father

I am sorry about your father’s illness and the dilemma in which you find yourself. Others here will have more experience with diabetes and hospice care, so I will confine myself to commenting on the moral issue.

It’s my thinking that we all make choices about how we want some future moment to be, without ever having enough information about what the future will bring or what our circumstances will be like. And you can’t know for sure when that six-month expected time frame is here.

Presumably hospice has the advance directive, and presumably you are empowered to make health care decisions for him? If so, then I think you are obliged to fulfill the spirit and principle of the directive, but not necessarily to fulfill it in a rigid fashion or in absolute terms. You are required to exercise good judgment for his best interests.

I think that people who say they do not want any interventions when they have six months to live are trying to accomplish a goal: if death is coming soon, let it come naturally. It would be my interpretation that hospice itself has exactly the same goal.

It is also a good and compassionate goal not to make choices that create suffering. This is also a hospice goal. I think you are obliged to hear advice from hospice professionals and to make choices that (1) do not prolong life unnecessarily and (2) do not cause suffering.

I think that if you choose to continue insulin on the advice of hospice professionals, you may be technically going against the “no intervention” request but may at the same time be fulfilling the directive to “let death come in its own time but with a minimum of suffering.”

I wish you well with the choices. This is hard stuff.

Edit: It is also true that what “intervention” means is open to interpretation. Unless the directive spells out “insulin,” can you know his views on this? He may have been thinking “no heart surgery,” “no mechanical ventilation.”

this is what they should be doing:

• Goal Shift: Focus moves from strict, long-term control to symptom management, avoiding symptomatic hyperglycemia (e.g., thirst, fatigue) and preventing dangerous hypoglycemia.
• Reduced Intake: As patients eat less, insulin doses usually need to be reduced or discontinued to prevent hypoglycemia.
• Deprescribing: Long-acting insulin or complex regimens may be simplified or stopped.
• Monitoring: Frequent blood sugar checks are often reduced or stopped, focusing only on checking if symptoms of severe, symptomatic hyperglycemia occur.