Establishing an Insulin Regimen for Hospice Patients
Many experts agree that sliding scale as it has been used has no proper place in diabetes care. However the idea of never using a correction dose or bolus insulin makes no sense. Using the formula for dosing a new patient based on weight makes sense, however since you are changing from a current regimen it is not all that valuable. Typically a euglycemic patient has about 50% basal and 50% bolus production. For hospice patients, quality of life is more important than glucose control. I am sure you will know the health and both long and short term prognosis for them, and probably for the majority the avoidance of hypoglycemia is of utmost concern. The best thing you can do is to establish a target BG based on these factors. This may be a goal of a fasting glucose of 120-140 mg/dl for healthier patients and possibly 180-200 in patients in the last stages of life. With this in mind, we’ve created the following guidelines.
- If the patient is very ill or has a short expected life span and is on low food intake or TPN or the like, then I would recommend that his total dose be 25% less and this be a basal insulin. The use of NPH is not a good choice due to the peak of action. The use a a sliding scale may never be indicated but if there is a reason to correct (as in medication or infection) then a proper scale is based on the 1800 rule (1800 divide by daily dose) should be indicated for the patient. In this patient correcting to a perfect glucose is not indicated.
- If the patient is is eating a very similar meal pattern carb wise each day and has a somewhat longer expectancy and better quality of life then I would recommend the total daily dose be split 50% for basal (again not NPH) and then a meal time injection based on an average carb ratio. This can be calculated but using the 500 rule (500 divided by the total daily dose) this can then be split into an average equal dose with each meal, and only inject directly after the meal (to make sure they have eaten) and do not dose if they do not eat. If there is a reason to correct (as in medication or infection) then a proper scale is based on the 1800 rule should be used with the meal time insulin.
- If the patient is in better health and is eating and active then I would recommend the use of Basal/Bolus with the use of both a correction and food bolus each meal