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Ok. Very good evening, everybody. Welcome back. Good to see familiar faces back again. Nice to see everyone. Um Welcome to our middle primary care Network event this evening. Um Delighted to have Doctor Jane mcauley back with us in the next installment of our Palliative Care series. Anyone who hasn't seen Doctor mcauley's previous talks get on me all, check out primary care network, all the catch up content is there and check them out. And Doctor mcauley is a consultant in Palliative Care Medicine in the Southern Trust in Northern Ireland and conflict of interest. Once again, a colleague that I'd worked with uh last last year. Um As usual, we're going to run through tonight's talks. Um I'd encourage you to pop questions and comments in the chat. Um We will do our best to address as many of them as we can at the end of the talks. And then after that, um I would appreciate if you fill out our feedback form. Not only because at the end of it, you get your certificate of attendance, but also because it helps us, it helps our speakers um for appraisals, it helps us know what you want to hear about. Um, so I'd encourage you to pop in the section of the feedback form about what topics you'd like to hear on as we look to building the schedule for 2025. So without any further ado, I am going to hand over to Doctor mcauley, I will click my camera off to be less distracting, but I am here and we will chat soon. Thanks, Doctor mcauley. Good evening. Uh, this evening, we're going to look at two slightly different topics. The first one I'm going to look at is managing diabetes in the last days of life. And then we're going to move on to uh something that you probably commonly struggle with, um which would be diabetes uh when someone has added steroids. Uh So steroid induced diabetes or quite commonly a diabetic that someone has had started steroids on and that has upset their, their diabetic management. So that's going to be the second, the second talk. So we'll move on to the first slide. So what I'm using for the top, uh and what I use in my clinical practice would be uh this document, it was updated in 2021. Uh It's the end of life guidance for diabetic diabetes, sorry, diabetes care. And it's from diabetes UK. So that's the, the, the guidance that we'll be using this evening. Now, I'm not gonna expect you to read that. So don't heart sync, but that's what it looks like if you're going to the guidance, uh it's a good idea to Google. Go to the guidance, find that page, uh and print it off. It's, it's very handy, then you can pop it in the patient's notes or have it as a resource uh in your surgery. It's useful, but we're gonna talk through the guidance. So that's what we're gonna do tonight. So the aim of what the guidance really is setting out to do, uh and what we're trying to do clinically is ensure effective symptom control at the end of life. So it's the focus on symptoms, what's bothering the patient rather than a focus on numbers, we can get all hung up on numbers. But actually what symptom is bothering the patient, particularly in the last days to week of life, also individualizing the treatment to the patient's need. So, you know, what type of diabetes do they have? What are their numbers? So it allows you to personalize that treatment rather than saying this is what we do with diabetic patients. No, actually what is this patient? So it allows us to individualize that care. What you're trying to do is avoid that metabolic decompensation and the diabetic emergency. So keep the patient between the hedges. You don't want any hypoglycemic episodes. You don't want DK A but you also don't want that hyperosmolar hyperglycemic state. You don't want them to feel thirsty. You don't want them to feel uncomfortable even if they're very drowsy and sleepy, you want them to feel uh comfortable at, at whatever low level they are. And you want to avoid that symptomatic clinical dehydration. So, if the sugars are running high, their body might well try to get rid of it and gets rid of the fluid as well. So you're wanting to avoid that and always, always supporting the patient and their family communication is key and that's certainly within the guidance is stressed, you're communicating with the patient again, if they're able to communicate at this stage, they may be used to a very set regime with their diabetes. And if you're changing that you need to communicate, that explain what the goals of care are, what you're actually planning to do and that you're, you're monitoring things really carefully and planning things similarly with the family. If they have been involved quite often in the diabetic uh regimen, that is being followed, explaining what the changes are explaining why the changes are happening. This is something that they may well have been very engaged with. Uh and will be quite uh maybe stressed about what's going on whenever the patient is not able to eat or drink because they've been trained to, to keep a very close eye on these things. And always remember, we do have the diabetic specialist nurses in most clinical settings and that and seeking advice from them early is really, really positive, but they've usually been involved very much with the patient if it's a tricky um situation and just making sure they're up to speed with the changes and seeking their advice if if you're needing that and also involving the ward team GP