Ask D'Mine: Diabetes Death By Cake?

Welcome back to our weekly diabetes advice column, Ask D’Mine, hosted by veteran type 1 and diabetes author Wil Dubois in New Mexico. Here, you can ask all the burning questions you may not want to ask your doctor. Today, Wil hears from a son of a type 1 in England who’s dealing with the emotional toll that diabetes can take on life, and how that can be navigated when it seems like too much…

{Got your own questions? Email us at AskDMine@diabetesmine.com}

Stewart, type 3 from England, writes: Dear Sir — I have been reading up on how long my father can live without his insulin and other medications. He just turned 70 years this Saturday, and announced that he hasn’t been taking his insulin and meds for the past 6 weeks because he doesn’t want to live anymore. This has come as a shock to us, but we respect his wishes as he has all of his faculties. He has lost 5 stone in weight [70 pounds for US readers], we have informed his doctors, who are coming out to assess him tomorrow to put a DNR in place… but all I keep reading is how he could go into a DKA possibly within 12-24 hours, or days at the most. He is drinking Coca Cola, eating chocolate, cakes, full English breakfasts, cod and chips and basically whatever he wants. He is getting very forgetful. I have told him what is going to happen to him and how his body is eating his muscles and how he will go into a DKA at any moment, but he just says, “Keep ya chin up son, it will be OK.” He has been a T1 for 15 years and a T2 before then for 20 years, how is he still going? Will he just pass away over night? I can’t take it, I lost my mother due to cancer, and that was a 6-month journey. He is my best friend and father please advise if you can…

Wil@Ask D’Mine answers: 

I can feel your pain. And that’s no lie. It drips from the page as if the ink were wet. I’m so sorry that you are going through this. Thank you for reaching out to me. There may be legitimate arguments here on the controversial concept of right to die — it’s your father’s body, and his right to say when he stays or goes. But moving beyond the “should” aspect here, let me just say that I hope you and your father have considered everything. Know that your family has a community of support, people who are willing to listen. And that resources do exist to talk through these tougher times, if needed.

That being said, let’s get to the direct question you asked me to address. Yes, I can advise you — in three separate ways, actually. As a diabetes expert, I can give you some insight into what’s happening — and what’s not happening — to your father physically. As a person with diabetes, I can also give some perspective into the psychology at play here. And as a human being, I have some thoughts to share with you about love and loss.

The first part is easy. You’re confused as to why your father hasn’t already died. And rightfully so. Anything you read will tell you that a type 1 who stops taking insulin should die within days, even without the Coca Cola, cakes, and cod. And he’s been bingeing for six weeks! So what’s going on? The secret is that he’s not a genuine type 1. I know this for two reasons. First, he’s still alive. Second, you told me that he’d been T2 for 20 years, then became T1.

It doesn’t work that way.

T2 and T1 are different diseases. T1 is an autoimmune disease in which the body’s immune system completely destroys the insulin-producing cells in the pancreas. Type 2 is a horse of a different color. It’s a disease of increasing insulin resistance that over-taxes the body’s ability to produce insulin, eventually resulting in deficiency that requires supplemental insulin.

At that point, a patient should be properly diagnosed as an insulin-dependent type 2. However, that’s not always what happens. All too commonly docs, especially the ones who aren’t diabetes specialists, say, “Ah ha! Now that you need insulin, you are a type 1.” But that’s wrong.

Still, normally being mis-classified wouldn’t matter. The treatment for advanced T2 and any level of T1 is largely the same—at least when it comes to blood sugar control. The only reason this matters to us today is that, as an advanced T2, your father’s body still produces some insulin. Not enough to control his blood sugar. Not enough to stay healthy. But enough to stay out of diabetic ketoacidosis (DKA). It takes very little insulin to hold off DKA. Could he consume enough sugar to overwhelm the scant fumes of insulin remaining in his body and trigger DKA? It’s theoretically possible, but not likely. So I think it’s safe to say he won’t go into DKA any moment. Still, there’s another “killer” risk at play. Although DKA is off the table, it’s possible that he’d fall into what’s called a hyperosmolar hyperglycemic state (HHS), sometimes called the “type 2 coma,” which is essentially a state of severe dehydration caused by the frequent urination triggered by crazy-high blood sugars. Still, this isn’t terribly likely. HHS is triggered by sustained BGLs of over 33.3 mmml/L [600 mg/dL] for an extended period of time, combined with a lack of fluid intake.

Could his sugar be that high? Maybe. The rapid weight loss shows us that it’s pretty high, but you can lose that kind of weight from sugars half as high. Still, how would you know if HHS is on the horizon? How would you recognize it? Notably, one of the key symptoms of HHS onset is confusion and disorientation. Is that the same as the forgetfulness you reported? I can’t say. See if you can get a few fingersticks. That will tell you how great the risk is. HHS, while rare, is every bit as dangerous as DKA. It, too, can be fatal. Oh, and unlike DKA, seizures are possible, as is temporary partial paralysis on one side of the body—so be on the lookout for those symptoms.

So, theoretically, HHS could kill him somewhat quickly, but I’d put my money on this being a very long process—way more than the six months your mother suffered—in which his quality of life will gradually reduce as complications from high blood sugar set in. Maybe. I say maybe because complications take a long time, decades, and he’s pretty old already. If he was well-controlled for most of his diabetes life, he could well die of natural causes long before he could develop complications that could do him in. I hope that doesn’t disappoint him, as he’s stated he doesn’t want to live anymore. But the fact of the matter is, diabetes is a poor suicide weapon.

Still, I admire him for trying. Think about it: Given how long he’s had diabetes, half his life, he must have made a serious effort to keep it in control. That’s a lot of work. A lot of sacrifice. I don’t think people without diabetes know how damn hard this is. Every single day. What a joyous relief it must have been for him to set down the syringe and pick up the Coke bottle. To stuff himself with abandon. To revel in the orgy of food that most people take for granted, that we people with diabetes must forgo. It makes me want to join him for one of those full English breakfasts that he’s been denying himself for decades. 

So I admire his spunk. He’s ready to go, and by God, he’s trying to go out with a bang. Of course, not only will it not work the way he hopes, he’s only thinking about himself. One thing I’ve noticed about the elderly, is that they often get so focused on themselves that they lose sight of the needs of the people who share their space. Sometimes this has a selfish flavor to it, other times elders perceive that their burden quotient exceeds their value. But either way, they often can’t see what they bring to our lives the way we can.

Which leads me to you. You say you respect his wishes. But is that accurate? He’s ready to go, or so he says, but you aren’t ready to let him. You lost your mother, and it sounds to me like he’s ready to join her, but you can’t face losing him, too. But you know what? Ultimately, this is his choice, not yours. That said, you owe it to both of you to be absolutely clear about how you feel. If you can’t choke out the words out to his face, write them in a letter.

In fact, I’d recommend using a letter anyway. Letters are clear. Letters make people think. Letters get read more than once. Make sure you tell him that you need him. That he’s not only your father but your best friend. That after the loss of your mother you really can’t face going it alone. Not yet. Make sure, for both of you, that you tell him what’s in your heart, and that he “hears” and understands it. Then it’s his choice whether to stay or to die.

But eating cake still isn’t the best way to do that.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the guidance and care of a licensed medical professional.