Abstract Hospice and palliative medicine practitioners frequently encounter diabetes and associated complications as comorbidities in end-of-life patients. As the patient with diabetes approaches end-of-life, there comes a time when tight glycemic control can not only prove of questionable benefit, but has the potential to cause harm. The medical literature offers little guidance on managing these complications appropriately. This article identifies three distinct classifications of patients with diabetes approaching the ends of their lives due to advanced illnesses. The authors propose a specific framework to guide management in patients with diabetes and advanced disease who are relatively stable, experiencing impending death or organ failure, or actively dying. The authors provide comprehensive information on commonly used diabetic medications, with necessary considerations and dose adjustments for these populations. The goal of the approach is to address individual patient needs, provide guidance for patients and caregivers, and ultimately maximize outcomes for patients with diabetes in the palliative care setting.