district nurse. So everybody is communicating well and clear documentation of what the plan of care is. Key points from the guidance. What are we aiming for when we say we're trying to keep them between the hedges, a capillary blood glucose of between 6 to 15. So nice safe numbers not going to be going too low, not going to be going too high. They shouldn't be symptomatic at that level of either hypo or hyperglycemia. And this is when you're on the last day comfort care that's really, really critical. Also being really clear. Are we dealing with type one and type two because that makes a major difference to our monitoring and to our plans. So actually checking that out, making sure that we've got the right diagnosis is really key involving the diabetic nurse specialist early. If you're seeking that advice and making sure that touching base, that they're aware of the patient and that and that they're happy with the plan. Keep the blood glucose test to minimum. I'm palliative care. I try not to poke and prod the patients unnecessarily, try not to have investigations that aren't going to change the management. And quite often, particularly in the hospital setting, you'll find bloods will be checked four times a day. Unless that is plan is made and the changes are documented, those bloods will still be done even if nobody's paying any attention to them. And if you imagine if you in the last days of life, if you don't need to have your fingers pricked and blood squeezed out, then having that, uh, management plan adjusted accordingly is really, really important. But still, if the patient is symptomatic, it's a clinical reason for doing that check, then it's important that it's done. So it's not stopping everything. Uh It's stopping what is not in the, to benefit the patient. And when I say symptomatic, what do I mean, the guidance very much talks about symptomatic. And it's for, for those of us that maybe don't manage diabetic patients very often, it's always useful to sort of think what actually are we would I be looking for in a patient that can't communicate with me? Can't tell me what's how they're feeling. So they might uh be shaky, they may seem sweaty, they might seem pale. It's, you may have an element of confusion, drowsiness, and coma. But obviously in an end of life care patient, that's what your, the typical clinical picture might be. So those symptoms are less uh specific to the hypoglycemia, but certainly the sweating, the pallor, maybe they may be able to say, you know, I feel dizzy or I feel jittery. They usually can, you know, do you feel anxious So anything that that would fit with that may well trigger you to check uh uh blood symptomatic from hyperglycemia. Again, if the patient seems to be thirsty, they may be able to communicate that uh dry mouth, blurred vision again, they may not be able to communicate. But if there's a catheter, you may notice that there's an increased journey output out of keeping with what they're orally taking in. They may complain of nausea. And if it's very high, you might notice that fruity smell to the breath, uh, and that might alert you that, that we need to be checking the blood glucose. But really, we want to be keeping ourselves well within the parameters that were not symptomatic from either direction. So I want to come back to that, er, the, the flow chart that, uh, we couldn't see at the start of the talk and really focus in on the different, uh, sections. So, the first patient or the first type of, uh, diabetes we want to look at is the type two diabetic whose diet controlled on Metformin. So, the milder end of the scale that patient might have, uh, been diabetic for a, a period of time, uh, might just be on diet or they might be on Metformin and they're now in the last days of life, they're not eating, they're, uh, not drinking unless it would be time to stop the Metformin. You also can stop monitoring the glucose, key things this would be discussing those changes with the patient and the family, making sure that they're aware of the changes and why you're changing. So that, that's probably the easiest one to, to manage. But again, the communication team and making sure we're bringing them, them around along with us on that journey, the type two diabetic who's on other tablets, possibly on insulin, uh, and on other medications to, to bring down the, the, the glucose, there's two divides with the, with the flow chart. In the first section, it's if the insulin is stopped. So if you're planning to stop the insulin for this patient, the tablets have obviously uh been stopped. And in this situation, the numbers have been relatively low. So you make the clinical decision to stop the insulin. If they appear symptomatic, you can check the blood glucose. But in that situation, they've been running relatively ok. And it, you wouldn't routinely be saying to check it. So you're only checking if you're developing symptoms that we talked about in the previous slides, if you're triggered to check the glucose, because the patient appears symptomatic, either pale clammy, sweaty or you're noticing increased thirst or symptoms that look like they've gone high. You, you would trigger to check the glucose. And if it's over 20 you're going to give some rapid acting insulin about six units, then recheck the blood glucose in two hours. And only if you're really needing to use that rapid acting insulin twice in the 24 hours, you would then trigger you