Blood chemistry changes that occur during dying phase

What changes

Predictable biochemical changes occur in the final days of life as multiple organ systems progressively fail - recognising these changes helps distinguish the expected dying process from a separate, potentially reversible acute problem
Occurs in the majority of patients in the final days of life, reflecting the near-universal multi-organ decline that characterises the active dying phase

Reduced oral intake, reduced renal perfusion, and progressive multi-organ dysfunction together produce a recognisable biochemical pattern: rising urea/creatinine (reduced renal perfusion/pre-renal component), electrolyte disturbance (variable - can include hyperkalaemia from reduced renal clearance, or other patterns depending on intake and organ involvement), and abnormal liver function if hepatic involvement/failure is part of the terminal process

In the actively dying patient, these changes are generally an expected part of the dying process, not a separate treatable problem requiring correction - routine blood testing in the final days of life is often of limited clinical value and can represent a low-value/burdensome investigation (see the judicious use of investigations principle) rather than something that should trigger reflexive intervention
Distinguishing expected terminal biochemical change from a genuinely new, reversible, and clinically significant problem (e.g. a treatable infection, an easily correctable electrolyte disturbance causing distressing symptoms) requires clinical judgement, not simply reacting to an abnormal number

Management in the actively dying phase generally shifts to symptom control rather than correcting biochemical abnormalities that are part of the expected dying process - routine blood testing is often stopped entirely once the patient is recognised to be in the terminal phase, unless a specific result would change symptom management
Explain to families that these changes are an expected, natural part of the dying process, which can provide reassurance and reduce the family's own distress at seeing abnormal results without intervention

Recognising disease trajectories/the dying phase, judicious use of investigations near end of life, hydration and nutrition decisions in the terminal phase

Ordering and reacting to routine blood tests in a patient recognised to be actively dying is a common example of low-value, potentially burdensome care that does not change management and should generally be avoided once the terminal phase is recognised

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