Des râles en fin de vie : une analyse biodynamique

The end of life is characterized by a progressive reduction of food and fluid intake. The need for water to excrete ingested osmoles is also reduced. The generation of metabolic water and its transfer out of the intracellular compartment is suddenly increased when a severe proteolysis is induced by a fall of fatty acid utilization. The increased metabolic production of free water originating from this terminal metabolism of body proteins now becomes a significant component of the total water input. This phenomenon may be diagnosed by a sudden rise in urinary urea content. Water is frequently retained to create an hypo-osmolar state when non-osmotic stimulation of ADH release reduces free water excretion. Therefore, the need for fluid intake is further reduced. An inappropriate fluid intake may then exaggerate a relative fluid excess at a time when the reduction of plasma albumin shifts some extracellular fluid out of the intravascular space and may induce or increase terminal pulmonary rattles. It is therefore advisable to be cautious about oral or i.v. fluid administration at this time in order to avoid adding to the discomfort of the last moments of life.