starting a long acting insulin such as Lantus. In that situation, you might well want to discuss things with the diabetic specialist nurse. So in the majority of these patients, you will stop the insulin, you'll stop the routine monitoring and they will not be symptomatic. So you're not checking blood. So that would be the vast majority of patients in this scenario. Their numbers have been ok. Up until this point, they're not eating or drinking. You stop the insulin, you stop the blood glucose, they don't appear symptomatic. And that's, that's, uh, that's how it is. And again discussing that with the family because particularly if they've had to step up to all of these medications and insulin, they will have had training and experience in monitoring that. Uh, and you will have to explain to them what, why with the numbers coming down and not needing all of these medications anymore and that you'll be monitoring for, for comfort, for any signs of any problems. But reducing the investigations and reducing the, the, the, the management as appropriate if the insulin is going to continue. So you're in a type two diabetic, they're on insulin as well as other medi oral medications. The plan because of how the numbers being relatively high, you're planning to continue the insulin, you're going to switch it, you're gonna switch it to the long acting insulin once daily in the morning, something like Lantus. Uh I know Lantus is what we tend to use in my trust. Uh I know when uh other areas of the UK, they may use a different long-acting insulin. So whichever longacting insulin that, that you're used to in your practice. But one thing we do, you work out what the previous daily insulin dose had been and you'd plan to reduce that by 25%. You're going to set up uh blood glucose monitoring at tea time. Uh So only monitoring once a day at tea time and then you're going to titrate uh that that Lantus dose. So if they're below eight, so at risk of hypoglycemia, you're gonna reduce the insulin going down by 10 to 20%. And again, you're checking that the following day and making the same clinical decision. If it's high, it's running about above 20 millimoles per liter. You're gonna consider increasing the insulin again, 1010 to 20% to reduce the risk of symptoms and ketosis. So you're wanting to keep them within that very safe range. And if you're in that situation where things uh you're having to do the monitoring and they're not staying within the range that you're wanting them to stay between the 6 to 15, then you might discuss with the diabetic specialist nurse for assistance. The type one diabetic, the one that uh I suppose that uh you're most concerned about is the patient that's most cons uh will need their insulin. Definitely continued. They uh require that. So that's an absolute, the insulin will continue when it's a type one diabetic. So that's why it's so important in the history that you know, that you're dealing with a type one or a type two. So in this situation, the insulin is continuing, but you again, are changing it to the once daily long acting insulin Lantus again would be the one I would be most familiar with and you would be going with a red a reduction in dose probably again, sort of around that 25%. You're going to check the blood glucose at tea time daily. And again, if it's below eight millimoles, you might reduce the insulin again by 10 to 20%. If it's above, you will increase it again, reducing the risk of symptoms. And this is a situation where I would definitely want the diabetic specialist, nurse aware and just giving that support and guidance to the team. So just making sure there's that because it's fine to have guidance, it's fine to have flow charts. But when you're in a situation where you really want to be um monitoring things safely and appropriately having that wee bit of extra advice is always useful. So I just wanted to put this in context of a case because that's what always would help me with my learning. Uh flow charts are all very well. It's usually the patients that that, that help you consolidate the learning. He was an 84 year old gentleman with advanced dementia. He was now in the end stages, he had an aspiration pneumonia and he hadn't responded to treatment. He hadn't been eating or drinking in the last couple of days just managing occasional sips, moistening his mouth with, with pink swabs. He had been on Metformin for type two diabetes but he hadn't managed, uh, the medications, um, that day they had been managing, I don't know how to get the Metformin into him, um, of the previous, uh, days, but it wasn't possible on the day, the day we were seeing him. And as is fairly typical, unfortunately, in the wards, he still was getting his bloods checked. The, the, the calorie blood glucose was being checked four times a day despite the fact that he wasn't eating and drinking and despite the fact that they actually were, were not high. So we stopped the Metformin. We weren't really stopping it because it already was no longer possible to give. But actually, just to be clear, it was stopped on the cardi and also all of his other oral medication that he wasn't able to take was stopped. We also stopped the monitoring of his blood gary blood glucose and we stopped his observations as well. So, no more news chart. Um, the anticipatory medications were prescribed to make sure that he was kept comfortable. So something's written up for pain for