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Ketosis in Death - beyond DKA

We've all been well versed around the pathophysiology of ketoacidosis as a complication of Type I Diabetes. Hyperglycemia + Ketosis = Metabolic acidosis. The patient usually presents with vague, non-descript flu like symptoms, weight loss, abdominal pain, as well as the "3 poly(s)" - polydipsia, polyphagia, and polyuria. This can lead to profound dehydration and even acute kidney injury.. This condition can be precipated by many things including: insulin non-adherence, infection, inflammatory conditions like pancreatitis, or iatrogenic causes like steroid use. Regardless of the underlying issue - it can be a life threatening condition that usually requires an ICU admission. Dietary changes, addition of medications like insulin, and nutritional counseling can go a long way in providing these patient a healthier lifestyle (free from the hospital).

However, did you know that ketosis (even outside of a glycemic control / diabetes Issues) can show up frequently during end of life? Appetite suppression is common in people near end-of-life. This blog may help you in explaining things to family members who insist their loved one eat until the very end. Withholding nutrition at the end of life causes remarkably little hunger or distress... People often have no hunger with total caloric deprivation, and the associated ketonemia [ketones in the blood] produces a sense of well-being, analgesia, and mild euphoria. However, carbohydrate intake even in small amounts (such as that provided by D5W) blocks ketone production and may blunt the positive effects of total caloric deprivation. For the person who is in the final stages of terminal illness, and is close to death, there is no proof that increasing calories (eating more food) will improve their strength, their energy levels, their ability to function, or even prolong their life.

We must keep in mind that our bodies are extremely resilient and they do a remarkable job of continuously repairing and reproducing. However, we must also remember that our bodies are also biologically built to die. Our bodies know how to do this too. Now let’s look what happens in the dying person. During the dying the dying process, the body shifts from an “anabolic” to a “catabolic” state. Instead of using energy to build and repair tissue, the body is now breaking down things to create energy. This is part of the dying process. We recently experienced this ketosis phenomena with my Grandma who died this past June.

It is the most natural thing in the world for all of us—families and clinicians alike—to want to feed and hydrate the patient. Food and water hold a great deal of meaning in all cultures. The meaning of food includes nurturing, love, fun, sustenance, and life itself. To withhold nutrition feels counterintuitive to the way we as humans understand caring for those we love or who are in our charge. However, even those who are not medical professionals need to understand the sometimes-difficult reality of how our bodies die and specifically how food and water can actually cause harm at the end of life. With such knowledge, we can come alongside the dying so that we not only intend to care but also actually cooperate with bodily processes as much as possible to offer comfort and healing at the end of life.

Ketone production at the end of life is a good thing. Ketones provide the sensation of satiation. It is heartening to know that as ketones are produced, simultaneously dynorphins are produced through the breakdown of proteins. These dynorphins are a type of endogenous opiate that is 6–10 times more potent than morphine and also provides an analgesic and anesthetic action.

To paraphrase, Dr. Rebecca Gagne-HendersonIt we should allow folks to die naturally.  A caveat is that for us to sit back and watch “it ain’t pretty”, but for the dying individual, it is an incredibly beautiful and mysterious mechanism.  Maybe you have experieced this BEAUTY first hand. Again, to the living to see our loved ones are dehydrated, with their eyes sunken in, Cheyne Stokes breathing patterns, death rattles, terminal secretions and peculiar smells it would be logical to believe that suffering is laying before us crying for help. However, this is all part of the process and your loved one is most certainly NOT struggling or hurting. Ketones amongst other things are part of the reason why.

December 11, 2023

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

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