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Diabetes Watch

When Patients With Diabetes Need Hospice Care

As the diabetic population continues to grow larger and older in the United States, more patients with diabetes will be in need of end-of-life care. Having a better understanding of palliative care and hospice services will better arm podiatrists with the information needed to give their patients the appropriate level of treatment and make timely referrals of patients to hospice care.

As the demographics of the United States continue to shift, there is an increasing number of people over the age of 65.1 Within this group, there is an epidemic growth of type 2 diabetes with a prevalence six times that of people aged 20 to 24 and an estimated prevalence of diabetes among all U.S. adults ranging from 5.8 to 12.9 percent.1–4

In older adults, the high prevalence of diabetes is due to age-related physiological changes such as increased abdominal fat, sarcopenia and chronic low grade inflammation, all of which increase the risk of cardiovascular and microvascular complications.1 In addition, adults with diabetes are at higher risk for obesity, hypertension, dyslipidemia, hearing impairment, sleep apnea, fatty liver disease, periodontal disease, cognitive impairment, depression, anxiety and fractures.4,5

Additional studies have suggested that, due to coincidental obesity, patients with diabetes have an increased risk of certain cancers: liver, pancreas, endometrial, colon/rectum, breast and bladder.4,6-12 A systematic review of 97 prospective studies (820,900 patients) shows that adults with diabetes have an increased risk of death from cancer.4,13 Patients with diabetes are also at increased risk for developing and dying from cardiovascular disease with a decreased life expectancy of six to eight years.4,13-19

Which Patients Need Hospice Care?

As our population of patients with diabetes and associated comorbidities ages, podiatrists need to become more familiar with making appropriate referrals to hospice services. One should consider referral to hospice care when patients are entering the last weeks to months to live, and patients and their families decide to forego disease-modifying therapies with curative/life-prolonging intent in order to focus on maximizing comfort and quality of life. This may occur when the burdens of the disease-modifying treatments outweigh their benefits and/or when the disease-modifying treatments are no longer deemed beneficial.20

Physicians should strongly consider a hospice referral for patients who have been chronically ill and meet any of the following criteria: a decreased functional status (spending more than one-half of their time in a bed or chair); poor quality of life; physical and psychological distress; family caregiver burden and heightened stress; increasing frequency of medical and symptom crises; or multiple hospitalizations and emergency room visits.20

Specific to podiatrists, one should consider hospice care for patients with terminal disease states. This includes patients with critical limb ischemia and severe gangrene who have no targets for revascularization and are not surgical candidates for amputation. Referral is also appropriate for patients who are not surgical candidates and have large, painful wounds causing sepsis. In addition, consider patients with severe lower extremity contractures and failure to thrive for palliative or hospice care.

How Palliative Medicine Evolved From Hospice Care

The practice of medical futility and palliative medicine comes from Hippocrates, who taught clinicians not to treat patients who were “overmastered by their disease, realizing that in such cases medicine is powerless.”21 Podiatrists who treat patients in the critical care setting and/or geriatric population will encounter patients with diabetes who are in need of palliative or hospice care. Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering, and supporting the best possible quality of life for patients who are facing a serious and/or life-threatening illness.22,23 Hospice care is a form of palliative care for patients with life-limiting illness with a prognosis of six months or less if the disease follows its natural course.20  

The specialty and practice of palliative medicine is a direct descendant of the hospice movement and holistic care developed by hospice specialists. While we can consider all care delivered by hospice providers to be palliative care, not all palliative care occurs in hospices.20 Palliative care is not limited to end-of-life care and it aims to relieve suffering in all stages of disease and healthcare professionals can provide it at the same time as curative or life-prolonging disease treatments.20,24

A Closer Look At Hospice Data And Guidelines

In the United States, there are guidelines from Medicare to help determine the terminal status for hospice qualification. However, individual prognostication remains difficult even with the guidelines, particularly with non-cancer diagnoses, making death difficult to predict.20,25 If the patient happens to live beyond the six-month prognosis while on hospice, patients can renew the benefits indefinitely as long as there is clinical evidence that that patient is in continued decline.20

The past 20 years have shown an incredible increase in hospice programs in the U.S.20,26,27 In 2014, there were 6,100 hospice programs helping approximately 1.6 to 1.7 million patients.20,27 In 2009, there were over 40 percent of Medicare decedents utilizing hospice in comparison to only 23 percent in 2000.20 Additionally, in 2010, 41.9 percent of deaths in the U.S. were under the care of hospice in comparison to approximately 8 percent in 1992.20,28

There are many misconceptions about hospice care. Hospice is not always a physical location. It is a model of care that can be provided in a hospital, nursing home or in a patient’s home.20 Patients can leave and return to hospice at any time as long as they continue to meet eligibility criteria. In addition, patients do not have to be actively dying to qualify for hospice care. A patient is not required to have a do not resuscitate order to receive hospice care. However, life-sustaining technologies such as vasopressors, intensive care and ventilator therapy are not recommended, or typically in use while the patient is under hospice care.

Some patients have fears concerning hospice care. Many are afraid that hospice shortens life. However, studies have shown that it actually gives the patient a survival advantage in comparison to similarly ill patients who do not have hospice care.20 Patients also fear losing their physicians if they enroll in hospice care but this is not always necessary, and physicians can continue to see their patients if patients desire it or the physician deems it appropriate.

Physicians who are not trained in palliative care and are struggling with communication and consensus with patients and families concerning end-of-life issues should obtain a palliative care consult. These highly trained clinicians can provide a different perspective about death and dying that may help patients transition from pursuing aggressive medical interventions to more appropriate treatments that can help control pain and suffering.29,30

In Conclusion

As we transition to a larger population of older people with higher levels of diabetes and cardiovascular disease, the need for appropriate hospice care will continue to grow. By educating ourselves, our patients and our patients’ families, we can help more people have a significantly better quality of life, reduce the aggressiveness of treatment at the end of life, and greatly reduce the risk of posttraumatic stress disorder and prolonged grief disorder among bereaved family members.20,31,32

Dr. Swain is a board-certified wound specialist physician (CWSP) of the American Board of Wound Management and a Diplomate of the American Board of Podiatric Medicine. He the Medical Director of the St. Vincent’s Wound Care and Hyperbaric Center at St. Vincent’s Southside Hospital, and is in private practice in Jacksonville, Fla.


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Diabetes Watch
David Swain, DPM, CWSP
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