nausea, vomiting, agitation, secretion. So those prn medications were prescribed and there was a full supportive discussion of the family and they were very clear that they were aware of how things were with him and that they felt that comfort care was, was the way that the goals of care were appropriate. He died very comfortably about three days later and there was no evidence of hyper or glycemia at any stage with his journey. The second case was Mrs C, 63 year old lady with metastatic bowel cancer and she had had type one diabetes for many, many years from her teenager. She was now end of life care from her metastatic bowel cancer and she wasn't eating or drinking blood glucose was being checked four times a day and it really had stayed quite well between six and six and 16. So everything had been relatively steady. She was, uh, still prescribed her Lantus 10 units in the evening and the novomix 30 units BD 20 units. Um, at, yeah, at both of those stages and the, as you would expect, the diabetic specialist nurse was, was involved in her care. So after discussion, the novomix was stopped. Uh and the Lantus moved to morning time. Uh there was a of about 25%. So it went down to 30 units. The monitoring was changed to tea time and her use was stopped. So we weren't doing the routine observations again, the anticipated medications were prescribed pain, nausea, vomiting, agitation, secretions and a full supportive discussion with the family. Again, they were aware that the that with her metastatic cancer, that uh time was very, very short and they were staying around the clock with her, her blood glucose ran a little bit higher 12 to 16. Um because we'd stopped some of uh and reduced the change the regime to the to the ones daily. But again, very safe numbers 12 to 16, not too high, not too low. Uh And that was very, very satisfactory and she died about two days later, again, very comfortably with the family present. And the last case is a 55 year old gentleman, Mister M pancreatic cancer and a type two diabetic. He has end of life care, not eating or drinking. Again, the blood glucose was being checked four times a day. Usually it was between six and 15. So not, not a major concern. He was still written up for his oral medications, but he hadn't taken them for a couple of days. He was also on novomix 3010 units twice a day. And the diabetic nurse specialist was, was involved. So the oral medication, including his diabetic drugs were stopped. He wasn't able to eat or drink and the blood glucose monitoring was changed to once daily at tea time, the insulin we changed to Lantus in the morning was a 25% dose reduction. So that went down to 15 units and his blood glu was reading the following tee time was five. So we felt that was just a wee bit low. So we went, reduced that his Lantus by 20%. So we brought it down to 12 units. The blood glucose remained over eight with no symptoms of either high or low and he died very comfortably about three days later, uh with no problems from his diabetes at all. So what are the key points to remember? Remit, finding out and being sure that you're deal what you're dealing with either a type one or a type two diabetic communication, good communication between the professionals and between the patient if possible. And with the family is really key involving the diabetic. Uh I keep looking at DSN which is what's in the guidance, but I always say diabetic nurse specialist. So I'm always going the wrong way around. I apologize and that's uh remembering that your goals are slightly different at the end of life. Worse between something between six and 15 with minimal testing is really uh perfectly fine and what we should be aiming for. So I wanted to move on to looking at uh a second uh episode of the aspect of the guidance, which is something that you may see fairly frequently, which is when steroids have been started, dexamethasone, usually quite frequently in the oncology setting. They will start steroids for wellbeing for pain for uh for a lot a lot of symptoms, somebody maybe develops spinal cord compression. We use steroids a lot in the palliative setting, but they're used a lot in the oncology setting as well. And that can upset the glucose control in someone that is already a diabetic, but also it can uh cause steroid induced diabetes. So somebody who wasn't known to be diabetic, uh when the add steroid suddenly becomes diabetic. So I wanted just to look at how we would manage that in the palliative setting. So as I said, it's frequently prescribed for symptom control. And we now have the steroid card that we are meant to give the patients when we start the steroids. So that if they have a crisis or emergency, that um it's a critical medication that we need to be aware of that, that it shouldn't be stopped abruptly, that it should be covered by some means to reduce the risk, particularly of an adrenal crisis. But they can, they do cause problems and one of their significant problems can be causing hyperglycemic symptoms in diabetic patients or also causing uh steroid induced diabetes in patients that are predisposed to diabetes. And you want to look at uh how that was usually a typically a once daily steroid uh therapy can affect the sugars, but sometimes we miss that and don't realize that quite often it, it got the sugars if they're gonna go up, will go up at sort of five o'clockish. Uh and then they actually dip quite significantly in the early hours of the