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
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.
- Munshi MN, Florez H, Huang ES, et al. Management of diabetes in long-term care and skilled nursing facilities: a position statement of the American Diabetes Association. Diabetes Care. 2016; 39(2):308-318.
- Li C, Balluz LS, Okoro CA, et al. Surveillance of certain health behaviours and conditions among states and selected local areas-Behavioral Risk Factor Surveillance System, United States, 2009. MMWR Surveill Summ. 2011; 60(9):1–250.
- Centers for Disease Control and Prevention. 2011 National Diabetes Fact Sheet. Available at https://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf .
- McCulloch D. Overview of medical care in adults with diabetes mellitus. UpToDate. Available at http://www.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus . Published Jan. 4, 2017.
- American Diabetes Association. 3. Comprehensive Medical Evaluation and Assessment of Comorbidities. Diabetes Care. 2017; 40(Suppl 1):S25–32.
- Inoue M, Iwasaki M, Otani T, et al. Diabetes mellitus and the risk of cancer: results from a large-scale population-based cohort study in Japan. Arch Intern Med. 2006; 166(17):1871–7.
- Stattin P, Björ O, Ferrari P, et al. Prospective study of hyperglycemia and cancer risk. Diabetes Care. 2007; 30(3):561–7.
- Hemminki K, Li X, Sundquist J, Sundquist K. Risk of cancer following hospitalization for type 2 diabetes. Oncologist. 2010; 15(6):548–55.
- Giovannucci E, Harlan DM, Archer MC, et al. Diabetes and cancer: a consensus report. Diabetes Care. 2010; 33(7):1674–85.
- Larsson SC, Mantzoros CS, Wolk A. Diabetes mellitus and risk of breast cancer: a meta-analysis. Int J Cancer. 2007; 121(4):856–62.
- Tsilidis KK, Kasimis JC, Lopez DS, et al. Type 2 diabetes and cancer: umbrella review of meta-analyses of observational studies. BMJ. 2015; 350:g7607.
- Liao WC, Tu YK, Wu MS, et al. Blood glucose concentration and risk of pancreatic cancer: systematic review and dose-response meta-analysis. BMJ. 2015; 349:g7371.
- Emerging Risk Factors Collaboration, Seshasai SR, Kaptoge S, et al. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med. 2011; 364(9):829–41.
- Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis. Diabetes Care. 1992; 15(7):815–9.
- Franco OH, Steyerberg EW, Hu FB, et al. Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med. 2007; 167(11):1145–51.
- Livingstone SJ, Levin D, Looker HC, et al. Estimated life expectancy in a Scottish cohort with type 1 diabetes, 2008-2010. JAMA. 2015; 313(1):37–44.
- Tancredi M, Rosengren A, Svensson AM, et al. Excess mortality among persons with type 2 diabetes. N Engl J Med. 2015; 373(18):1720–32.
- Uusitupa MI, Niskanen LK, Siitonen O, et al. Ten-year cardiovascular mortality in relation to risk factors and abnormalities in lipoprotein composition in type 2 (non-insulin-dependent) diabetic and non-diabetic subjects. Diabetologia. 1993; 36(11):1175–84.
- Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993; 16(2):434–44.
- Meier D, McCormick E, Lagman RL. Hospice: Philosophy of care and appropriate utilization in the United States. UpToDate. Available at http://www.uptodate.com/contents/hospice-philosophy-of-care-and-appropriate-utilization-in-the-united-states . Published Feb. 3, 2017.
- Hippocrates. The art. In Jones WHS (ed.): Hippocrates: the Loeb Classical Library. Harvard University Press, Cambridge, 1923.
- Sepulveda C, Marlin A, Yoshida T, Ullrich A. Palliative care: the World Health Organization’s global perspective. J Pain Symptom Manage. 2002; 24(2):91–6.
- Okon TR. Overview of comprehensive patient assessment in palliative care. Available at http://www.uptodate.com/contents/overview-of-comprehensive-patient-assessment-in-palliative-care . Published March 28, 2016.
- Teno JM, Connor SR. Referring a patient and family to high-quality palliative care at the close of life: “We met a new personality … with this level of compassion and empathy.” JAMA. 2009; 301(6):651–9.
- Fox E, Landrum-McNiff K, Zhong Z, et al. Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. JAMA. 1999; 282(17):1638–45.
- MedPAC. Report to the Congress: Medicare Payment Policies. 2010; 148. Available at http://www.medpac.gov/docs/default-source/reports/mar14_entirereport.pdf .
- NHPCO Facts and Figures on Hospice. Available at http://www.nhpco.org/hospice-statistics-research-press-room/facts-hospice-and-palliative-care . Published September 2015.
- National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. National Quality Forum, New York, 2004.
- Miller-Smith L, Lantos J. Palliative care: medically futile and potentially inappropriate/inadvisable therapies. Available at http://www.uptodate.com/contents/palliative-care-medically-futile-and-potentially-inappropriate-inadvisable-therapies . Published April 1, 2016.
- O’Mahony S, McHenry J, Blank AE, et al. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med. 2010; 24(2):154–65.
- Wright AA, Keating NL, Balboni TA, et al. Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. J Clin Oncol. 2010; 28(29):4457–64.
- Obermeyer Z, Makar M, Abujaber S, et al. Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA. 2014; 312(18):1888–96.