycemic crises is crucial, as they require urgent medical attention. Some of these signs and symptoms include high blood sugar levels, altered mental status, rapid breathing, fruity breath odor, dry mouth and skin, weakness and fatigue, and abdominal pain. When managing DKA or HHS at the end of life, the main goal is to make the patient feel comfortable and less distressed. This involves fluid and electrolyte management, symptom control, pain management, mouth care, psychosocial and emotional support, and family education. It’s important to remember that managing hyperglycemic crises at the end of life is about maintaining comfort and dignity. The hospice team will work closely with the patient, family, and caregivers to ensure the best possible quality of life during this challenging time
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