morning. So you're having to tailor your uh management to take account of that rise, but also not to be causing hypoglycemia in the early morning when it's actually quite difficult to spot and uh could cause significant harm. So it's quite a difficult one to, to manage. So again, this is guidance that I'm using and this is the one that we would use in our clinical practice at the end of life guidance for diabetes care. So in this situation, they're really talking about end of life care uh really in that last year of life. Uh so the steroid guidance and the sick day rules and all of those things are in here. So it's a very useful uh guidance um supported by the diabetes UK. And this is the flow chart that is designed for the steroid um taking steroids and having an impact on your diabetes. I know you can't see it, but we're gonna work our way through it very similarly uh to the to we did before. So the aim again is to find that effective symptom control in the last year of life in this situation rather than the last days. So you're having to individualize the treatment. So it depends what's going on. Are they a type one diabetic or they a type two diabetic? But they're never diabetic before. So you really are having to individualize the treatment you're trying to avoid that uh decompensation in the emergencies and it's key hypoglycemia in the early hours in the morning could cause very bad damage. Um diabetic ketoacidosis again, you don't want to be in that situation and you want to avoid the symptomatic clinical dehydration, particularly this, maybe patients that are undergoing other treatments. Uh they might be getting chemotherapy and they might be having problems with nausea and vomiting and it could be at risk of dehydration or it could be hypercalcemic. So there's a lot going on with these patients and trying to support them through that is really key communication. Again, if you're having to explain to someone that you've given them tablets and they has now made them diabetic and they're going to have to manage that diabetes. You can see where education and communication with the patient in the family is really, really key or if you've given them the, the steroids and that's upset their previously. Ok. Uh diabetic control, you're gonna have to have that conversation on the education and the changes that are needed also very important to involve your diabetic nerve specialist and the team that's that all of the communication needs to be going all directions. Again, we're looking for tight, tight control because you're in the last year of life, you're not worrying about the long, long term complications. So aiming for the for the 6 to 15 is also ok, here in this situation. Key point as well. This guidance is only for steroids that are being used in the, in the palliative care setting or the oncology setting. Not when you were, when steroids were being used for COVID-19, because that's managed very, very differently. So it's for patients that are having it for oncology, palliative care, not for COVID-19. And just a reminder again, w when we say symptomatic, what do we mean? Obviously, this patient is more able to communicate than in the, the previous uh uh talk. So they might say I'm feeling dizzy, I'm feeling faint. They will describe the sweating. If they become confused, drowsy or sleepy, you're gonna be investigating that because that's not the clinical picture that you're expecting. You're gonna be working out whether it's an infection, it, it's a calcium high as medication causing a problem. But the immediate thing that you'll want to check, uh you know, all of those things can take a couple of hours to check. But if you have someone in this situation, you will want to check a blood glucose to make sure that you're not dealing with a hyper glycemia or a hypoglycemia. And again, if they're complaining of thirst or having to rub the toilet, a lot dry mouth that can be caused by a lot of things in the oncology, palliative setting. But you're going to want to know what their blood glucose is as part of that differential diagnosis. So, coming back to the, the flow chart. The first uh situation or scenario is a patient has a type one, diabetes has type one diabetes. So it's obviously high risk of being the blood glucose control being knocked by the steroids being introduced. If they're already on a basal bolus insulin, you can consider transferring that evening basal bolus insulin to the morning. So if you remember we talked about the blood glucose going out up uh when it's steroids that are being given in the morning time at five o'clock. So changing the timing so that it's acting uh at that peak time and thinking about titr the short acting up maybe by 10 or 20% until you get the control. So going gently, uh you're not wanting to, to see, saw too much. If you remember, we talked about the fact that hypoglycemia can happen in the early hours of the morning because you peak up at five o'clock. I'm sorry, I'm not telling you to put the slides on. I'm waving my hands. I apologize. I apologize to him. I'm a hand waver. Um Again, I would be really, this would be somebody that would be very much on the diabetics s uh specialist nurse radar. Uh This is not something you would be trying to manage. If you're a generalist and don't have endocrine experience, you'll be doing the safe things and then uh really seeking advice, particularly if they're going too high or if there, there's a risk of going too low, even with, with snacks and things, if they're on twice daily insulin and they're a type one or a type two diabetic again, you're going to titrate that morning dose. You're trying to deal with that peak at the pre evening meal. So you're gonna go up by 10 or 20%. Again, you're not want to bring them too low. You're just wanna keep them safe, that sort of 1516 and seeking advice, particularly if they're running still too high, despite what you've done, or you're finding that when you being checked in the morning that, that they're, they're going too low. So if you're really struggling to, to seek advice, type two diabetic, if they're on nightly insulin at night again, you are likely going to change that to the morning. Uh, and you might want to titrate that up by 10 to 20%. Just if the, if you're noticing that the pre evening meal readings are high, obviously, you're not, if they're fine, you're not going to be titr. But if they're reading high, you're going to titrate up and you're going to seek that to help and support if they're still high despite that titration, uh, cause you might need to change that. They might need to look at Bolus insulin. Uh, they might need to look at changing things to maybe even BD if it's type two. and they're not having any hypoglycemic symptoms and they're not on a sulfer urea and they're not on any um insulin, but the sugars are now running high. So they were not needing a lot of management until you put the steroids in. And you're the one that has caused the problem. Um You've added the steroids, you know, you find that the blood sugars are running high and you're needing to do something to manage that. In that situation, we're usually starting glycoside 40 mg in the morning and titrating them until the blood sugars are satisfactory. Get a maximum dose of 240 mg in the morning. But you would usually be discussing that with the diabetics, uh specialist nurse. When you're getting 160 or higher, you're gonna be wanting that advice to see. Is there something different that should be done might be appropriate? Um After they may advise something like maybe BD glycoside or adding insulin. Again, that's specialist advice you'd be following rather than just blindly following a, a flow chart. This is the situation that uh I'm always monitoring for. And usually when you're starting steroids in someone who isn't diabetic, we are always communicating with the, the nursing staff that they at least for that first initial period. Um or if there's any changes in the steroid dose, any escalation of that, you're wanting to check a blood sugar at least once a day. And that would be the, the, the tee time to check so that you're wanting to pick up rather than waiting for the patient to become symptomatic. You're actually proactively looking. Now, if their blood sugars are fine for a week or two and nothing has changed, you could probably step that back. But, um, when that, if we're monitoring that and we pick up that the patient has high blood sugars wasn't previously diabetic. They now are because they're on the steroids. It's very similar to the last slide. You're going to be starting the glycoside 40 mg and titrating until the blood sugars are satisfactory. Maximum dose of 240. And again, you'd be chatting that over with the diabetic specialist nurse. I would be chatting that over quite, you know, we, we've caused a problem. We want to be monitoring that closely. It's also really key to remember when we then are reducing or stopping uh the steroids that we need to reset. So things need to be titrated back down. If you're uh on diabetic medication or if you've just been started on diabetic me medication purely in this scenario, then we need to be continuing the glucose monitoring if the blood glucose, blood glucose over 12. So that you're thinking, um you know, the steroids have stopped, you're still over 12. Was this a diabetic diagnosis that hadn't been picked up? Was this person diabetic and the steroids have made it worse? But actually, they were already diabetic and actually need to be treated as that. And, and um onward referred to the service So I wanted to set that the case just to uh have consolidated our learning this this evening. So Mrs is a 48 year old lady, four year history of breast cancer and she had bone metastases. So she presented with the, the palliative care emergency that I talked about a couple of months back spinal cord compression. So she had one week history of back pain radiating down both legs. She also had neurological weakness. She was commenced on high dose steroids, 16 mg and she had an urgent MRI which confirmed the spinal cord compression and she had wanted tr uh fraction of radiotherapy for that. So because we had started the steroids, we were checking the blood papillary blood glucose at at around five o'clock and it was consistently above 18. So too high. We this was a new onset steroid induced diabetes. So we discussed this with the diabetic specialist nurse and she advised yes, go with what the guidance says. Start on the glycoside 40 mg daily. We titrated that up to 80 mg daily. And at that level, the blood glucose was well controlled. She was under 15 and no hyperglycemic episodes. So we were felt that we, we got things well under control. The plan was to reduce the steroids. We don't leave them on steroids long term in this scenario. Usually after the radiotherapy, you began to reduce and titrate with the plan to stop over a period of weeks. Uh and they, we also then had to make sure that we had plans to reduce and stop the glycoside as well. And that was, again, was supported with the diabetic nurse specialist. So making sure we were regularly monitoring because we were more concerned when the stairs were coming down that we didn't want to give her hypoglycemia and cause harm in that way, particularly when it's an early morning when somebody's still sleeping. And that's obviously a time when you can't monitor if they're confused or clammy because they're sleeping in bed. So that's a particularly dangerous time for that. So we wanted to be monitoring that very, very carefully. So again, the key points to remember in this situation, it's really important to know what we're dealing with a type one or a type two diabetic or somebody who isn't diabetic at all. Uh Previous to this, uh It's the steroids that have induced the hyperglycemia communication really critical to have that communication with the patient and family. So they know what's going on and the changes that are being made and that the diabetic specialist nurses involved and, and really supporting the decisions that are being made. And probably the slight change from your normal would be the fact that we're dealing with a slightly different range because in that last year of life, it's more important that the person isn't symptomatic and that they're not at risk of hypoglycemia, um maybe than the long term. Uh year and year of effects of, of hyperglycemia and that glucose control, I think that's us, isn't it? I think that is us doctor. Yes, I think so. Um, can I, first of all say absolutely amazing. Thank you so much once again. Um, I have taken a lot away from that in the sense that it's one of those things that is always there and you have to consider, but maybe we don't get teaching on these things and it's only whenever it crops up in that patient that has really volatile blood sugars that you're like, oh when they're approaching the end of it, how are we, what are we going to do about this? Um I'm going to stop sharing the slides and make our lovely faces a little bit bigger for the audience. Um um There are a couple of questions have came in and I encourage anyone in the chat who wants to ask a question to please do so now or forever hold your peace. Um Yvonne has said about community man when I first say I'm not an endocrine specialist in palliative care. So all I can do is go to the guide and say this is what the endocrine people have told us to do. Uh That's the caveat to our patients. So the endocrine decisions are the endocrine decisions. So we're happy to discuss the palliative end of the endocrine decision. Absolutely. Absolutely. And a fair caveat as well. And I know, one of the questions would maybe be better directed towards um one of our other speakers who's recurrently back with us with an interest in endocrinology. Yvonne has said just maybe from a practical point of view in the community. Um because that long acting insulin that you're keeping going um is maybe given in the morning and there's an inability to then get blood sugars checked later on in the day. Um Is there, is there any ideas or thoughts on how that could be made more practical to suit with the normal working day or other services that can help with that? Depending on where people are based. It's the physiological peak, you know, that's the time it happens. Um You can provide suboptimal monitoring if you go either side of it. Uh So you're probably gonna, if you go before or after it's going to be lower. Um So you might miss, but I'm always a bit safety. Um So if it's, if you're getting lower readings, you're going to give less insulin or less uh other things. So you're gonna be less risky with hypoglycemia, which is probably the one we fear the most. That's probably me. Um, not being an endocrine person, but it's the hypoglycemia, particularly with the steroid induced. If you're giving them steroids, you've caused the glucose to go up and then you're giving them a drug to bring it back down and you have them confused, sweaty clammy in the middle and sort of six in the morning or five in the morning and they're, you know, you're knocking off brain cells and you're causing harm. So that's the one you fear. So probably if you're getting lower readings before or after the peak, you're less, you're, you're more likely that they're going to run a little bit high, but hopefully not too bad. So, you're probably, it's not perfect. Um, but at least you're on the element of the safer side. That would be my thought. Absolutely. And I guess very much service dependent on what's available. But one thought I had on that was perhaps looking at your, you know, your other colleagues who do work outside of the working day. The likes of linking in with, if you have a district nursing service, who could potentially look at that for a period of four or five days to try and get an idea of that trend that might make it easier for GP colleagues today and adjust the doses um appropriately, you're usually not, usually not having to do it, you know, even with the steroids, if the dose isn't changing, you'll find what works. And usually you can sit on it if it's the last days of life again, it's only going to be one or two checks and then you're done. So, you know, it's not, it's not that you're doing this for the rest of, for months in either scenario. Absolutely. No, that, that's an absolutely fair comment. Um Georgia has asked interestingly and I guess this again is very case dependent. But um when we look at diabetes management in the palliative setting, would we change the method of administration? Obviously, there's different, you know, protocols out there for um people who aren't in the palliative setting where we do IV insulin infusions, variable rate infusions, things like that. But is there any reason to change the way we give insulin? No, I think you'd be just choosing the usual route because you're wanting to keep that usual pattern of absorption. Um No, I would think just keep going with what the usual. Yeah. Stick, stick with what, what's familiar to the to the patient's physiology per se. Um And Manuela has asked and in the interests of, of, of Doctor mcauley's specialty, I'm going to protect from this. I don't know the answer to this. I'm sure it is out there and I'm sure if, if we do have a series on endocrinology, we can try and get this answered for you. But um there is obviously different protocols out there and guidelines with regards as to why um Gliclazide was used for the steroid induced um high glucose levels. It certainly was something that I came across a lot as an F one. at the sort of tail end of COVID uh F one being first year out of medical school, there was a lot of corrections and things that had to be done there. But um guidelines are very good on this and I know there are very good guidelines out there. Um So I maybe maybe cover that question with that slightly sidestepped answer if you don't mind. Um Anna has made a lovely comment about how well the talk was presented. Thank you so much for that. Jane. Jane has asked one question. Let me just get a little look at this to see. Um Jane has mentioned in her area. Um There's a wider use of continuous blood glucose monitoring. Yes, the freestyle libra that a lot of people have. Um, do you have any experience with the patients obviously becoming more common? Now that our diabetes teams have people on continuous blood glucose monitoring. Have you any experience on how to manage that differently? It's not something we've had, we've been sort of watching and wondering, um, where I told when they come into the hospital they don't use it. It might still be in place, but in hospital, they will still do the capillary ones because that's more immediate. It's what they're, what they're working to if they're managing things so that they're very clear that that's the, the plan, the concern would be if somebody's at the end of life. Is it as accurate as it, it's it, you know, you would be concerned. Does it make a difference? Um But again, it's an area, if somebody has one and they're at home and you're not needing to monitor. I certainly would be happy to explore and look at it. But again, I would probably chat over with endocrine and see if they're happy because they're telling me because they're very clear that they're not going to use that in the hospital setting. Uh It is my understanding that when they come through the door, you just default back to infusions monitoring because the person's more unwell and they're more, you're needing more acute real time uh results. But certainly if somebody was at home, they're actively dying again, I would, I couldn't see a reason why you wouldn't explore that, but I probably wouldn't just do it myself. I would be chatting over with the rest of the endocrine team and making sure they're telling me I'm not crazy and that they're happy with it. It's not communication. It's an interesting one because obviously that is going to be a foreseeable future, um, thing as the, the, you know, the, the, the, the labor devices and that are becoming more widespread, certainly where, where we are. Um It'll be interesting to see. Um, I suspect there'll be some guidance or research on that in the not too distant future. Um Folks, I don't see any other questions coming in. Um So I think we will leave it there for this evening. Um Thank you very much again to Doctor mcauley. Um We are indebted to your expertise and we look forward to to perhaps another talk in the new year at some stage as we continue the series, um I am going to pop the feedback form into the chat, as I had said at the start. Um Please do fill that out right to the end and a special focus on what uh what you want to see coming up in 2025. Um Our next talks are if I can just get my links here next week, we have a familiar colleague as well, Doctor Steve Holmes, um with his respiratory interest is back with us as we look at asthma, the diagnosis um have popped the link for that into the chat at the moment. And then shortly after that, we are continuing our psychiatry series um with Dr Roslin Buckland and Doctor Zoe Sciola. Um We'll be looking at depression the last time we covered anxiety um with those colleagues and we look forward to that coming up as well, please register. Um And you will get all the notifications, anyone asking for a slide and catch up content that will go on to the platform shortly after tonight's talk and I would direct you to doctor mcauley's previous talks in this series. Um They are very, very useful on symptomatic management was the last one I was able to make. Um which which is really, really helpful. I am going to stop our lives share there and say goodnight, I hope everyone has a good rest. Of the week and we will see you next time. Correct.